Primary anastomosis

In May 2008, the U.S. Food and Drug Administration (FDA) approved 3 for accelerating the time to upper and lower gastrointestinal recovery following partial large or small bowel resection with primary anastomosis. 

Murray JJ, Schoetz DJ, Coller JA, Roberts PL, Viedenheimer MC Intraoperative colonic lavage and primary anastomosis in nonelective colon resection. Dis Colon Rectum 1991 34 527-531. 

Biliary anastomosis Reconstruction of the biliary flow is achieved by side-to-side anastomosis of the two choledochal stumps or, when primary bile-duct disease is present in the recipient, by anastomosis using a jejunum sling in the Roux-en-Y technique. 

FIGURE 45-1. The predominant types of vascular access for chronic dialysis patients are (A) the arteriovenous fistula and (B) the synthetic arteriovenous forearm graft. The first primary arteriovenous fistula is usually created by the surgical anastomosis of the cephalic vein with the radial artery. The flow of blood from the higher-pressure arterial system results in hypertrophy of the vein. The most common AV graft is between the brachial artery and the basilic or... 

Fig. 2.12. Post-anastomotic narrowing of the esophagus. Routine post-operative swallow with non-ionic isotonic contrast medium shows esophageal narrowing at the primary anastomosis without evidence of hold up. No leak was demonstrated. Tracheomalacia is evident. Contrast medium in the airway is the result of an episode of aspiration (arrow)...

The primary problem with ureteral-intestinal strictures is due to scarring secondary to impaired blood flow to the site of the anastomosis. Endoscopic incision combined with balloon dilatation gives better results than dilatation alone. In contrast, a permanent stent is the preferred way to manage patients with metastatic cancer. It is important that the side holes of the pigtail should lie only in the renal pelvis and in the stoma collection bag as, if left in the conduit, they may become blocked by mucous. The stents should be changed every 4-6 months. 

In case of minimal disruption, immediate urethral catheterization can be tried by gentle maneuver. If the catheter placement is not simple, it is better to avoid further handling. Suprapubic catheter placement is performed, and the lesion is then repaired within 15 days from the injury. This delayed primary repair seems to be the best choice because it avoids the risk of immediate abdominal exploration. The urethra can be repaired by endoscopic realignment or by surgical tension-free anastomosis via a perineal approach using one of a variety of techniques. 

Experimental and clinical tracheal repair or anastomosis began in the late 19th century. A few examples of limited tracheal resection and primary anastomosis were cited in the first half of the 20th century [12]. Fmther experimental investigation on potential extent of tracheal resection and primary anastomosis without prosthesis greatly widened these possibilities. Approximately one-half of the adult trachea can be removed and primary reanastomosis performed [99—102], so most tracheal lesions can now be resected and primary anastomosed safely. But resection has several limitations in adult patients, only one-half the tracheal length can be successfully treated and only one-third in pediatric patients [7]. These patients are now treated with palliative techniques such as subpotent laser treatments and stents or T-tubes [14]. 

Gastrointestinal In a retrospective case-control study of 75 patients undergoing laparoscopic colorectal resection with primary anastomosis, there was a higher rate of anastomotic leakages in patients who took oral diclofenac for postoperative analgesia (seven of 33 patients) compared with patients who received opioid analgesia (one of 42 patients) [36 ]. 

In marked contrast to AVFs, AVGs do not have a problem with early maturation failure, with the vast majority being cannulated between 3-6 weeks after surgery. Unfortunately, they do have significant problems with stenosis (most commonly at the graft-vein anastomosis) and thrombosis, with a recorded one year unassisted primary patency as low as 23% [9]. In addition, polytetrafluroethylene (PTFE) grafts have an infection rate of approximately 10% over the lifetime of the graft. 

The primary function of sutures is to hold a wound in a good position for the promotion of wound heaUng. Incised surgical wounds and clean, fresh incised traumatic wounds which are not associated with contamination or devitalized tissue can be closed with sutures, staples, or tissue adhesives. Careful apposition of tissues allows healing by primary intention, resulting in cosmetically and functionally acceptable scars in skin, nerve, or tendon. Sutures are also used in bowel anastomosis and vascular arterial anastomosis, which demand a leak-proof technique using a permanent suture. 

The technique of retransplantation is nearly the same as for primary transplantation with excision of the old graft along the suture lines of the previous anastomoses. If not carried out in the first procedure, bicaval anastomosis for the right atrium can be done in the repeat procedure in order to prevent arrhythmias, tricuspid valve insufficiency and right-sided heart dysfunction. As retransplantation is a second surgical intervention, expertise in reoperative procedures are of importance. 

The arterial axis is first palpated to evaluate the quality of its wall. Arterial and venous dissection is limited to segments to be used for anastomoses. In most cases, the renal vein is attached to the external iliac vein. The arterial anastomosis is more variable end-to-side to the external iliac, most often above the venous implantation, or to the primary iliac artery sometimes end-to-end to the hypogastric artery, when taken from a living donor, because the graft s artery does not have an aortic patch. All these sites can be used in combination when multiple arteries are reimplanted, even the epigastric artery for the small isolated polar branches. 

Fig. 3.1a,b. Vascular and ureterovesical anastomoses. The renal vein is attached to the external iliac vein. The arterial anastomosis is variable a end-to-side to the primary iliac artery, or b to the external iliac artery, most often above the venous implantation... 

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