Background
The experience of bowel surgery until the
latter part of the nineteenth century was limited to dealing with protruding
intestine following abdominal injury usually sustained during wars. If a
laceration of the bowel was encountered attempts were made to repair it using
the jaws of ants (described by Sushruta and Albucasis) or by suturing (Celsus).
Probably the first surgeon to describe a suture made from animal gut was
Albucasis. In Salerno, Italy, between the twelfth and thirteenth centuries, it
was advised that if a piece of bowel had to be repaired it should be done over a
stent of elder wood or animal trachea. Alternatives for dealing with injured
intestine were to suture it to the abdominal wall to create a fistula or do
nothing and let nature take its course. The latter management was frequently
considered safer.
For
centuries, no attempt was made to define the process of healing of the
gastrointestinal tract. However, in 1812, Travers reported that intestinal
wounds healed as a result of ‘adhesive inflammation’ binding down the
peritoneal (‘serosal’) coat. Fourteen years later Lembert described a
suturing technique in which serosa apposition was obtained.
As
a consequence of the adoption of the Listerian. principles of wound care and
antiseptic surgery (Chapter 1) (together with general anaesthesia) surgeons in
the second half of the nineteenth century began to perform laparotomies with the
express purpose of resecting a piece of intestine and subsequently restoring
continuity. Gastrointestinal surgery expanded rapidly and with it various
methods of suturing the bowel together. All were modifications of Lembert’s
basic principles and were reviewed by Senn in 1893. A year earlier Murphy
introduced his button but an adverse report appeared in the surgical literature
citing colocolic anastomotic stricture which resulted in the patient’s death.
In
1893, Senn advised two-layer interrupted anastomoses. His suture was of fine
aseptic silk applied with ordinary sewing needles. Halsted favoured a one-layer
anastomosis without penetration of the lumen. In contrast, Connell in 1903
strongly recommended a single layer of interrupted sutures which passed through
all coats of the bowel and with the knots ligated intraluminally. Kocher also
suggested an all-coats suture technique in two layers using catgut and silk. In
1907 Kerr and Parker used a temporary suture to close the bowel whilst the
permanent sutures were inserted; once the anastomosis was completed these
preliminary sutures were removed. Shoemaker and Remkin (1928) performed
end-to-end anastomoses over narrow crushing clamps.
In
1922 Halsted described a closed colorectal technique in which the bowel was
crushed, ligated and divided at the resection margins. Next submucosal buttress
sutures joined the two ends of the bowel and finally an instrument with a knife
blade was passed per rectum through the anastomotic diaphragm to divide the two
Sutures which had closed the lumen: the forerunner of our contemporary stapling
devices. Stapling techniques have been ‘reinvented’ recently.
The
closed method of anastomosis has been replaced by the open method for four major
reasons (Table 49.1):
•
the introduction of antibiotics;
•
improved preoperative bowel cleaning;
•
the use of atraumatic sutures;
•
better on-table control of suture-line bleeding.
Alexis
Carrel was a recognised revolutionist in vascular surgery. In 1902 he described
a suture technique that he had developed that created a perfect end-to-end
anastomosis of blood vessels. His method employed three retaining sutures which,
when drawn taut, pulled the edges into an equilateral triangle which could then
be easily sutured. This technique preserved the full patency of the lumen, and
gave a smooth interior surface to reduce platelet and fibrin deposition.