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TRIANGULATION

An alternative to open anastomosis for the large intestine is the method of triangulation using three separate staple lines. It is particularly useful in colocolostomy anastomoses, as in left-sided colectomies, because it does not require rotation of the mesentery. It can also be used to close a loop colostomy as an alternative to the sutured technique in Chapter 57. If there is adequate length to rotate the mesentery, an anastomosis can be created in a side-to-side fashion, similar to that seen in Chapter 49.

DETAILS OF THE PROCEDURE

The section of the bowel to be excised is isolated with Kocher clamps while thin, straight clamps such as Glassman clamps are placed transversely on the colon (FIGURE 1). Several inches beyond these clamps, noncrushing Scudder or rubber-shod clamps are applied to prevent gross contamination. The specimen is excised between the Kocher and straight clamps. The field is walled off with laparotomy pads, and the clamps are opened. Obvious bleeding points are controlled with fine ligatures. The two limbs of open bowel are brought into approximation with correct mesentery-to-mesentery alignment (FIGURE 2). The mesenteric opening is closed with interrupted fine silk sutures (FIGURE 3). Anterior and posterior traction sutures (A and B) are placed halfway between the mesenteric and antimesenteric borders. The full thickness of bowel wall along the mesenteric border is aligned with several through-and-through traction sutures or a row of Allis clamps (FIGURE 4). A noncutting linear stapler (TL 60) is positioned transversely below the Allis clamps and traction sutures (FIGURE 5). This ensures inclusion of all bowel wall in the deep staple line. After discharging the stapling instrument, the excess tissue is cut from above the instrument jaws while preserving the traction sutures on either end (FIGURE 6).

A bisecting third traction suture (C) is placed through each stoma in a position corresponding to the apex of the antimesenteric border (FIGURE 7). The open jaws of the noncutting linear stapler (TL 60) are positioned for the second side of the triangle using traction suture (B) to elevate the end of the posterior staple line within the jaws (FIGURE 8). After discharging the staple gun, the excess tissue above the jaws is excised, leaving the apical traction suture (C) intact.

The procedure is then repeated using the two remaining traction sutures (C and A). This final limb of the triangulation must transect each of the other two staple lines (FIGURE 9). On its completion, the excess tissue is excised. The bowel is inspected for hemostasis, and any bleeding points are secured with fine silk ligatures. Any residual mesenteric defect is closed with interrupted sutures. The anastomosis is palpated for patency (FIGURE 10), and the bowel ...

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