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Use of Auto Suture for Construction of Ileal Conduits
Vol. 109, May Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1973 by The Williams & Wilkins Co.
USE OF AUTO SUTURE FOR CONSTRUCTION OF ILEAL CONDUITS DOUGLAS E. JOHNSON AND DONALD E. FUERST
From the Department of Surgery, Section of Urology, University of Texas at Houston, M. D. Anderson Hospital and Tumor Institute, Houston, Texas
In the 22 years since Bricker described the use of the ilea! requmng su1 numerous modificahave been suggested in hopes of the operative time. 2 - 5 Although auto suture instruments have been shown to greatly facilitate enteroanastomosis, urologists have been slow to include stapling devices and techniques in their surgical armamentarium. 7 • 8 Therefore, we are reporting on our experience with these instruments, since we believe that they offer many more advantages than the currently used approaches in constructing ilea! conduits. MATERIALS AND METHODS
An auto suture technique was used in constructing ilea! conduits in 24 consecutive patients undergoing ureteroileocutaneous urinary diversion as part of their management for malignant disease of the bladder or prostate. This series consisted of 19 men and 5 women ranging in age from 14 to 75 years, with a median age of 65 years. The procedure was performed in association with total cystectomy in 20 patients. In 10 patients, 5,000 to 7,000 rads tumor dose of cobalt 60 had been delivered 6 weeks to 6 months prior to the surgical treatment. INSTRUMENTS
The stapling devices used were originally developed by the Scientific Research Institute for Experimental Surgical Apparatus and Instruments in Moscow, and later perfected in this Accepted for publication October 13, 1972. 1 Bricker, E. M.: Symposium on clinical surgery: bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 2 Wallace, D. M.: Ureteric diversion using a conduit: a simplified technique. Brit. J. Urol., 38: 522, 1966. 3 Barzilay, B. I. and Goodwin, W. E.: Clinical application of an experimental study of uretero-ileal anastomosis. J. Urol., 99: 35, 1968. 4 Wendel, R. G., Henning, D. C. and Evans, A. T.: End-to-end ureteroileal anastomosis for iliac conduits: preliminary report. J. Urol., 102: 42, 1969. 5 Draper, J. vV., Fernandes, M., Lavengood, R. W., Jr., Talarico, R. D., Ward, J. N. and Ray, P.: Ureteroileal conduit: modifications of the surgical technique. J. Urol., HJ6: 664, 1971. 6 Knoblaugh, R. A. and Evans, A. T.: Simplified bowel anastomosis: a method of shortening ilea] diversion time. J. Urol., Hl5: 516, 1971. 7 Ravitch, M. M. and A.: Enteroanastomosis with an automatic instrument. 59: 270, 1966. 'Steichen, F. M .. The use of in anatomical side-to-side anC functional 2nteroanastornoses. Surg:ery, 64~ 948, 1968.
FIG. 1. Auto suture instruments. A, TA-30. B, TA-55. C, GIA.
country by the United States Surgical Corporation. The auto suture instruments used are designated as TA-30, TA-55 and GIA (fig. 1). These numbers refer to the length in millimeters of the staggered double rows of staples inserted. The small stainless steel staples are supplied in sterile, disposable cartridges. TECHNIQUE
Aner the ilea! segment is identified and the incisions in the mesentery are completed, the auto suture TA-30 instrument is applied to the proximal end of the segment. The jaws of the instrument are approximated by turning the thumbscrew clockwise to a point at which the black line on the movable arm is opposite a similar line on the handle. Once the safety catch is released, firm pressure on the handles results in the insertion of a double row of staggered staples. A non-crushing clamp is applied and the bowel is transected between the 2). The TA-30 instrument is .removed and the distal end of the segment is divided bet·.veen 821
822
JOHNSON AND FUERST
The steps necessary for re-establishing bowel continuity have been described by Steichen and are shown in figure 3. 8 With the use of traction sutures to aid in maintaining proper alignment, the limbs of the GIA stapler are introduced into the open lumen of each bowel segment. Both
limbs are inserted an equal distance into their corresponding loops and then locked in place opposite the mesenteric border. The staple device and knife are pushed forward, creating a doublebarrel, side-to-side anastomosis by inserting 2 double rows of staggered staples as well as cutting between them. The driver is removed first; this is followed by unlocking the limbs and removing the instrument. A mucosa-to-mucosa closure of the double-barrel stump is achieved by the use of the TA-55 instrument (its application and use are identical to that of the TA-30). Excess bowel tissue is resected flush with the stapler. Although an anatomical side-to-side anastomosis is created, a functional end-to-end anastomosis is achieved. Early in the series a reinforcing row of interrupted 2-zero silk sutures were placed on the proximal end of the conduit and over the closure of the double-barrel stump. However, in more recent cases we have eliminated this step without complications. RESULTS
FIG. 2. Demonstrates closure of proximal end of ilea! conduit with TA-55 instrument.
There were no postoperative deaths and no case of intestinal obstruction. The only postoperative complication directly related to the auto suture technique was the development of a small enteroanastomotic leak in 1 patient who underwent operation early in the series. After local drainage had been instituted the fistula healed spontaneously within a week. It appears that operative time was shortened and postoperative paralytic ileus resolved sooner; however, statistical eviB
C
D
FIG. 3. Technique for side-to-side enteroanastomosis. A, limbs of GIA are introduced, one into each lumen. B, formation of double-barrel, side-to-side anastomosis. C, closure of double-barrel stump with TA-55 instrument. D, appearance of enteroanastomosis after closure of mesentery.
AUTO SUTURE FOR CONSTRUCTION OF !LEAL CONDUITS
dence is lacking because of the multiple factors associated with each case. CONCLUSION
The use of auto suture in constructing an ileal conduit offers distinct advantages. It is a simple,
823
efficient and safe procedure which not only minimizes bowel handling and tissue trauma but also assures a watertight ileal anastomosis and a patent enteroanastomosis. The technique warrants wider application.
THE JOURNAL OF UROLOGY
Copyright © 1973 by The Williams & Wilkins Co.
USE OF AUTO SUTURE FOR CONSTRUCTION OF ILEAL CONDUITS DOUGLAS E. JOHNSON AND DONALD E. FUERST
From the Department of Surgery, Section of Urology, University of Texas at Houston, M. D. Anderson Hospital and Tumor Institute, Houston, Texas
In the 22 years since Bricker described the use of the ilea! requmng su1 numerous modificahave been suggested in hopes of the operative time. 2 - 5 Although auto suture instruments have been shown to greatly facilitate enteroanastomosis, urologists have been slow to include stapling devices and techniques in their surgical armamentarium. 7 • 8 Therefore, we are reporting on our experience with these instruments, since we believe that they offer many more advantages than the currently used approaches in constructing ilea! conduits. MATERIALS AND METHODS
An auto suture technique was used in constructing ilea! conduits in 24 consecutive patients undergoing ureteroileocutaneous urinary diversion as part of their management for malignant disease of the bladder or prostate. This series consisted of 19 men and 5 women ranging in age from 14 to 75 years, with a median age of 65 years. The procedure was performed in association with total cystectomy in 20 patients. In 10 patients, 5,000 to 7,000 rads tumor dose of cobalt 60 had been delivered 6 weeks to 6 months prior to the surgical treatment. INSTRUMENTS
The stapling devices used were originally developed by the Scientific Research Institute for Experimental Surgical Apparatus and Instruments in Moscow, and later perfected in this Accepted for publication October 13, 1972. 1 Bricker, E. M.: Symposium on clinical surgery: bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 2 Wallace, D. M.: Ureteric diversion using a conduit: a simplified technique. Brit. J. Urol., 38: 522, 1966. 3 Barzilay, B. I. and Goodwin, W. E.: Clinical application of an experimental study of uretero-ileal anastomosis. J. Urol., 99: 35, 1968. 4 Wendel, R. G., Henning, D. C. and Evans, A. T.: End-to-end ureteroileal anastomosis for iliac conduits: preliminary report. J. Urol., 102: 42, 1969. 5 Draper, J. vV., Fernandes, M., Lavengood, R. W., Jr., Talarico, R. D., Ward, J. N. and Ray, P.: Ureteroileal conduit: modifications of the surgical technique. J. Urol., HJ6: 664, 1971. 6 Knoblaugh, R. A. and Evans, A. T.: Simplified bowel anastomosis: a method of shortening ilea] diversion time. J. Urol., Hl5: 516, 1971. 7 Ravitch, M. M. and A.: Enteroanastomosis with an automatic instrument. 59: 270, 1966. 'Steichen, F. M .. The use of in anatomical side-to-side anC functional 2nteroanastornoses. Surg:ery, 64~ 948, 1968.
FIG. 1. Auto suture instruments. A, TA-30. B, TA-55. C, GIA.
country by the United States Surgical Corporation. The auto suture instruments used are designated as TA-30, TA-55 and GIA (fig. 1). These numbers refer to the length in millimeters of the staggered double rows of staples inserted. The small stainless steel staples are supplied in sterile, disposable cartridges. TECHNIQUE
Aner the ilea! segment is identified and the incisions in the mesentery are completed, the auto suture TA-30 instrument is applied to the proximal end of the segment. The jaws of the instrument are approximated by turning the thumbscrew clockwise to a point at which the black line on the movable arm is opposite a similar line on the handle. Once the safety catch is released, firm pressure on the handles results in the insertion of a double row of staggered staples. A non-crushing clamp is applied and the bowel is transected between the 2). The TA-30 instrument is .removed and the distal end of the segment is divided bet·.veen 821
822
JOHNSON AND FUERST
The steps necessary for re-establishing bowel continuity have been described by Steichen and are shown in figure 3. 8 With the use of traction sutures to aid in maintaining proper alignment, the limbs of the GIA stapler are introduced into the open lumen of each bowel segment. Both
limbs are inserted an equal distance into their corresponding loops and then locked in place opposite the mesenteric border. The staple device and knife are pushed forward, creating a doublebarrel, side-to-side anastomosis by inserting 2 double rows of staggered staples as well as cutting between them. The driver is removed first; this is followed by unlocking the limbs and removing the instrument. A mucosa-to-mucosa closure of the double-barrel stump is achieved by the use of the TA-55 instrument (its application and use are identical to that of the TA-30). Excess bowel tissue is resected flush with the stapler. Although an anatomical side-to-side anastomosis is created, a functional end-to-end anastomosis is achieved. Early in the series a reinforcing row of interrupted 2-zero silk sutures were placed on the proximal end of the conduit and over the closure of the double-barrel stump. However, in more recent cases we have eliminated this step without complications. RESULTS
FIG. 2. Demonstrates closure of proximal end of ilea! conduit with TA-55 instrument.
There were no postoperative deaths and no case of intestinal obstruction. The only postoperative complication directly related to the auto suture technique was the development of a small enteroanastomotic leak in 1 patient who underwent operation early in the series. After local drainage had been instituted the fistula healed spontaneously within a week. It appears that operative time was shortened and postoperative paralytic ileus resolved sooner; however, statistical eviB
C
D
FIG. 3. Technique for side-to-side enteroanastomosis. A, limbs of GIA are introduced, one into each lumen. B, formation of double-barrel, side-to-side anastomosis. C, closure of double-barrel stump with TA-55 instrument. D, appearance of enteroanastomosis after closure of mesentery.
AUTO SUTURE FOR CONSTRUCTION OF !LEAL CONDUITS
dence is lacking because of the multiple factors associated with each case. CONCLUSION
The use of auto suture in constructing an ileal conduit offers distinct advantages. It is a simple,
823
efficient and safe procedure which not only minimizes bowel handling and tissue trauma but also assures a watertight ileal anastomosis and a patent enteroanastomosis. The technique warrants wider application.