Techniques of bowel resection and anastomosis

ABSTRACT The ability to perform a safe bowel resection andanastomosis is an essential part of the gynaecologists’ arma-mentarium. When performing a large or small bowel anasto-mosis, using a hand-sewn or stapling device, the principlesthat ensure a successful outcome are that the apposed bowelsegments are viable, the repair is tension-free, and there is nodistal obstruction. In patients requiring colon surgery,mechanical preparation of the bowel reduces the incidence ofanastomotic dehiscence. Failure to progress postoperativelyshould alert the surgeon to the possibility of suture break-down, necessitating radiological investigation and appropriatemanagement. Key words gynaecologic surgery, bowel anastomosis, surgicaltechniques, stoma formation, suture dehiscence INTRODUCTION Bowel pathology is frequently encounteredduring gynaecology surgery. Gynaecological malignancies,particularly of the ovaries or cervix, may involve the small orlarge bowel, necessitating resection. In cases of extensive pel-vic disease, debulking procedures may require removal of seg-ments of sigmoid colon or rectum (1). Knowledge of the basicprinciples of bowel resection, anastomosis, and stoma forma-tion, will allow the gynaecologist to competently manage manyscenarios in which malignancies involve the bowel and requireresection for restoration of bowel continuity. In patients withcomplex pelvic tumours, a colorectal surgeon may be requiredas part of the multidisciplinary approach to ensure completeremoval of the cancer.The type of intestinal anastomosis one performs depends onpersonnel preference but irrespective of the technique used,principles that ensure a successful outcome include: good vas-cular supply to segments being approximated, no distal ob-struction, and a tension free repair. Ideally the cut edges of thebowel segments should bleed freely. Dusky, cyanosed, bowelends indicate an inadequate arterial supply and the affectedsegment should be sacrificed. In general, if the segments beingapposed can overlap then the suture line will be tension free.Adequate mobilization is particularly important for anastomo-sis and stoma formation involving the large bowel (2). In recent years, there has been a large shift towards the use ofintestinal stapling devices. They offer potential reduction inoperative time and are associated with a faster learning curvethan for hand-sewn techniques, making them popular withthe trainee (3). The circular stapling devices are particularlyuseful when performing a low anterior resection. However,we believe that one should be familiar with both techniqueswith intraoperative circumstances and available resources dic-tating clinical decisions.When performing bowel surgery one should be able to com-petently form an ileostomy or colostomy. It is preferable tomark the stoma site preoperatively, away from bony promi-nences, skin creases, and within the surface marking of therectus abdominus. A defunctioning loop ileostomy will pro-vide protection of a distal anastomosis or faecal diversion inpatients with an associated fistula and can be easily reversedonce the underlying pathology has resolved. Iatrogenic largebowel injuries, particularly those involving the left colon andassociated with faecal contamination or a delay in diagnosis,may necessitate a colostomy (4). The aim of this article is to provide an overview of the differenttechniques for intestinal anastomosis. It highlights the impor-tance of decision-making at the time of surgical intervention. Weindicate our personnel preference for bowel anastomosis andstoma formation but appreciate this is by no means the only way.