All that portion of bowel which has been condemned having been removed and a careful toilet of the parts having been made the surgeon next proceeds to restore the bowel lumen. A V-shaped defect in the mesentery should be united with sutures. The line of former mesenteric border left after removal of bowel should be not only carefully protected with ligatures, but the whole margin should be overcast and so folded in or drawn together in tucks as to make it easy to bring the bowel ends together without undue stress.
Fig. 577
Fig. 578
Circular anastomosis of portions of the bowel having different lumina. (Bergmann.)
The sutures by which the divided bowel is restored should begin at the mesenteric border, and every care should be taken to make the joint at this point absolutely water-tight. Suture methods have been described. To unite bowel ends of the same diameter it is an easy matter to suture together first the mucosa and then the outer layer, so long as the intestine is on the outside of the body and equally accessible on all sides ([Fig. 578]). The surgeon is sometimes compelled to do this work within the body cavity, as in resection of the rectum for cancer. It may be advisable to first place a row of sutures between the serosa and muscularis on the further side of the margins to be united, then to close the mucosa completely around, and then to finish the outer layer of sutures. So long as differences of size are not conspicuous, end-to-end approximation can be made almost anywhere. When, however, it is necessary to attach small bowel to large, the size of the larger opening should be reduced to fit the smaller, or one or both ends may be closed, turning in the stump, as already described, and then making lateral or end-to-side anastomosis. Any such anastomotic opening should be so placed, and bowel so directed, that there shall be no interference in the direction of the natural bowel stream, failure to observe this precaution producing not only added immediate danger but more or less permanent obstruction ([Figs. 579] and [580]).
Fig. 579
Isoperistaltic lateral apposition.