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Following the approximation of the mucosal layer, all contaminated instruments are discarded. The field is covered with fresh moist gauze sponges and towels. It is desirable for the members of the surgical team to change gloves. The anastomosis is further reinforced by an anterior serosal layer of interrupted 000 silk sutures (Figure 12). It is sometimes advisable to reinforce the mesenteric angle with one or two additional mattress sutures. Any remaining opening of the mesentery is then closed with interrupted sutures of fine silk. If there is a great deal of fat in the mesentery, which tends to hide the location of blood vessels, it is unwise to pass a needle blindly through it lest a hematoma form between the leaves of the mesentery. It is safer to grasp the peritoneal margins of the mesentery with small, pointed clamps and effect a closure by simple ligation of their contents. Finally, adequacy of the blood supply to the site of the anastomosis should be inspected. Active, pulsating vessels should be present adjacent to the anastomosis on both sides (Figure 13). If the blood supply appears to be interfered with and the color of the bowel is altered, it is better to resect the anastomosis rather than risk leakage and potentially fatal peritonitis. The patency of the stoma is carefully tested by compression between the thumb and index finger (Figure 14). It is usually possible to obtain a two-finger stoma.
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To ensure easy approximation of the open ends of the large bowel, especially if the lesion is located near the splenic flexure, it is necessary to free the intestine from adjacent structures. The abdominal incision may have to be extended up to the costal margin, since exposure of the uppermost portion of the splenic flexure may be difficult. After the relatively avascular peritoneal attachments to the descending colon have been divided, it is necessary to free the splenic flexure from the diaphragm, spleen, and stomach. The splenocolic ligament is divided between curved clamps, and the contents are ligated to avoid possible injury to the spleen, with troublesome hemorrhage (Figure 15). Following this, ...