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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
via the Strasbourg-Baker Technique

The Strasbourg-Baker technique allows side-to-end anastomosis of the sigmoid colon to the rectal stump without sacrificing the inferior mesenteric artery. It also usually allows preservation of the superior hemorrhoidal artery. It can be performed with the suture technique or the new EEA (end-to-end anastomosis) stapler.

When the blood supply to the proximal colon has been compromised from pelvic irradiation or inflammatory disease of the bowel, the anastomosis between the colon and rectum may be compromised by inadequate blood supply. In this procedure, it is important that the sigmoid colon be of sufficient length to perform the anastomosis without sacrificing the superior hemorrhoidal branch of the inferior mesenteric artery. If both these arteries are sacrificed, the blood supply for the descending and sigmoid colon becomes dependent on the middle colic artery and the integrity of the marginal artery of the colon; and if the marginal artery has been compromised through inflammation or radiation, a portion of the sigmoid colon may become ischemic.

Points of Caution. Adequate mobilization of the descending colon must be achieved to prevent tension on the anastomosis. Occasionally, the terminal branch of the superior hemorrhoidal artery may have to be sacrificed to accomplish this. Care should be taken to retain as many of the sigmoid artery branches of the inferior mesenteric artery as possible to improve the blood supply to the terminal colon and the anastomosis.

After achieving anastomosis with the EEA stapler, the surgeon should perform the three standard tests that confirm that an anastomosis is without defects: (1) the sterile sigmoidoscope should be inserted through the anus, and the anastomosis should be thoroughly inspected by visualization; (2) a small mount of air should be pumped into the rectum, and the pelvis should be filled with sterile saline solution-a stream of bubbles from the anastomosis indicates a defect; and (3) the two intact concentric rings of the bowel retrieved from the anvil of the EEA stapler should be observed.

In resecting the excessive sigmoid colon distal to anastomosis by the EEA stapler, the surgeon must be careful not to inadvertently place the TA-55 stapler across the superior hemorrhoidal artery or one of its main branches.


The anatomy of the sigmoid colon and its mesenteric blood supply are illustrated. If possible, the proximal sigmoid should be resected below the superior hemorrhoidal artery. The disease process itself, however, must dictate the level of sigmoid resection.

Anterior resection has been completed. The EEA stapler, with the anvil detached, has been inserted through the open end of the sigmoid colon, and the stapler rod has been brought through the antimesenteric border of the colon with sharp dissection. After the rod has emerged from the antimesenteric border of the colon, the anvil is reattached.

Pursestring sutures are placed around the rectal stump and around the antimesenteric border of the sigmoid colon at the site where the rod has emerged.

The wing nut on the EEA stapler is tightened, the stapler is activated, and the anastomosis is completed.

Care is taken to identify the terminal branches of the superior hemorrhoidal artery. A small defect is made in the mesentery with a blunt instrument. The TA-55 stapler is inserted through the defect, encompassing the redundant portion of the sigmoid colon. The TA-55 stapler is fired, and the redundant portion of the colon is excised. Care must be taken to try to place the TA-55 stapler distal to the superior hemorrhoidal artery if possible. Insufficient mobilization of the colon, however, may require the sacrifice of the terminal branch of the superior hemorrhoidal artery. It is more important to have a tension-free anastomosis than to retain this branch.

Copyright - all rights reserved / Clifford R. Wheeless, Jr., M.D. and Marcella L. Roenneburg, M.D.
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