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Appendectomy Using
the Linear Dissecting

Transverse Loop

End Sigmoid Colostomy With Hartmann's Pouch

Closure of a Loop

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

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

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

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

The purpose of this operation is to resect the rectosigmoid colon and reanastomose the descending colon to the rectum by utilizing the Gambee single-layer suture technique.

Physiologic Changes. The physiologic changes associated with removal of the rectosigmoid colon are minimal.

If the patient has had total pelvic irradiation, a low anastomosis should be protected by a temporary diverting colostomy for 8-10 weeks. If there has been no pelvic irradiation and an adequate preoperative bowel preparation has been performed, however, a diverting colostomy may not be required.

Points of Caution. Adequate mobilization of the descending colon, even if this means mobilizing the splenic flexure and transverse colon, must be made in order that the descending colon will reach the rectum without tension. Anastomoses performed under tension. Anastomoses performed under tension do not heal well.


Two positions may be used for this operation. First, if a simple anterior resection with low anastomosis of the rectosigmoid colon is to be performed and 10-12 cm of rectum are to be preserved; the patient can be operated on in the supine position. If there is a chance that the rectum may require transection below 10 cm, however, the patient should be operated on in the modified dorsal lithotomy position, exposing the perineum for anastomosis using an EEA (end-to-end anastomosis) stapler.

The abdomen, vagina, and perineum should be surgically prepped prior to the procedure, and a Foley catheter should be placed in the bladder. The abdomen should be opened through a left paramedian or midline incision.

The diseased portion of the rectosigmoid colon has been identified, and the appropriate segment of colon has been selected for resection. Two linen-shod clamps are placed at each end of the section designated. The surgeon clamps the colonic vessels by opening small holes in the mesentery. If possible, the left colonic branch of the inferior mesenteric artery is preserved. The remaining portion of the mesentery is transected with scissors. The colonic segment and its mesentery are removed.

After the descending colon has been sufficiently mobilized to allow approximation to the rectum without tension, a stabilizing
3-0 synthetic absorbable suture is placed at the mesenteric border (S) with a Lembert stitch.

A Gambee through-and-through single-layer anastomosis is begun with interrupted 3-0 synthetic absorbable sutures. The needle is passed through the walls of the rectum and descending colon, and each knot is tied on the inside of the lumen (see Small Bowel Resection With End-to-End Anastomosis Using the Gambee Technique).

The anastomosis is continued left and right around the circumference of the lumen.

The last sutures in the antimesenteric border of the bowel should be placed using a  near-far inverting stitch as demonstrated in Small Bowel Resection With End-to-End Anastomosis Using the Gambee Technique.

A few Lembert 3-0 synthetic absorbable sutures are placed around the anastomosis to relieve tension.

The anastomosis, completed with Lembert tension-relieving sutures placed east (E), north (N), and west (W) around the bowel, is shown.

Where the vaginal cuff has been reefed following a hysterectomy is a convenient site for insertion of a closed suction drain.

A Salem pump nasogastric tube is placed in the stomach and connected to low suction until bowel function is established.


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