Key principles
• To restore intestinal continuity
Specific preoperative preparation
• Ensure no distal obstruction – if for rectal anastomosis – preoperative gastrogaffin enema and flexible sigmoidoscopy • If concern about continence consider preoperative anal manometry prior to reversal • No bowel preparation
Operation Details
• Position patient supine after induction of general anaesthesia • IV antibiotics on induction • Remove stoma appliance and prep and drape with non-alcoholic betadine • Infiltrate with LA for hydro-dissection • Circumferential peri-stomal incision including 1-2mm skin • Sharp dissection to separate subcutaneous tissue from bowel • Once reach fascial level safely enter peritoneal cavity at one point and then continue to free ileum from fascia circumferentially using Metzenbaum scissors • Ensure adequate bowel mobilised to be able to form anastomosis – 8cm each limb • Revert spout and excised skin leaving fresh clean ends for anastomosis • My preference is for a side to side stapled anastomosis with the GIA 80mm stapler blue reload o I place the ends of the stapler down each limb, clamp, ensure no other structures/ mesentery is trapped & after 30 seconds as recommended by the manufacturer I fire the stapler o I carefully inspect the new lumen for haemostasis, I offset the two staple lines with Babcock retractors o I then get the stapler cleaned & re-loaded & fire across the remaining defect at the apex of my anastomosis o I would place 2 x 3/0 PDS crutch sutures at trouser leg and oversew the transverse staple line with continuous 3/0 PDS for haemostasis • I would return the bowel back to the abdominal cavity once satisfied with haemostasis • I would then close any mesenteric defect with 3/0 vicryl • Close the fascia with 1 PDS figure of 8 sutures and close skin with a purse-string suture
Intraoperative complications & challenges
• Unable to adequately mobilise the stoma o Attempt adhesionolysis carefully, if unable convert to laparotomy to perform formal adhesionolysis and safely complete mobilisation under direct vision • Associated parastomal hernia o Carefully dissect out hernia and reduce contents o Excise the sac o Close with fascia with 1 PDS
Post-operative complications
• Immediate o Conversion to laparotomy o Bleeding • Early o Infection o Anastomotic leak • Late o Stricture o Hernia
Specific post-operative care
• Light diet • Mobilise