Dec. 30, 2024
Intestinal resection and anastomosis are frequently carried out in small animal practices to eliminate segments of bowel that are nonviable or affected by disease, often caused by foreign bodies or neoplasia.
Ezisurg provides professional and trustworthy service.
Involved in both human and veterinary medicine, stapling devices have been introduced for gastrointestinal surgery. Various stapling methods for intestinal anastomosis have been developed, including:
Everting, triangulating end-to-end anastomosis (EEA) employing a thoracoabdominal linear stapler.
Inverting EEA using a circular stapler.
EEA with a skin stapler.
Antiperistaltic side-to-side (functional end-to-end) anastomosis utilizing a gastrointestinal anastomosis (GIA) linear and/or cutting stapler.
The GIA stapler has also been employed in both dogs and cats, and more recently, a technique in dogs for stapled functional end-to-end anastomosis (SFEEA) has been documented using solely a GIA stapler. SFEEA is ideally applied following an enteric resection of the jejunum and/or ascending duodenum, taking into account the mobility of this specific segment of small intestine. In contrast, other areas such as the duodenum and large intestine have a shorter mesentery, limiting the use of this technique.
Research has focused on assessing the methodology and outcomes associated with SFEEA in the context of veterinary medicine. Potential advantages of SFEEA compared to hand-sewn anastomosis include reduced procedural time, diminished tissue trauma, lowered risk of intraoperative contamination, and consistent, reliable anastomosis while maintaining blood supply. Additionally, significant luminal disparities between the cut ends of the bowel, such as severe segmental dilation due to an obstructive foreign body, can easily be addressed using SFEEA. A multi-institutional retrospective study in dogs showed no notable differences in anastomosis dehiscence rates or operative timing between SFEEA and hand-sewn methods.
However, there are some drawbacks to SFEEA when contrasted with hand-sewn anastomosis. These include a steep learning curve and the limitation of applying this technique only to the jejunum and ascending duodenum. The financial aspect may also be a factor since SFEEA instruments and staple cartridges can be significantly more expensive than traditional suturing materials. Despite this, in certain institutions, the total time savings in procedure length might make costs comparable between SFEEA and hand-sewn methods.
Classically reported risk factors for intestinal anastomosis dehiscence after hand-sewn techniques include preoperative peritonitis, serum albumin levels below 2.5 g/dL, and the presence of an intestinal foreign body. In studies that specifically investigated risk factors related to SFEEA dehiscence, preoperative inflammatory bowel disease, intraoperative hypotension, and resection involving the large intestine were identified as risks.
Interestingly, preoperative peritonitis was not found to be a risk for SFEEA, contradicting earlier reports. In another retrospective study, it was shown that SFEEA is less likely to experience dehiscence compared to hand-sewn methods in dogs presenting with preoperative septic peritonitis. This underlines that, with the right training, SFEEA can be a dependable technique for surgeons, proving beneficial during emergency situations to expedite anastomosis and potentially lessen the risk of dehiscence in cases of septic peritonitis.
Prior to conducting a linear-stapled intestinal anastomosis, the surgeon should familiarize themselves with the GIA stapling device utilized for SFEEA. The GIA stapler consists of two interlocking halves; when the push-bar handle is activated, it delivers four staggered rows of B-shaped titanium staples while simultaneously cutting between two rows of staples with a knife blade. The knife blade ceases cutting approximately 8 mm before the last staple at the fork’s tip.
Staple cartridges for the DST series GIA stapler vary in length and closed staple height, with colors indicating the height. Blue cartridges (1.5-mm closed staple height) are typically preferred for small animals during SFEEA, while white (1-mm) and green (2-mm) cartridges are available but not commonly utilized in this context.
Standard surgical instrument kit
Balfour retractor
GIA stapler (60-mm or 80-mm or 100-mm for medium-to-large breed dogs) with blue staple cartridges matching the stapler length
Two pairs of Doyen intestinal forceps (atraumatic)
Two pairs of DeBakey thumb forceps
One pair of traumatic forceps (e.g., Rochester-Carmalt)
3-0 monofilament absorbable suture material
Begin by anesthetizing the patient and positioning them in dorsal recumbency. Administer antimicrobial treatment 30 minutes prior to incision and at regular intervals until skin closure. Prepare and drape the abdomen for sterile surgery.
Perform a ventral midline exploratory laparotomy, excising the falciform ligament for improved exposure. Insert a Balfour retractor and systematically explore the abdomen, isolating the impacted intestinal sections with multiple saline-soaked laparotomy sponges. Execute an enterectomy and, where necessary, submit excised tissue for histopathological analysis.
Utilizing an initial pair of Doyen forceps to grip the segment of bowel to remain can assist with manipulation during the resection and anastomosis. Traumatic forceps can limit surgical-site contamination. Only one ratchet of the Doyen forceps should be engaged to avoid devitalizing tissue.
Once the affected bowel is resected, manually shift the intestinal content orally and aborally past the Doyen forceps. Insert a second pair of Doyen forceps approximately 10 cm from the first set to minimize contamination while using stapling devices during anastomosis.
Next, place stay sutures (e.g., 3-0 polydioxanone) into the cut ends of each bowel segment along the mesenteric border. After the stay sutures are applied, remove the first set of Doyen forceps at the bowel ends; allow the second set to remain until the stapled anastomosis is finalized. The stay sutures will aid in elevating the bowel ends for the GIA stapler’s fork insertion. Ensure that the antimesenteric borders align symmetrically before engaging the stapler.
Exercise caution when utilizing stapling techniques in cases with significantly thickened intestinal walls, as staple lengths may be insufficient. Under such circumstances, hand-sewn anastomosis is the recommended alternative.
Utilize the stay sutures to position the GIA stapler perpendicular to the intestine’s lumen. Prior to securing, offset staple rows using two sets of DeBakey thumb forceps to prevent overlap. Lock and fire the device, leaving 1 mm to 3 mm of tissue past the edge for a complete seal. The GIA stapler will simultaneously transect the intestine.
In medium-to-large dogs, the GIA 60 stapler might not adequately engage all tissues; a longer stapler may be needed.
Two interrupted, prolonged absorbable sutures should be placed below the base of the anastomosis to reduce tension on the staple line, targeting submucosa for strength.
Finally, remove all laparotomy sponges and, with new sterile gloves, complete the surgical closure. Thoroughly lavage the abdomen with sterile saline and utilize monofilament absorbable sutures to close the mesenteric defect, taking care to avoid damage to adjacent blood vessels. Drape omentum over the anastomosis before routinely closing the abdominal incision.
For further information on manual endoscopic stapler, please feel free to contact us.
If you are interested in sending in a Guest Blogger Submission,welcome to write for us!
All Comments ( 0 )