Small Bowel Resection With End-to-End Anastomosis Using the Gambee Technique

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Small Bowel Resection
With End-to-End Anastomosis
Using the Gambee Technique

Small bowel resection is preferred over small bowel bypass in situations where the pathologic condition is confined to a segment of the small bowel that is not impacted in a dense irradiation fibrotic pelvis or where a knuckle of small bowel is involved within a pelvic tumor. Resection over bypass should also be performed in those cases where extensive dissection of the small bowel to locate and mobilize the pathologic segment is not required. If the surgeon insists on mobilization and resection of all small bowel disease, the surgeon must be willing to resect the ileum and right colon and perform a high ileotransverse colostomy. The multiple enterotomies not only spill intestinal contents into the wound but also are frequently overlooked at the time of repair. In addition, those enterotomies that are repaired become adherent to the dense irradiated fibrotic pelvic walls and break down at the suture line to form recurrent enteric cutaneous and/or vaginal fistulae. In summary, experienced pelvic surgeons have learned (usually the hard way) that small bowel resection should be confined to those few cases where the pathologic segment of the small bowel can be easily mobilized and isolated. Otherwise, small bowel bypass should be performed.

The pathologic segment of small bowel is removed, and the remaining small bowel is reanastomosed to a healthy segment of intestine.

Physiologic Changes. Removal of extensive segments of small bowel may produce postoperative diarrhea and failure of fat-soluble vitamin absorption.

Points of Caution. The predominant point of caution in resection of the small bowel is to ensure the vascular integrity of the anastomosis. The vascular supply of the terminal 10 cm of small bowel is unreliable. In heavily irradiated patients it is preferable to perform an ileoascending colostomy rather than an ileoileostomy for anastomosis in the terminal 10 cm of the ileum.

Technique

Small bowel resection with end-to-end anastomosis using the Gambee technique is demonstrated here. Anastomosis using the surgical stapler technique is shown in Bladder and Ureter - Intestinal Loop Urinary Diversion.

Patients for small bowel resection are placed in the supine position. A Foley catheter is inserted into the bladder. A sump-type nasogastric tube is passed into the stomach.

A thorough bimanual examination is performed prior to the operation.

A midline incision is made, usually extending around the umbilicus. The abdomen is entered and explored. As previously stated, in the majority of cases, small bowel disease associated with pelvic disorders is located within 3 feet of the ileocecal bowel. This fact is of significant value to the pelvic surgeon in that it allows the surgeon to trace the small bowel back from the cecum rather than trace the bowel down from the ligament of Treitz.

At this point, the decision must be made to perform either a small bowel resection or small bowel bypass. If the limits of the small bowel disease are identifiable and can be mobilized without extensive dissection, small bowel resection is the procedure of choice. If, however, as in the majority of cases, the diseased segment of small bowel is embedded deep in the true pelvis, particularly after heavy pelvic irradiation, it is wiser to perform a small bowel bypass.

The small bowel to be resected is mobilized, and the mesentery is carefully studied for vascular arcades. A point of transection is selected sufficiently distant from the diseased portion and in the immediate vicinity of a healthy vascular arcade. The bowel should be suspended between Babcock clamps or warm moist saline gauze held between the thumb and first finger. The peritoneum of the mesentery is opened with a scalpel, using a delicate technique that does not transect the underlying blood vessels.

Linen-shod intestinal clamps are applied proximal and distal to the point of transection. The mesentery is opened in a V-shaped fashion. The small vessels crossing the line of transection are clamped and tied.

The bowel to be resected is held by an assistant while the surgeon creates small openings in avascular segments of the mesentery along the line of transection. Small vessels are clamped and tied with Dexon suture.

Note that the line of transection in the bowel is oblique rather than perpendicular. The blood supply to the small bowel is such that the antimesenteric border of the bowel can become ischemic if the vascular arcade supplying the edge of the resected bowel is transected perpendicularly. A second reason for transecting the bowel in an oblique rather than a perpendicular line is that an oblique transection will give a larger anastomosis and reduce the incidence of stricture formation.

The bowel has been transected, and the diseased portion has been stapled off with the TA-55 surgical stapler and separated from the health terminal ileum and cecum.

The diseased portion of bowel has been removed to the side, and a healthy segment of the proximal ileum (P) is brought down to anastomose to a healthy segment of the distal ileum (D).

The first step in this anastomosis is to place a Lembert suture of 3-0 Dexon through the mesenteric border approximately 1 cm from the edge of the mucosa. The purpose of this stitch is to take tension off the future suture line and to hold the intestine in appropriate approximation for the remainder of the anastomosis.

The intestine is now available for the Gambee technique of single-layer through-and-through suture anastomosis.

GAMBEE TECHNIQUE The steps of the Gambee technique are outlined in Figures 10-17.

The first step in the Gambee technique is to place the suture, previously noted in Figure 8, on the mesenteric border of the intestine. This is referred to here as the south (S) suture.

The Gambee technique is a single-layer through-and-through anastomosis; all knots are tied within the lumen of the bowel. b is a cross section of a. Note that the initial Lembert suture (L) placed at the mesenteric border of the bowel has been tied and thus tends to invert the edges of the mucosa. The Gambee suture (G) has been placed through the mucosa; the entire wall of the bowel exits the serosa, enters the serosa of the bowel on the opposite side, passes the bowel wall, and emerges from the mucosa. When tied, it further inverts the edge of the bowel.

Each successive Gambee suture is placed approximately 3 mm apart around the entire circumstance of the bowel.

A cross section of the Gambee suture reveals the path of the suture. In a, the suture enters the bowel through the mucosa, passes through the entire wall of the bowel, exits from the serosa, passes back through the serosa of the opposite segment of bowel, penetrates the entire bowel wall, and exits the mucosa. In b, the Gambee suture is tied with the knot on the lumen side of the bowel, tending to invert the anastomosis.

The process has been almost completed around the entire circumference of bowel.

When all but a 5-mm defect in the bowel remains, the near-far inverting suture can be applied. a shows the near-far inverting suture in place. When tied, it will dramatically invert the entire suture line. b is a cross section of the near-far inverting suture, outlining the details of the technique. Note that the near-far inverting suture is the only stitch in the Gambee technique that is tied on the serosa of the bowel rather than the mucosa of the bowel. The stitch is started by placing the suture through the serosa of one segment of bowel approximately 1 cm from the edge. It penetrates the entire surface of bowel and exits the mucosa approximately 1 cm from the edge. The suture is immediately reversed and is passed back through the mucosa of the same segment of bowel 3 mm from the edge, penetrates the entire wall of the same segment of bowel, and exits the serosa. This is the near and the far aspect of this stitch. The suture is then placed through the near edge of the opposite segment of bowel 3 mm from the edge through its serosa to penetrate the entire wall of the intestine and exit from the mucosa. The needle is immediately placed back through the mucosa approximately 1 cm from its edge, penetrates the entire wall of the bowel, and exits from the serosa approximately 1 cm from its edge. Tying the suture dramatically inverts the entire anastomosis.

Four tension-relieving Lembert sutures of 3-0 Dexon are placed north (N), east (E), and west (W) of the bowel. These sutures further invert the anastomosis and take tension off the suture line to improve healing.

The mesentery of the small intestine is closed with interrupted 3-0 synthetic absorbable sutures to prevent internal hernia.