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The end of the colon is closed by a continuous absorbable suture on an atraumatic needle and whipped loosely over a Pace-Potts or similar noncrushing clamp (Figure 5). Interrupted 000 silk sutures placed beneath the clamp may be used. The clamp is then opened and removed. If a continuous suture is used, it is pulled up snugly and tied. A single layer of 000 silk Halsted mattress sutures is placed about 2 or 3 cm from the original suture line, care being taken that no fat is included. As these sutures are tied, the original suture line is invaginated so that serosa meets serosa (Figure 6). The surgeon must determine before closing the ends of the colon whether an end-to-end, end-to-side, side-to-end, or lateral anastomosis is to be carried out (Figures 14, 16, 17, and 18).
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The end-to-side approximation is physiologic, simple, and safe to perform. The small intestine, still held in its clamp, is brought up adjacent to the anterior taenia of the colon (Figure 7). The small intestine should retain a good color and give evidence of adequate blood supply before the anastomosis is attempted. If its color indicates an inadequate blood supply, the surgeon should not hesitate to resect a sufficient length until its viability is unquestionable. Next, the omentum, if not previously excised, is retracted upward, and the anterior taenia of the transverse colon is grasped with Babcock forceps at the site chosen for anastomosis (Figure 7). Following this, the edge of the mesentery of the small intestine should be approximated to the edge of that of the large intestine, so that herniation of the small intestine ...