After the EEA stapler has been fired and before the stapler is removed, it may be efficacious to place interrupted Lembert sutures with synthetic absorbable material north, south, and west around the stapled bowel to relieve tension on the staple suture line and improve wound healing.

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In this view, a 2-0 nylon suture on a Keith needle passes through the eye of the special pursestring-applying clamp on the opposite side; the suture exits at the heel of the clamp, reenters the eye on the proximal side, and exits the eye at the toe of the clamp. Thus, a pursestring suture is placed 3 mm from the margin of the dotted line for transecting the descending colon. The colon is now transected beneath the double row of stainless steel surgical staplers at the level of the dotted line.

In cases where the pelvis has been previously irradiated, a protective diverting transverse loop colostomy is performed at a convenient location.

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When the mechanical approximation of the two ends of bowel is satisfactorily completed, four synthetic absorbable Lembert sutures are placed north, east (E), south (S), and west (w) to relieve tension on the suture line and to give added support to the anastomosis.

Physiologic Changes. The low anastomosis preformed with the EEA surgical stapler has a superior blood supply. It is associated with less tissue trauma and has a lower incidence of leaks from the anastomosis. Therefore, we feel it is a superior anastomosis, particularly in scarred ischemic bowel following irradiation therapy to the pelvis.

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Mobilization of the descending colon is illustrated. The peritoneum in the left lateral gutter has been incised up to the splenocolic ligament. The splenocolic ligament has been clamped and divided. When the colon can be placed into the pelvis adjacent to the rectal stump without tension, mobilization will be considered complete. Note the identification of the left ureter, which must be kept in view at all times. At the top, the EEA stapler has been placed through the rectal stump. The pursestring suture has been tied around the central rod, and the anvil of the stapler has been opened. Allis clamps are used to guide the descending colon over the anvil.

There are two techniques for low anastomosis of colon to rectum: the suture technique and the EEA (end-to-end anastomosis) stapler technique.

Anterior Resection of the Colon With Low Anastomosis via the Strasbourg-Baker Technique

The lumen of the descending colon is held open with Allis clamps. The anvil of the EEA stapler is inserted through the open lumen. Note the pursestring on the left side of the colon.

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The last step in the operation involves three tests: inspection of the anastomosis, observation of the "O" rings from the stapler, and the "bubble test." The last of these, the so-called "bubble test," is of maximum importance. Most anastomotic leaks can be diagnosed at the time of surgery, and therefore, the surgeon should not wait until the fifth to seventh postoperative day to learn that the anastomosis is leaking.

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Anterior Resection of the Colon With Low Anastomosis Using the Gambee Suture Technique

In this sagittal section showing the approximated rectum and colon, the EEA stapler is loaded with a double row of staples that have passed through the inverted margins of the intestine. At the same time, the circular scalpel within the stapler cuts away excessive inverted bowel.

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If adequate omentum is available, a J flap is made and brought into the pelvis to cover the anastomosis (see Omental Pedicle "J" Flap).

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The surgeon reopens the stapler by turning the wing nut on the handle. The stapler is slowly brought through the fresh anastomosis with a twisting motion and is removed from the patient.

In gynecologic oncology, it is wise to protect these very low anastomoses with a proximal colostomy if the patient (1) has previously been irradiated, (2) has significant diverticular disease, or (3) has had no bowel preparation.

In this view into the pelvis after anterior resection of the colon and complete hysterectomy have been performed, the vaginal cuff can be seen to be reefed with absorbable suture. The rectal stump is shown at the level of the levator ani muscles. The descending colon has been closed with the automatic surgical stapler.

In this sagittal section of the female pelvis following removal of the uterus and lower rectosigmoid colon, note that the vaginal vault has been reefed with interrupted absorbable sutures. The EEA stapler is in position to be inserted through the anus. The rectal stump has a pursestring suture of 2-0 nylon in place. The descending colon is noted at the pelvic brim. B indicates bladder; and Symph, pubic symphysis.

The EEA stapler technique has allowed very low anastomoses to be performed that were previously thought to be extremely difficult with suture. Suture anastomoses below 7 cm have been associated with a high incidence of anastomotic leaks. The stapler technique offers a clean, vascular, and safe method for very low anastomoses of colon to rectum with a resultant fecal incontinence rate of less than 5% and anastomotic leak rate of less than 7%.

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Low Anastomosis of Colon to Rectum Using the End-to-End Surgical Stapler Technique

The pursestring suture is tied around the central rod. By closing the wing nut on the handle of the automatic surgical stapler, the surgeon mechanically approximates the two ends of the bowel.

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In this sagittal section of the pelvis after the EEA stapler anastomosis has been completed, the pelvic cavity is filled with sterile saline solution (a), and a sterile sigmoidoscope is advanced through the anus up to the level of the anastomosis (b). The entire anastomosis is observed. If points of hemorrhage are noted, they are coagulated. If defects are present, they are noted. A small volume of air is pumped into the rectum. The stapled anastomosis should be airtight. If there is a defect, bubbles will rise to the surface of the saline solution and can be observed by the surgeon. The EEA stapler is dismantled, and the two pieces of bowel, rectum and colon (c), are removed from the stapling device. In all cases they should be complete circles. If they are not complete circles, a defect in the anastomosis is indicated, and the anastomosis should be taken down and repeated, or the defect should be appropriately closed with suture.

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Care must be taken in placing the pursestring sutures. They should not be placed more 0.5 cm from the margin of the bowel. Otherwise, too much tissue will be gathered into the anvil and jam the stapling mechanism of the EEA stapler. This will result in a defective anastomosis. The size of the EEA stapler must be carefully selected to conform with the diameter or the colon and rectum. Forcing a stapler that is too large will only split the colon and result in ischemia and necrosis.

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Points of Caution. Adequate mobilization of the descending colon must be made. Frequently, the splenocolic ligament must be transected and the transverse colon must be adequately mobilized to ensure that there is no tension on the anastomosis. If complete mobilization requires sacrificing the inferior mesenteric artery, extreme care must be taken to ensure that the blood supply from the middle colic artery is intact along with the marginal artery of the colon.

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A pelvic view shows the vaginal cuff reefed with synthetic absorbable suture. A pursestring suture has been placed in the rectal stump and tied around the central rod of the EEA stapler. The anvil of the stapler has been advanced, and the descending colon has been mobilized from above. At this point, the descending colon contains two rows of surgical staples that prevent spillage of its contents into the wound.