New Techniques of Gastrointestinal Anastomoses with the EEA Stapler FRANCIS C. NANCE, M.D.
A new instrument for accomplishing inverted stapled anastomoses in the gastrointestinal tract is described. Side-to-side, end-to-side and end-to-end anastomoses can be performed. Techniques developed for utilization of the instrument in virtually all gastrointestinal anastomoses are described. In most instances a proximal or distal enterotomy is required. Experience with 57 anastomoses in 42 patients is reported. One leak occurred; no other complications not recognized intraoperatively were observed. Anastomoses completed included gastroduodenostomy, gastrojejunostomy, cholecystojejunostomy, colocolostomy and ileocolostomy. Hazards and complications associated with the use of the instrument are described. It should be used only after the surgeon has acquired the skills to operate the instrument properly. The instrument saves time, creates better anastomoses than can be obtained by hand sewing and is extremely versatile. It may permit safer anastomoses in adverse conditions, such as in obstruction and peritonitis. The instrument opens new horizons in gastrointestinal surgery.
A LTHOUGH STAPLING INSTRUMENTS have enjoyed
26widespread use in the Soviet Union for over two decades,1 their employment in surgical practice in the United States has been slow to evolve. Ravitch first evaluated the Russian instruments in 1959.2,3 After modification of several Russian models, the instruments were marketed by the United States Surgical Corporation. In 1972 before the Southern Surgical Association, Ravitch presented a definitive paper which described various techniques for staple suturing in the gastrointestinal tract.4 Since then, a variety of techniques have been developed, particularly by Ravitch and Steichen, for virtually all phases of gastrointestinal surgery.5'6 All techniques previously described utilize the TA or GIA series of instruments, which produce a straight, double, staggered row of staples in everted tissue. The requirement for everted, straight suture lines has limited the application of these instruments. Recently Presented at the Annual Meeting of the Southern Surgical Association, December 4-6, 1978, Hot Springs, Virginia. Reprint requests: Francis C. Nance, M.D., Department of Surgery, 1542 Tulane Avenue, New Orleans, Louisiana 70112. Submitted for publication: December 7, 1978.
From the Department of Surgery, Louisiana State University Medical Center, New Orleans, Louisiana
the United States Surgical Corporation has introduced a new series of instruments, the EEA Stapler. This instrument, which appears to be a modification of the Russian PKS Stapler, permits the creation of an inverted, circular anastomosis held by a double, staggered row of staples.' Although initially introduced for low rectal anastomoses, the author has developed techniques for utilizing the new instrument in virtually all gastrointestinal anastomoses. These techniques greatly increase the versatility for all stapling instruments and should permit their extensive use by gastrointestinal surgeons. The EEA instrument (Fig. 1) works by first compressing the tissues to be anastomosed. When subsequently "fired" by the surgeon, the instrument simultaneously introduces a circular staggered double row of staples and cuts a circular "doughnut" out of the center of each of the structures to be anastomosed. The disposable cartridge head (Fig. 2), which contains the staples and a circular knife, is compressed against the disposable anvil. The anvil is attached to the spindle of the instrument by a threaded screw. When the bowel to be anastomosed has been properly placed over the cartridge and the anvil, compression is achieved by turning the wing-nut on the handle of the instrument. Correct compression is achieved by aligning vernier controls on the handle. After tissue compression has been achieved, the instrument is fired by squeezing the handles together firmly, which simultaneously drives the staples through the tissue, bends the staples in a "B" shape and cuts a central core of tissue in the lumen. When completed, an inverted circular anastomosis is created with a small internal ridge consisting of the staple line and compressed tissue. Currently only cartridges measuring 31 mm in diameter are available. In January 1979, 25 mm and 28 mm
0003-4932/79/0500/0587 $01.20 © J. B. Lippincott Company
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TABLE 1. Technique of End-to-End Anastomosis 1. Place purse-string in proximal and distal bowel; monofilament suture. 2. Judge or measure size of stapler cartridge. 3. Make proximal or distal transverse enterotomy; insert instrument. 4. Open instrument; insert anvil into distal bowel segment. Tie down purse-strings over spindle. 5. Close instrument; fire staples; open instrument two complete turns; dislodge from anastomosis. 6. Remove instrument; check "doughnuts"; inspect anastomosis. 7. Close enterotomy with TA55 stapler.
FIG. 1. The EEA stapler. Note the wing-nut for closing the cartridge against the anvil and for compressing tissues. The instrument is activated by firmly squeezing the handle. Below is an instrument to facilitate introduction of purse-string sutures.
cartridges will be introduced, enabling use of the instrument in bowel with a smaller diameter. Since in most instances at least one limb of any anastomosis requires a purse-string suture (to snug the bowel to the spindle of the instrument), the utilization of the EEA stapler is greatly facilitated by another device, the "purse-string instrument." When this instrument is placed across bowel, a purse-string suture can be rapidly introduced by two passes of a Keith needle through the ends of the jaws of the instrument. We have been using 2-0 nylon atraumatic suture on a Keith needle. General Technique
All anastomoses (except low rectal through the anus) require introduction of the instrument through a proximal or distal enterotomy. In general, we have employed ~~~~~~~~~~~~~~~~~~~~~~~~..
....,
..
the "cleanest" limb or the largest diameter limb for introduction of the instrument. Thus, if stomach is part of the anastomosis, the enterotomy almost always is placed there. If more than one anastomosis is to be made, the enterotomy is located to permit construction of the various anastomoses through the same opening (see Fig. 22). All enterotomy sites are closed transversely with a TA55 staple line. The various steps of an anastomosis are listed in Tables 1 and 2. End-to-end anastomoses require two purse-string suture lines, and the instrument usually is introduced with the anvil attached. Side-to-side and end-to-side anastomoses require one purse-string suture. The instrument is introduced without the anvil. The spindle exits the side of the bowel at the site of the anastomosis, and the anvil is then attached. We illustrate the technique of constructing a side-toside gastrojejunostomy in Figures 3 to 12. An antrectomy has been performed, and the distal stomach is closed with a TA90 4.8 mm staple line. The jejunum is grasped with Allis clamps transversely, and the pursestring instrument is placed across it (Figs. 3 and 4). The 2-0 nylon purse-string suture is introduced with two passes of a Keith needle. The excess tissue is cut away, leaving an enterotomy large enough to accommodate the anvil (Fig. 5). The purse-string instrument is kept on the bowel until the anvil is ready for introduction. A transverse proximal gastrotomy is then made with electrocautery (Fig. 6). The instrument without the anvil attached is introduced. The spindle is then directed toward the site for anastomosis (just adjacent to the stapled closure of the distal stomach). A small stab wound is made. Care should be exercised not to allow this exit wound to enlarge. The spindle TABLE 2. Technique of Side-to-Side Anastomosis
.......
..
....
FIG. 2. Close-up of cartridge and anvil with anvil detached from the spindle. The anvil is attached to the spindle by the threaded screw. In side-to-side anastomoses, the instrument is introduced through the bowel spindle first, without the anvil attached.
1. Place purse-string in distal bowel; monofilament suture. 2. Judge or measure size of head needed. 3. Make proximal enterotomy; insert instrument without anvil; guide out of bowel at anastomosis; attach anvil. 4. Insert anvil into distal bowel; tie down purse-string. 5. Close instrument; fire staples; dislodge from anastomosis. 6. Remove instrument; check "doughnuts"; impact anastomosis. 7. Close enterotomy with TA55 stapler.
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FIG. 6. Proximal gastrotomy made with electrocautery.
FIGS. 3 and 4. Jejunum grasped with Allis forceps transversely; pursestring instrument applied.
FIG. 5. Purse-string has been inserted; excess tissue excised producing jejunotomy.
is guided out of the stab wound (Fig. 7), and the anvil is attached (Fig. 8). The purse-string instrument is removed from the jejunum. The enterotomy is grasped circumferentially with four Allis clamps and gently lifted over the anvil (Fig. 9). The Allis clamps are removed, and the purse-string is tied snugly around the spindle of the instrument (Fig. 10). The instrument is ready to be closed by turning the wing-nut. Note that the circular staple line will overlap the TA90 staples previously placed. This side-to-side anastomosis differs in appearance from end-to-end only in that there is one purse-string instead of two. As the instrument is closed, care is taken to smooth out the bowel (Fig. 11) to prevent stapling of folded bowel. The instrument is closed, compression achieved, the safety released
FIG. 7. Spindle of EEA introduced through gastrotomy and guided out of small stab wound adjacent to distal TA90 staple line.
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FIG. 8. Anvil is attached to spindle.
FIG. 10. Purse-string snugged down over anvil against the spindle.
and the handle squeezed. The staples are driven home, and the center core of tissue is cut. (This usually is felt as a popping sensation.) The wing-nut is backed off two complete turns and dislodged from the anastomosis by gently pressing the bowel over the cartridge and pulling distally while rocking the instrument back and forth. The anastomosis can be inspected distally and by palpation through the enterotomy if desired. Bleeding seldom occurs (we have had no instances of bleeding). The gastrotomy is then closed transversely with a TA55 staple line. The central core of tissues ("doughnuts") are carefully removed from the spent cartridge and inspected to ensure that a complete circle has been obtained (Fig. 12).
Billroth II Gastrectomy (Fig. 13) We almost invariably close the duodenum with TA55 staples. The proximal stomach is closed with a TA90. The EEA is then introduced, and the anastomosis is completed as described above.
Specific Techniques The EEA instrument has proved to be very versatile. We have performed anastomosis of every hollow viscus of the gastrointestinal tract, except the common duct.
FIG. 9. Anvil gently inserted into jejunum. Four Allis forceps aid in positioning bowel over anvil.
Billroth I Gastrectomy (Fig. 14) The proximal stomach is closed with a TA90. A purse-string suture is introduced into the duodenum distal to the line of resection. The gastrotomy is made, and the instrument is inserted without the anvil. The spindle exits through a small stab wound adjacent to the TA90 staple line. The anvil is attached and gently inserted into the duodenum. The purse-string is tied snugly over the anvil, and the instrument is closed to compress the tissue. After driving home the staples, the instrument is removed by turning the wing-nut two
FIG. 11. Instrument is closed. Care is exercised to avoid compressing folds of bowel. Instrument is then fired, opened and dislodged from
anastomosis.
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FIG. 12. Cartridge removed from instrument, and "doughnuts" inspected. Note complete circle of tissue from both limbs of the anastomosis.
full turns, grasping stomach just proximal to the anastomosis and gently rocking the instrument out of the anastomosis. We have not performed this anastomosis in the presence of a large posterior duodenal ulcer.
591
Side-to-Side Gastroduodenostomy (Fig. 15) A Kocher maneuver is performed to mobilize the duodenum. The purse-string instrument is placed transversely across the second portion of the duodenum, taking care to include only the anterolateral wall. After placement of the purse-string, excess tissue is cut to produce a duodenotomy. A gastrotomy is made, the EEA is inserted and the spindle is guided out of the stomach through a small stab wound. The anvil is attached and gently introduced into the duodenum. The purse-string suture is tied down. In narrow quarters, the anvil may have to be angled downstream in the lumen of the bowel to permit snugging of the purse-string tie. As the instrument is closed, care should be exercised to avoid including folded bowel or a portion of pancreas in the anastomosis. The instrument is fired and removed by gentle rocking as previously described. End-to-End Colocolostomy (Fig. 16) Purse-string sutures are placed at the proximal and distal lines of resection. A colotomy is made proximal or distal to the anastomosis. We usually utilize the larger diameter bowel but, in the presence of significant stool, would choose the cleanest side. We have
B.
FIG. 13. Billroth 11
gas-
trectomy. (A) The duodenal stump is closed with a
TA55 staple line. The proximal stomach is closed with the TA90 stapler. (B) The EEA instrument has been inserted through a proximal gastrotomy and is about to be closed. (C) Completed anastomosis. The gastrotomy has been closed with a TA55 staple line.
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FIG. 14. Billroth I gastrectomy. (A) The proximal stomach is stapled with a TA90. The purse-string instrument is employed to put a purse-string suture line in the proximal duodenum. (B) The EEA has been inserted through a proximal gastrotomy; the anvil is attached, and the duodenal pursestring tied. The instrument will now be closed and fired. (C) Completed anastomosis. The gastroduodenotomy may overlap the TA90 staple line.
Ba
C.
utilized the stump of the appendix on two occasions. The instrument is introduced with the anvil attached and is passed down to the proximal purse-string. The instrument is then opened and the anvil allowed to exit
from the proximal bowel. The purse-string of the proximal bowel is tied over the cartridge against the spindle. The anvil is introduced into distal bowel, and the purse-string is snugged down. The instrument is
FIG. 15. Side-to-Side
B.
gas-
troduodenostomy (Jaboulay
pyloroplasty). (A) A transversely oriented purse-string has been placed into the duodenum. The EEA has been inserted through a gastrotomy without the anvil and brought out through a small stab wound in the distal stomach. The anvil is then attached to the spindle, inserted into the duodenotomy, is
tied
and the
down
purse-string
against
the
spindle. The instrument will now be closed and fired. (B) Completed anastomosis and closed gastrotomy.
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ANASTOMOSES WITH THE EEA STAPLER
A
FIG. 16. End-to-End colbcolostomy. (A) The pursestring instrument has been placed across the proximal and distal lines of resection, and the purse-string sutures are inserted. (B) A proximal colotomy has been performed, and the instrument is inserted toward the line of anastomosis. The bowel ends are being tied snugly to spindle of the instrument. The EEA will then be closed and fired. (C) Shows closed colotomy and completed anastomosis.
closed. As the bowel segments come together, care should be taken to align the mesentric borders of the bowel. The instrument is fired, opened slightly and dislodged as previously described. An additional technique for dislodging the instrument is to pass a single suture through the anastomosis and lift the anastomosis over the anvil. We have seldom had to employ this maneuver.
Low Anterior Resection (Fig. 17)
This technique avoids an enterotomy but is difficult a narrow pelvis. In most cases we have accepted the added risk of a proximal enterotomy and performed the anastomosis with the instrument from above. Proximal and distal purse-string sutures are required. In an extremely low anastomosis, the pursestring instrument cannot be accommodated in the pelvis, and the purse-string will have to be made by hand. The EEA instrument is introduced closed through the anus by an assistant. Once the anvil pops out of the distal bowel segment, the instrument is opened, advancing the anvil into the pelvis. The pursestring of the distal bowel segment is tied down to the spindle. The anvil is introduced into the proximal bowel segment, the purse-string is tied and the instrument to perform in
593
a
C
is closed and fired. The instrument is then rocked free by the assistant and removed. End-to-End Ileocolostomy (Fig. 18)
This anastomosis is useful when considerable disin bowel size exists (ileum to colon or obstructed bowel to unobstructed bowel). The proximal (or smaller) bowel is grasped with the purse-string instrument. The distal (or larger) bowel is closed with a TA55 staple line. The instrument is introduced into the larger bowel, and the spindle is guided out through a stab wound adjacent to the staple line. The anvil is attached and gently inserted into the proximal bowel segment. After snugging the purse-strings, the instrument is closed and fired. crepancy
Side-to-Side Ileocolostomy (Fig. 19)
The site of the colon anastomosis is chosen and the purse-string instrument is placed transversely across the bowel wall. The purse-string is introduced, and excess tissue is cut away, leaving a colotomy. An enterotomy is made proximal or distal to the site of the small bowel anastomosis. The instrument without anvil attached is introduced, and the spindle is guided out of the bowel at the anastomosis site. The anvil is
Sure. Ann. .Ll. _ *D- Mav 1979 17-' ....
XT A 'kTf-l
LI NANCE
594
A.
C.
i~ V
D.
I
.
t
FIG. 17. Low anterior resecion. (A) The site for resection is identified. (B) Pursestring sutures have been placed in proximal and distal bowel to be anastomosed. GThedistal purse-string inmaya require hand sewing deep narrow pelvis. (C) The well-lubricated instrument has been inserted through the anus. The purse-string sutures are being tied down.
The instrument will then be closed and fired. (D) Com-
pleted anastomosis.
)B. j Ifi/ \
FIG. 18. End-to-end ileo-
X
/ N\
/ 10/1\ S
C. *
e
\
\
/colostomy. t {i . Useful for anas-
7Ktomosis where considerable exists be\gWsize 1t discrepancy /
tween proximal and distal bowel segments. (A) Distal line of resection closed by TA55 staples. Proximal line clamped with purse-string instrument. (B) Enterotomy has been made in distal bowel segment (the one with the greater diameter). Instrument inserted without anvil. Spindle has been brought out of a small stab wound adjacent to the TA55 staple line. After attaching anvil, the instrument is inserted into ileum, and the is tied down; \\purse-string &\"2 the instrument will be closed \\and fired. (C) Shows com-
pleted anastomosis.
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ANASTOMOSES WITH THE EEA STAPLER
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A. FIG. 19. Side-to-side ileocolostomy. (A) A transversely oriented purse-stfing suture line/enterotomy is placed at the site of the colon anastomosis. (B) The EEA instrument has been inserted through a proximal enterotomy wt'ithout the anvil. The spindle of the EEA is brought out of a small stab wound at the site of the anastomosis. The anvil is attached and inserted into the purse-stringed colotomy, which is tied snugly over the spindle. The instrument is closed and fired. (C) Completed anastomosis.
D.
attached and inserted into the colon. The purse-string is snugged down; the instrument is closed, the tissue is compressed and the staples are driven home. Following removal of the instrument, the enterotomy is closed with a TA55 stapler.
Esophagectomy; Gastroesophagostomy (Fig. 20) Following mobilization of the lesion, the proximal line of resection in the esophagus is cross-clamped with the purse-string instrument, and a purse-string is introduced. The distal line of resection (proximal stomach) is stapled closed with the TA55 or TA90. A gastrotomy is made, and the instrument is introduced into the lumen. The spindle is guided out through a stab wound in the fundus of the stomach. The anvil is attached and introduced into the esophagus. The purse-string is tied, and the instrument is closed and compressed. The staples are driven home, and the instrument is removed. If desired, a Jaboulay pyloroplasty may be performed through the same gastrotomy. The gastrotomy is then closed with a TA55 staple line. Roux-en- Y Cholecystojejunostomy (Fig. 21) The fundus of the gallbladder is clamped with the purse-string instrument, and a purse-string suture is placed. Excess tissue is trimmed away, leaving a chole-
C.
cystostomy. The jejunum is divided distal to the ligament of Treitz, and purse-strings are introduced proximally and distally. The distal limb is mobilized for anastomosis to gallbladder. An enterotomy is made midway between the gallbladder anastomosis and the side-toside Roux-en-Y anastomosis. The EEA instrument is introduced proximally for the cholecystojejunostomy and distally for the side-to-end jejunojejunostomy. Upon completion of the anastomosis, the enterotomy is stapled closed with a TA55 stapler.
Total Gastrectomy; Hunt-Lawrence Pouch (Fig. 22) The stomach is completely mobilized for resection. The duodenum is stapled closed with a TA55 staple line. The proximal esophagus is clamped with the purse-string instrument, and a purse-string is introduced. The jejunum is divided distal to the ligament of Treitz. The proximal jejunal segment is crossclamped with the purse-string instrument, and a pursestring is introduced. The distal segment is closed with a TA55 staple line. A jejunal loop is formed to make a pouch. The pouch is created by aligning the two limbs of the loop at their antimesenteric border. At the midpoint of the loop, paired enterotomy incisions are made, and the GIA instrument is utilized upward and downward to produce side-to-side anastomoses in the
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Ann. Surg. * May 1979
a
X
Vinqx\
1l
\
Esophagectomy;
20.
FIG.
gastroesophagostomy. (A) The proximal stomach is stapled or
across
TA90
with the TA55
instrument.
proximal esophagus
clamped with the string instrument
The
is
purseand
di-
vided distally. (B) The been
has
EEA
inserted,
without the anvil attached,
through a gastrotomy and brought out through a stab wound at the anastomosis site. The anvil is then attached, and the purse-string
is tied down. The instrument
will be closed and fired. (C) Completed anastomosis; the gastrostomy has been closed with a TA55 staple line.
C.
A. FIG. 21. Roux-en-Y chole-
cystojejunostomy. (A) The Roux-en-Y limb has been brought up to the gallbladder and purse-strings inserted into both organs. The EEA
is
instrument
§i\d \ M r I \ AL \ r_
through
a
inserted
distal enterotomy,
and the purse-strings tied over
the spindle. The in-
strument is then closed and (B) The side-to-end
fired.
Roux-en-Y
is
constructed
by passing the instrument distally to the site of anastomosis, passing the spindle out through a stab wound, attaching
the
anvil, tying
the purse-stringed proximal jejunum over the anvil, closing and firing the instrument. (C) Shows completed anastomosis. The enterottransversely staple line.
omy is closed
with
a
TA55
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FIG. 22. Total gastrectomy; Hunt-Lawrence pouch. (A) The duodenum is closed by a TA55 staple line. The distal esophagus is cross-clamped with the purse-string instrument and a purse-string is inserted. The proximal jejunum is cross-clamped with the purse-string instrument, and a purse-string inserted. The distal jejunum is closed by a TA55 staple line. (B and C) The pouch is formed by two GIA side-to-side staple lines. The GIA has been introduced through the same enterotomy. (D) Utilizing the same enterotomy, the EEA is introduced proximally, and an end-to-end anastomosis is performed as in Figure 20. (E) The same enterotomy is utilized to complete the anastomosis as in Figure 21. (F) Shows completed procedure. The enterotomy has been closed by a transverse TA55 staple line.
loop. Utilizing the same enterotomy, the EEA instrument is introduced, and the spindle is guided out of a stab wound at the apex of the jejunal loop. The anvil is attached and introduced into the esophagus, and the anastomosis is completed. A Roux-en-Y sideto-side anastomosis is created in identical fashion, utilizing the same enterotomy for introduction of the EEA. The enterotomy is closed with a transverse TA55 staple line. Hazards and Complications
The EEA instrument has proved versatile and reliable, but there is a definite learning curve associated with its use. It is particularly helpful to employ the instrument in dogs in order to practice the procedures required for its safe use. Time is well spent instructing scrub nurses on the proper handling of the instrument. We have had difficulty with premature firing of the staples, usually caused by incorrect loading of the cartridge by the scrub nurse. Complications have consisted of leaks, an incomplete "doughnut," split bowel, inability to use the
instruments because of insufficient bowel diameter and difficulty dislodging the head from the anastomosis. We have observed two leaks intraoperatively, which were successfully repaired with interrupted Lembert sutures. We have routinely tacked omentum to colon anastomoses, if it was available. One postoperative leak occurred, the result of a serious error in judgment by the author. An attempt was made to complete a gastroesophageal anastomosis well into the mediastinum from the abdomen. An incomplete "doughnut" was obtained. On palpation through the gastrotomy, a defect in the anastomosis could be felt. This was closed with difficulty with interrupted sutures, and the anastomosis subsequently leaked into the right chest. A thoracotomy should have been performed, and the anastomosis should have been redone at the first surgical procedure. Fortunately, the patient survived, and the esophagocutaneous fistula healed. An incomplete "doughnut" should be regarded as a sign of a defective anastomosis. The anastomosis should be resected, unless careful inspection shows it to be intact. Occasionally the "doughnut" of tissue may be torn in removing it from the cartridge.
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In our early experience split bowel occurred several times from over exuberant attempts to utilize the instrument in small diameter bowel. With the present 31-mm cartridge, normal distal ileum and, in some cases, sigmoid colon cannot be anastomosed with the EEA. We have tested the 25-mm and 28-mm cartridge in dogs and are confident these cartridges can be used in ileum and sigmoid colon. We have been able to anastomose obstructed (and therefore dilated) distal ileum in several cases. Templates are now available to aid in selecting the proper size cartridge for anastomosis. Although we have had very little trouble dislodging the anvil from the anastomosis, other surgeons have reported such difficulty. The ridge of tissue created by the anastomosis must be lifted off and over the anvil. We found that grasping the side of the anastomosis at the proximal side of the head of the instrument with a dry sponge and milking away from the instrument while simultaneously rocking the instrument back and forth is effective. We would never tug on the distal bowel segment, since this puts tension on the staple line and may disrupt the anastomosis. In difficult situations a Lembert suture placed across the anastomosis, with outward tugging, aids in dislodging the head, but we have seldom had to employ this technique. It should be emphasized that good results can be expected only if the instrument is used carefully and correctly. Clinical Experience The instrument has been employed in 57 anastomoses performed in 42 patients. In eight additional patients, anastomosis was attempted but abandoned, almost always because of insufficient size of the bowel lumen. (In all instances but one, the anastomosis was completed using other staple techniques.) Three deaths occurred, but in no instance was the death related to the anastomosis. Table 3 lists the number of anastomoses performed with the instrument and illustrates its great versatility. In most instances the EEA stapler replaces the GIA as the instrument of choice for stapled anastomoses. In practiced hands the instrument can create a neat, secure inverted anastomosis which is superior to hand sewing. After practice the stapled anastomoses can be DISCUSSION DR. J. LYNWOOD HERRINGTON, JR. (Nashville, Tennessee): I think it should be emphasized that this technique should be mastered first, preferably, in the experimental laboratory, before we apply it to the clinical setting.
Ann. Surg. * May 1979
TABLE 3. Anastomoses Performed (42 Patients)
Anastomosis
No. Times Performed
Gastroduodenostomy (Jaboulay) Gastrojejunostomy Gastric resection, Bilroth I Gastric resection, Bilroth II Esophagogastrostomy Esophagojejunostomy Cholecystojejunostomy End-to-end colocolostomy End-to-end ileocolostomy Side-to-side ileocolostomy End-to-end small bowel Roux-en-Y jejunojejunostomy
2 6 3 7 2 I 1 17 5 1 5 7
Eight attempts unsuccessful; three deaths.
made faster than by conventional techniques. We have employed the instrument successfully under adverse conditions, such as diffuse peritonitis, and in the presence of acute obstruction. The only significant disadvantages associated with use of the instrument are the following: 1) An enterotomy is required. 2) Significant fecal soiling may occur after introduction into unprepared bowel. 3) The maximum and minimum size limitations are 31 mm and 25 mm. 4) The cost of the instrument and the disposable cartridges is considerable. On balance, we believe that the instrument opens new horizons in surgery and deserves consideration for use by gastrointestinal surgeons. References 1. Guthy, E. and Brendel, W.: Stapling Devices and Their Use in
Surgery. Prog. Surg., 7:56-113, 1969. 2. Ravitch, M. M., Brown, I. V. and Daviglus, G. F.: Experimental and Clinical Use of the Soviet Bronchus Stapling Instruments. Surgery, 46:1, 1959. 3. Ravitch, M. M., Lane, R., Cornell, W. R. et al.: Closure of Duodenal, Gastric, and Intestinal Stumps with Wire Staples: Experimental and Clinical Studies. Ann Surg., 163:573, 1966. 4. Ravitch, M. M. and Steichen, F. M.: Techniques of Staple Suturing in the Gastrointestinal Tract. Ann. Surg., 175:815, 1972. 5. Steichen, F. M.: The Creation of Autologous Substitute Organs with Stapling Instruments. Am. J. Surg., 134:659, 1977. 6. Steichen, F. M. and Ravitch, M. M.: Mechanical Sutures in Surgery. Br. J. Surg., 60:191, 1973.
From having reviewed the manuscript very carefully, I can certainly appreciate the advantages of the EEA instrument over the GIA in performing a low colorectal anastomosis. We have done five such anastomoses during the past several months and in four of these the EEA worked beautifully. In one case we had difficulty introducing the anvil into the proximal (sigmoid) segment as the
A new instrument for accomplishing inverted stapled anastomoses in the gastrointestinal tract is described. Side-to-side, end-to-side and end-to-end anastomoses can be performed. Techniques developed for utilization of the instrument in virtually all gastrointestinal anastomoses are described. In most instances a proximal or distal enterotomy is required. Experience with 57 anastomoses in 42 patients is reported. One leak occurred; no other complications not recognized intraoperatively were observed. Anastomoses completed included gastroduodenostomy, gastrojejunostomy, cholecystojejunostomy, colocolostomy and ileocolostomy. Hazards and complications associated with the use of the instrument are described. It should be used only after the surgeon has acquired the skills to operate the instrument properly. The instrument saves time, creates better anastomoses than can be obtained by hand sewing and is extremely versatile. It may permit safer anastomoses in adverse conditions, such as in obstruction and peritonitis. The instrument opens new horizons in gastrointestinal surgery.
A LTHOUGH STAPLING INSTRUMENTS have enjoyed
26widespread use in the Soviet Union for over two decades,1 their employment in surgical practice in the United States has been slow to evolve. Ravitch first evaluated the Russian instruments in 1959.2,3 After modification of several Russian models, the instruments were marketed by the United States Surgical Corporation. In 1972 before the Southern Surgical Association, Ravitch presented a definitive paper which described various techniques for staple suturing in the gastrointestinal tract.4 Since then, a variety of techniques have been developed, particularly by Ravitch and Steichen, for virtually all phases of gastrointestinal surgery.5'6 All techniques previously described utilize the TA or GIA series of instruments, which produce a straight, double, staggered row of staples in everted tissue. The requirement for everted, straight suture lines has limited the application of these instruments. Recently Presented at the Annual Meeting of the Southern Surgical Association, December 4-6, 1978, Hot Springs, Virginia. Reprint requests: Francis C. Nance, M.D., Department of Surgery, 1542 Tulane Avenue, New Orleans, Louisiana 70112. Submitted for publication: December 7, 1978.
From the Department of Surgery, Louisiana State University Medical Center, New Orleans, Louisiana
the United States Surgical Corporation has introduced a new series of instruments, the EEA Stapler. This instrument, which appears to be a modification of the Russian PKS Stapler, permits the creation of an inverted, circular anastomosis held by a double, staggered row of staples.' Although initially introduced for low rectal anastomoses, the author has developed techniques for utilizing the new instrument in virtually all gastrointestinal anastomoses. These techniques greatly increase the versatility for all stapling instruments and should permit their extensive use by gastrointestinal surgeons. The EEA instrument (Fig. 1) works by first compressing the tissues to be anastomosed. When subsequently "fired" by the surgeon, the instrument simultaneously introduces a circular staggered double row of staples and cuts a circular "doughnut" out of the center of each of the structures to be anastomosed. The disposable cartridge head (Fig. 2), which contains the staples and a circular knife, is compressed against the disposable anvil. The anvil is attached to the spindle of the instrument by a threaded screw. When the bowel to be anastomosed has been properly placed over the cartridge and the anvil, compression is achieved by turning the wing-nut on the handle of the instrument. Correct compression is achieved by aligning vernier controls on the handle. After tissue compression has been achieved, the instrument is fired by squeezing the handles together firmly, which simultaneously drives the staples through the tissue, bends the staples in a "B" shape and cuts a central core of tissue in the lumen. When completed, an inverted circular anastomosis is created with a small internal ridge consisting of the staple line and compressed tissue. Currently only cartridges measuring 31 mm in diameter are available. In January 1979, 25 mm and 28 mm
0003-4932/79/0500/0587 $01.20 © J. B. Lippincott Company
587
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TABLE 1. Technique of End-to-End Anastomosis 1. Place purse-string in proximal and distal bowel; monofilament suture. 2. Judge or measure size of stapler cartridge. 3. Make proximal or distal transverse enterotomy; insert instrument. 4. Open instrument; insert anvil into distal bowel segment. Tie down purse-strings over spindle. 5. Close instrument; fire staples; open instrument two complete turns; dislodge from anastomosis. 6. Remove instrument; check "doughnuts"; inspect anastomosis. 7. Close enterotomy with TA55 stapler.
FIG. 1. The EEA stapler. Note the wing-nut for closing the cartridge against the anvil and for compressing tissues. The instrument is activated by firmly squeezing the handle. Below is an instrument to facilitate introduction of purse-string sutures.
cartridges will be introduced, enabling use of the instrument in bowel with a smaller diameter. Since in most instances at least one limb of any anastomosis requires a purse-string suture (to snug the bowel to the spindle of the instrument), the utilization of the EEA stapler is greatly facilitated by another device, the "purse-string instrument." When this instrument is placed across bowel, a purse-string suture can be rapidly introduced by two passes of a Keith needle through the ends of the jaws of the instrument. We have been using 2-0 nylon atraumatic suture on a Keith needle. General Technique
All anastomoses (except low rectal through the anus) require introduction of the instrument through a proximal or distal enterotomy. In general, we have employed ~~~~~~~~~~~~~~~~~~~~~~~~..
....,
..
the "cleanest" limb or the largest diameter limb for introduction of the instrument. Thus, if stomach is part of the anastomosis, the enterotomy almost always is placed there. If more than one anastomosis is to be made, the enterotomy is located to permit construction of the various anastomoses through the same opening (see Fig. 22). All enterotomy sites are closed transversely with a TA55 staple line. The various steps of an anastomosis are listed in Tables 1 and 2. End-to-end anastomoses require two purse-string suture lines, and the instrument usually is introduced with the anvil attached. Side-to-side and end-to-side anastomoses require one purse-string suture. The instrument is introduced without the anvil. The spindle exits the side of the bowel at the site of the anastomosis, and the anvil is then attached. We illustrate the technique of constructing a side-toside gastrojejunostomy in Figures 3 to 12. An antrectomy has been performed, and the distal stomach is closed with a TA90 4.8 mm staple line. The jejunum is grasped with Allis clamps transversely, and the pursestring instrument is placed across it (Figs. 3 and 4). The 2-0 nylon purse-string suture is introduced with two passes of a Keith needle. The excess tissue is cut away, leaving an enterotomy large enough to accommodate the anvil (Fig. 5). The purse-string instrument is kept on the bowel until the anvil is ready for introduction. A transverse proximal gastrotomy is then made with electrocautery (Fig. 6). The instrument without the anvil attached is introduced. The spindle is then directed toward the site for anastomosis (just adjacent to the stapled closure of the distal stomach). A small stab wound is made. Care should be exercised not to allow this exit wound to enlarge. The spindle TABLE 2. Technique of Side-to-Side Anastomosis
.......
..
....
FIG. 2. Close-up of cartridge and anvil with anvil detached from the spindle. The anvil is attached to the spindle by the threaded screw. In side-to-side anastomoses, the instrument is introduced through the bowel spindle first, without the anvil attached.
1. Place purse-string in distal bowel; monofilament suture. 2. Judge or measure size of head needed. 3. Make proximal enterotomy; insert instrument without anvil; guide out of bowel at anastomosis; attach anvil. 4. Insert anvil into distal bowel; tie down purse-string. 5. Close instrument; fire staples; dislodge from anastomosis. 6. Remove instrument; check "doughnuts"; impact anastomosis. 7. Close enterotomy with TA55 stapler.
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589
FIG. 6. Proximal gastrotomy made with electrocautery.
FIGS. 3 and 4. Jejunum grasped with Allis forceps transversely; pursestring instrument applied.
FIG. 5. Purse-string has been inserted; excess tissue excised producing jejunotomy.
is guided out of the stab wound (Fig. 7), and the anvil is attached (Fig. 8). The purse-string instrument is removed from the jejunum. The enterotomy is grasped circumferentially with four Allis clamps and gently lifted over the anvil (Fig. 9). The Allis clamps are removed, and the purse-string is tied snugly around the spindle of the instrument (Fig. 10). The instrument is ready to be closed by turning the wing-nut. Note that the circular staple line will overlap the TA90 staples previously placed. This side-to-side anastomosis differs in appearance from end-to-end only in that there is one purse-string instead of two. As the instrument is closed, care is taken to smooth out the bowel (Fig. 11) to prevent stapling of folded bowel. The instrument is closed, compression achieved, the safety released
FIG. 7. Spindle of EEA introduced through gastrotomy and guided out of small stab wound adjacent to distal TA90 staple line.
590
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1979
FIG. 8. Anvil is attached to spindle.
FIG. 10. Purse-string snugged down over anvil against the spindle.
and the handle squeezed. The staples are driven home, and the center core of tissue is cut. (This usually is felt as a popping sensation.) The wing-nut is backed off two complete turns and dislodged from the anastomosis by gently pressing the bowel over the cartridge and pulling distally while rocking the instrument back and forth. The anastomosis can be inspected distally and by palpation through the enterotomy if desired. Bleeding seldom occurs (we have had no instances of bleeding). The gastrotomy is then closed transversely with a TA55 staple line. The central core of tissues ("doughnuts") are carefully removed from the spent cartridge and inspected to ensure that a complete circle has been obtained (Fig. 12).
Billroth II Gastrectomy (Fig. 13) We almost invariably close the duodenum with TA55 staples. The proximal stomach is closed with a TA90. The EEA is then introduced, and the anastomosis is completed as described above.
Specific Techniques The EEA instrument has proved to be very versatile. We have performed anastomosis of every hollow viscus of the gastrointestinal tract, except the common duct.
FIG. 9. Anvil gently inserted into jejunum. Four Allis forceps aid in positioning bowel over anvil.
Billroth I Gastrectomy (Fig. 14) The proximal stomach is closed with a TA90. A purse-string suture is introduced into the duodenum distal to the line of resection. The gastrotomy is made, and the instrument is inserted without the anvil. The spindle exits through a small stab wound adjacent to the TA90 staple line. The anvil is attached and gently inserted into the duodenum. The purse-string is tied snugly over the anvil, and the instrument is closed to compress the tissue. After driving home the staples, the instrument is removed by turning the wing-nut two
FIG. 11. Instrument is closed. Care is exercised to avoid compressing folds of bowel. Instrument is then fired, opened and dislodged from
anastomosis.
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ANASTOMOSES WITH THE EEA STAPLER
FIG. 12. Cartridge removed from instrument, and "doughnuts" inspected. Note complete circle of tissue from both limbs of the anastomosis.
full turns, grasping stomach just proximal to the anastomosis and gently rocking the instrument out of the anastomosis. We have not performed this anastomosis in the presence of a large posterior duodenal ulcer.
591
Side-to-Side Gastroduodenostomy (Fig. 15) A Kocher maneuver is performed to mobilize the duodenum. The purse-string instrument is placed transversely across the second portion of the duodenum, taking care to include only the anterolateral wall. After placement of the purse-string, excess tissue is cut to produce a duodenotomy. A gastrotomy is made, the EEA is inserted and the spindle is guided out of the stomach through a small stab wound. The anvil is attached and gently introduced into the duodenum. The purse-string suture is tied down. In narrow quarters, the anvil may have to be angled downstream in the lumen of the bowel to permit snugging of the purse-string tie. As the instrument is closed, care should be exercised to avoid including folded bowel or a portion of pancreas in the anastomosis. The instrument is fired and removed by gentle rocking as previously described. End-to-End Colocolostomy (Fig. 16) Purse-string sutures are placed at the proximal and distal lines of resection. A colotomy is made proximal or distal to the anastomosis. We usually utilize the larger diameter bowel but, in the presence of significant stool, would choose the cleanest side. We have
B.
FIG. 13. Billroth 11
gas-
trectomy. (A) The duodenal stump is closed with a
TA55 staple line. The proximal stomach is closed with the TA90 stapler. (B) The EEA instrument has been inserted through a proximal gastrotomy and is about to be closed. (C) Completed anastomosis. The gastrotomy has been closed with a TA55 staple line.
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Ann. Surg. * May 1979
FIG. 14. Billroth I gastrectomy. (A) The proximal stomach is stapled with a TA90. The purse-string instrument is employed to put a purse-string suture line in the proximal duodenum. (B) The EEA has been inserted through a proximal gastrotomy; the anvil is attached, and the duodenal pursestring tied. The instrument will now be closed and fired. (C) Completed anastomosis. The gastroduodenotomy may overlap the TA90 staple line.
Ba
C.
utilized the stump of the appendix on two occasions. The instrument is introduced with the anvil attached and is passed down to the proximal purse-string. The instrument is then opened and the anvil allowed to exit
from the proximal bowel. The purse-string of the proximal bowel is tied over the cartridge against the spindle. The anvil is introduced into distal bowel, and the purse-string is snugged down. The instrument is
FIG. 15. Side-to-Side
B.
gas-
troduodenostomy (Jaboulay
pyloroplasty). (A) A transversely oriented purse-string has been placed into the duodenum. The EEA has been inserted through a gastrotomy without the anvil and brought out through a small stab wound in the distal stomach. The anvil is then attached to the spindle, inserted into the duodenotomy, is
tied
and the
down
purse-string
against
the
spindle. The instrument will now be closed and fired. (B) Completed anastomosis and closed gastrotomy.
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ANASTOMOSES WITH THE EEA STAPLER
A
FIG. 16. End-to-End colbcolostomy. (A) The pursestring instrument has been placed across the proximal and distal lines of resection, and the purse-string sutures are inserted. (B) A proximal colotomy has been performed, and the instrument is inserted toward the line of anastomosis. The bowel ends are being tied snugly to spindle of the instrument. The EEA will then be closed and fired. (C) Shows closed colotomy and completed anastomosis.
closed. As the bowel segments come together, care should be taken to align the mesentric borders of the bowel. The instrument is fired, opened slightly and dislodged as previously described. An additional technique for dislodging the instrument is to pass a single suture through the anastomosis and lift the anastomosis over the anvil. We have seldom had to employ this maneuver.
Low Anterior Resection (Fig. 17)
This technique avoids an enterotomy but is difficult a narrow pelvis. In most cases we have accepted the added risk of a proximal enterotomy and performed the anastomosis with the instrument from above. Proximal and distal purse-string sutures are required. In an extremely low anastomosis, the pursestring instrument cannot be accommodated in the pelvis, and the purse-string will have to be made by hand. The EEA instrument is introduced closed through the anus by an assistant. Once the anvil pops out of the distal bowel segment, the instrument is opened, advancing the anvil into the pelvis. The pursestring of the distal bowel segment is tied down to the spindle. The anvil is introduced into the proximal bowel segment, the purse-string is tied and the instrument to perform in
593
a
C
is closed and fired. The instrument is then rocked free by the assistant and removed. End-to-End Ileocolostomy (Fig. 18)
This anastomosis is useful when considerable disin bowel size exists (ileum to colon or obstructed bowel to unobstructed bowel). The proximal (or smaller) bowel is grasped with the purse-string instrument. The distal (or larger) bowel is closed with a TA55 staple line. The instrument is introduced into the larger bowel, and the spindle is guided out through a stab wound adjacent to the staple line. The anvil is attached and gently inserted into the proximal bowel segment. After snugging the purse-strings, the instrument is closed and fired. crepancy
Side-to-Side Ileocolostomy (Fig. 19)
The site of the colon anastomosis is chosen and the purse-string instrument is placed transversely across the bowel wall. The purse-string is introduced, and excess tissue is cut away, leaving a colotomy. An enterotomy is made proximal or distal to the site of the small bowel anastomosis. The instrument without anvil attached is introduced, and the spindle is guided out of the bowel at the anastomosis site. The anvil is
Sure. Ann. .Ll. _ *D- Mav 1979 17-' ....
XT A 'kTf-l
LI NANCE
594
A.
C.
i~ V
D.
I
.
t
FIG. 17. Low anterior resecion. (A) The site for resection is identified. (B) Pursestring sutures have been placed in proximal and distal bowel to be anastomosed. GThedistal purse-string inmaya require hand sewing deep narrow pelvis. (C) The well-lubricated instrument has been inserted through the anus. The purse-string sutures are being tied down.
The instrument will then be closed and fired. (D) Com-
pleted anastomosis.
)B. j Ifi/ \
FIG. 18. End-to-end ileo-
X
/ N\
/ 10/1\ S
C. *
e
\
\
/colostomy. t {i . Useful for anas-
7Ktomosis where considerable exists be\gWsize 1t discrepancy /
tween proximal and distal bowel segments. (A) Distal line of resection closed by TA55 staples. Proximal line clamped with purse-string instrument. (B) Enterotomy has been made in distal bowel segment (the one with the greater diameter). Instrument inserted without anvil. Spindle has been brought out of a small stab wound adjacent to the TA55 staple line. After attaching anvil, the instrument is inserted into ileum, and the is tied down; \\purse-string &\"2 the instrument will be closed \\and fired. (C) Shows com-
pleted anastomosis.
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.
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ANASTOMOSES WITH THE EEA STAPLER
595
A. FIG. 19. Side-to-side ileocolostomy. (A) A transversely oriented purse-stfing suture line/enterotomy is placed at the site of the colon anastomosis. (B) The EEA instrument has been inserted through a proximal enterotomy wt'ithout the anvil. The spindle of the EEA is brought out of a small stab wound at the site of the anastomosis. The anvil is attached and inserted into the purse-stringed colotomy, which is tied snugly over the spindle. The instrument is closed and fired. (C) Completed anastomosis.
D.
attached and inserted into the colon. The purse-string is snugged down; the instrument is closed, the tissue is compressed and the staples are driven home. Following removal of the instrument, the enterotomy is closed with a TA55 stapler.
Esophagectomy; Gastroesophagostomy (Fig. 20) Following mobilization of the lesion, the proximal line of resection in the esophagus is cross-clamped with the purse-string instrument, and a purse-string is introduced. The distal line of resection (proximal stomach) is stapled closed with the TA55 or TA90. A gastrotomy is made, and the instrument is introduced into the lumen. The spindle is guided out through a stab wound in the fundus of the stomach. The anvil is attached and introduced into the esophagus. The purse-string is tied, and the instrument is closed and compressed. The staples are driven home, and the instrument is removed. If desired, a Jaboulay pyloroplasty may be performed through the same gastrotomy. The gastrotomy is then closed with a TA55 staple line. Roux-en- Y Cholecystojejunostomy (Fig. 21) The fundus of the gallbladder is clamped with the purse-string instrument, and a purse-string suture is placed. Excess tissue is trimmed away, leaving a chole-
C.
cystostomy. The jejunum is divided distal to the ligament of Treitz, and purse-strings are introduced proximally and distally. The distal limb is mobilized for anastomosis to gallbladder. An enterotomy is made midway between the gallbladder anastomosis and the side-toside Roux-en-Y anastomosis. The EEA instrument is introduced proximally for the cholecystojejunostomy and distally for the side-to-end jejunojejunostomy. Upon completion of the anastomosis, the enterotomy is stapled closed with a TA55 stapler.
Total Gastrectomy; Hunt-Lawrence Pouch (Fig. 22) The stomach is completely mobilized for resection. The duodenum is stapled closed with a TA55 staple line. The proximal esophagus is clamped with the purse-string instrument, and a purse-string is introduced. The jejunum is divided distal to the ligament of Treitz. The proximal jejunal segment is crossclamped with the purse-string instrument, and a pursestring is introduced. The distal segment is closed with a TA55 staple line. A jejunal loop is formed to make a pouch. The pouch is created by aligning the two limbs of the loop at their antimesenteric border. At the midpoint of the loop, paired enterotomy incisions are made, and the GIA instrument is utilized upward and downward to produce side-to-side anastomoses in the
596
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Ann. Surg. * May 1979
a
X
Vinqx\
1l
\
Esophagectomy;
20.
FIG.
gastroesophagostomy. (A) The proximal stomach is stapled or
across
TA90
with the TA55
instrument.
proximal esophagus
clamped with the string instrument
The
is
purseand
di-
vided distally. (B) The been
has
EEA
inserted,
without the anvil attached,
through a gastrotomy and brought out through a stab wound at the anastomosis site. The anvil is then attached, and the purse-string
is tied down. The instrument
will be closed and fired. (C) Completed anastomosis; the gastrostomy has been closed with a TA55 staple line.
C.
A. FIG. 21. Roux-en-Y chole-
cystojejunostomy. (A) The Roux-en-Y limb has been brought up to the gallbladder and purse-strings inserted into both organs. The EEA
is
instrument
§i\d \ M r I \ AL \ r_
through
a
inserted
distal enterotomy,
and the purse-strings tied over
the spindle. The in-
strument is then closed and (B) The side-to-end
fired.
Roux-en-Y
is
constructed
by passing the instrument distally to the site of anastomosis, passing the spindle out through a stab wound, attaching
the
anvil, tying
the purse-stringed proximal jejunum over the anvil, closing and firing the instrument. (C) Shows completed anastomosis. The enterottransversely staple line.
omy is closed
with
a
TA55
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ANASTOMOSES WITH THE EEA STAPLER
597
FIG. 22. Total gastrectomy; Hunt-Lawrence pouch. (A) The duodenum is closed by a TA55 staple line. The distal esophagus is cross-clamped with the purse-string instrument and a purse-string is inserted. The proximal jejunum is cross-clamped with the purse-string instrument, and a purse-string inserted. The distal jejunum is closed by a TA55 staple line. (B and C) The pouch is formed by two GIA side-to-side staple lines. The GIA has been introduced through the same enterotomy. (D) Utilizing the same enterotomy, the EEA is introduced proximally, and an end-to-end anastomosis is performed as in Figure 20. (E) The same enterotomy is utilized to complete the anastomosis as in Figure 21. (F) Shows completed procedure. The enterotomy has been closed by a transverse TA55 staple line.
loop. Utilizing the same enterotomy, the EEA instrument is introduced, and the spindle is guided out of a stab wound at the apex of the jejunal loop. The anvil is attached and introduced into the esophagus, and the anastomosis is completed. A Roux-en-Y sideto-side anastomosis is created in identical fashion, utilizing the same enterotomy for introduction of the EEA. The enterotomy is closed with a transverse TA55 staple line. Hazards and Complications
The EEA instrument has proved versatile and reliable, but there is a definite learning curve associated with its use. It is particularly helpful to employ the instrument in dogs in order to practice the procedures required for its safe use. Time is well spent instructing scrub nurses on the proper handling of the instrument. We have had difficulty with premature firing of the staples, usually caused by incorrect loading of the cartridge by the scrub nurse. Complications have consisted of leaks, an incomplete "doughnut," split bowel, inability to use the
instruments because of insufficient bowel diameter and difficulty dislodging the head from the anastomosis. We have observed two leaks intraoperatively, which were successfully repaired with interrupted Lembert sutures. We have routinely tacked omentum to colon anastomoses, if it was available. One postoperative leak occurred, the result of a serious error in judgment by the author. An attempt was made to complete a gastroesophageal anastomosis well into the mediastinum from the abdomen. An incomplete "doughnut" was obtained. On palpation through the gastrotomy, a defect in the anastomosis could be felt. This was closed with difficulty with interrupted sutures, and the anastomosis subsequently leaked into the right chest. A thoracotomy should have been performed, and the anastomosis should have been redone at the first surgical procedure. Fortunately, the patient survived, and the esophagocutaneous fistula healed. An incomplete "doughnut" should be regarded as a sign of a defective anastomosis. The anastomosis should be resected, unless careful inspection shows it to be intact. Occasionally the "doughnut" of tissue may be torn in removing it from the cartridge.
598
NANCE
In our early experience split bowel occurred several times from over exuberant attempts to utilize the instrument in small diameter bowel. With the present 31-mm cartridge, normal distal ileum and, in some cases, sigmoid colon cannot be anastomosed with the EEA. We have tested the 25-mm and 28-mm cartridge in dogs and are confident these cartridges can be used in ileum and sigmoid colon. We have been able to anastomose obstructed (and therefore dilated) distal ileum in several cases. Templates are now available to aid in selecting the proper size cartridge for anastomosis. Although we have had very little trouble dislodging the anvil from the anastomosis, other surgeons have reported such difficulty. The ridge of tissue created by the anastomosis must be lifted off and over the anvil. We found that grasping the side of the anastomosis at the proximal side of the head of the instrument with a dry sponge and milking away from the instrument while simultaneously rocking the instrument back and forth is effective. We would never tug on the distal bowel segment, since this puts tension on the staple line and may disrupt the anastomosis. In difficult situations a Lembert suture placed across the anastomosis, with outward tugging, aids in dislodging the head, but we have seldom had to employ this technique. It should be emphasized that good results can be expected only if the instrument is used carefully and correctly. Clinical Experience The instrument has been employed in 57 anastomoses performed in 42 patients. In eight additional patients, anastomosis was attempted but abandoned, almost always because of insufficient size of the bowel lumen. (In all instances but one, the anastomosis was completed using other staple techniques.) Three deaths occurred, but in no instance was the death related to the anastomosis. Table 3 lists the number of anastomoses performed with the instrument and illustrates its great versatility. In most instances the EEA stapler replaces the GIA as the instrument of choice for stapled anastomoses. In practiced hands the instrument can create a neat, secure inverted anastomosis which is superior to hand sewing. After practice the stapled anastomoses can be DISCUSSION DR. J. LYNWOOD HERRINGTON, JR. (Nashville, Tennessee): I think it should be emphasized that this technique should be mastered first, preferably, in the experimental laboratory, before we apply it to the clinical setting.
Ann. Surg. * May 1979
TABLE 3. Anastomoses Performed (42 Patients)
Anastomosis
No. Times Performed
Gastroduodenostomy (Jaboulay) Gastrojejunostomy Gastric resection, Bilroth I Gastric resection, Bilroth II Esophagogastrostomy Esophagojejunostomy Cholecystojejunostomy End-to-end colocolostomy End-to-end ileocolostomy Side-to-side ileocolostomy End-to-end small bowel Roux-en-Y jejunojejunostomy
2 6 3 7 2 I 1 17 5 1 5 7
Eight attempts unsuccessful; three deaths.
made faster than by conventional techniques. We have employed the instrument successfully under adverse conditions, such as diffuse peritonitis, and in the presence of acute obstruction. The only significant disadvantages associated with use of the instrument are the following: 1) An enterotomy is required. 2) Significant fecal soiling may occur after introduction into unprepared bowel. 3) The maximum and minimum size limitations are 31 mm and 25 mm. 4) The cost of the instrument and the disposable cartridges is considerable. On balance, we believe that the instrument opens new horizons in surgery and deserves consideration for use by gastrointestinal surgeons. References 1. Guthy, E. and Brendel, W.: Stapling Devices and Their Use in
Surgery. Prog. Surg., 7:56-113, 1969. 2. Ravitch, M. M., Brown, I. V. and Daviglus, G. F.: Experimental and Clinical Use of the Soviet Bronchus Stapling Instruments. Surgery, 46:1, 1959. 3. Ravitch, M. M., Lane, R., Cornell, W. R. et al.: Closure of Duodenal, Gastric, and Intestinal Stumps with Wire Staples: Experimental and Clinical Studies. Ann Surg., 163:573, 1966. 4. Ravitch, M. M. and Steichen, F. M.: Techniques of Staple Suturing in the Gastrointestinal Tract. Ann. Surg., 175:815, 1972. 5. Steichen, F. M.: The Creation of Autologous Substitute Organs with Stapling Instruments. Am. J. Surg., 134:659, 1977. 6. Steichen, F. M. and Ravitch, M. M.: Mechanical Sutures in Surgery. Br. J. Surg., 60:191, 1973.
From having reviewed the manuscript very carefully, I can certainly appreciate the advantages of the EEA instrument over the GIA in performing a low colorectal anastomosis. We have done five such anastomoses during the past several months and in four of these the EEA worked beautifully. In one case we had difficulty introducing the anvil into the proximal (sigmoid) segment as the
