Plate 49

An alternative method of anastomosing the small intestine that is similar to the preceding open-lumen anastomosis may be performed after first resecting the specimen segment using the cutting linear stapler (GIA) (Figure 1). This prevents gross contamination by closing all lumens with a row of staples. Assuming the mesenteric mobilization, ligation, and divisions have been performed, the specimen is removed. The proximal and distal limbs of remaining bowel are then rotated 180 degrees in order to align the antimesenteric borders. Traction sutures are placed near the planned staple line and approximately 6 to 8 cm distally so as to be beyond the apex of the new anastomosis. A portion of the antimesenteric border staple line is obliquely excised from each limb so as to create an opening large enough for insertion of the forks of the cutting linear stapler (GIA 60) instrument (Figure 2). Both forks are inserted fully to maximize the size of the anastomotic opening. After assembling the cutting linear stapler (GIA 50) and aligning the antimesenteric septum appropriately using the distal traction suture, the stapling instrument is discharged (Figure 3). The anastomosis is inspected for bleeding, which, if present, is controlled with interrupted sutures.

Traction sutures are placed at either end of the new opening, and an additional one is placed centrally, bringing together the newly created staple lines along the antimesenteric border. The three traction sutures are brought within the jaws of a noncutting linear stapler (TA 30 or 60), which then closes the common opening (Figure 4). The excess tissue is excised above the stapling instrument and this suture line is inspected for hemostasis. The mesentery is reapproximated with interrupted sutures and the patency of the anastomosis is tested by palpation (Figure 5).

See Plate 47.