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The bowel is divided obliquely after the mesentery has been cleared off to about 1 cm from the clamp (Figure 14). The mobility of this segment of bowel is tested by bringing it down to the region of the rectal stump to be absolutely certain that side-to-end anastomosis can be carried out without tension. If the initial segment is too tight, additional transverse colon may be mobilized. The hepatic flexure can be freed as well as the entire right colon. Any attachments constricting the mesentery of the descending colon can be divided. The presence of active arterial pulsations should be determined while the closed end of the colon is held deep in the pelvis. The end of the bowel is closed using a running absorbable suture followed by 000 interrupted silk Halsted mattress sutures. Alternatively, a stapled closure and division with a GIA instrument can be used. Some surgeons oversew this staple line with interrupted 000 silks for better security and inversion.
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The taenia adjacent to the mesentery along the inferior surface of the mobilized segment is grasped with Babcock forceps, and traction sutures (A and B) are placed at either end of the proposed opening (Figure 15). These sutures keep the inferior taenia under traction during the subsequent placement of the posterior serosal row of interrupted 00 silk sutures (Figure 16). The traction suture (B) should be within 2 cm of the closed end of the bowel, since it is undesirable to leave a long blind stump of colon beyond the site of the anastomosis. After this, the Pace-Potts clamp is removed. The margins of the rectal stump are protected by gauze pads to avoid gross spilling and contamination. It is advisable to excise the edge of the rectal stump if it has been damaged by the clamp. The color of the mucosa and viability of the rectal stump should be rechecked. Any bleeding points on the edge of the rectal stump are grasped and ligated with 0000 absorbable sutures. It has been found useful for exposure to insert a traction suture (C) in the midportion of the anterior wall of the rectum (Figure 17). This keeps the bowel under modest traction and aids in subsequent placement of mucosal sutures. A noncrushing clamp may be applied across the colon to ...