Gastrointestinal Surgical Techniques in Small Animals. Группа авторов
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the lumen on the deep side of the anastomosis. The sutures are generally preplaced and tied such that the knots are within the lumen of the tubular organ. This results in cut edges that are sealed and inverted within the lumen. No knots are exposed on the serosal surface. The remaining anastomosis on the exposed near side is closed with an appositional suture pattern.
3.5 Inverting Suture Patterns
3.5.1 Halsted
This is an interrupted inverting suture pattern that is occasionally chosen by some surgeons when trying to purchase friable tissue edges in hollow organ incisions (Figure 3.2). The needle is passed into the hollow organ wall perpendicular and about 5 mm from the edge, through the serosa, muscularis, and submucosa and exits 2 mm from the edge on the same side. Across the incision, the needle is passed through the serosa perpendicular and about 2 mm from the edge into the serosa, muscularis, and submucosa before exiting 5 mm from the cut edge. Next the needle is reversed and identical bites are taken in the opposite direction about 5 mm from the first bite sequence. The free suture ends are tied to complete the stitch.
3.5.2 Cushing and Connell
These continuous patterns are often used to close hollow organs because they cause tissue inversion and provide a reliable leak‐proof seal. The Cushing and Connell patterns are similar except that the Cushing pattern is placed so that the suture purchases the serosa, muscularis, and submucosa, but it does not pierce the mucosa so it is not exposed to the lumen of the organ (Figure 3.3). For the Connell pattern, suture extends into the organ lumen (Figure 3.4). Some surgeons choose to avoid penetrating the lumen of hollow viscera to help reduce the potential for contamination from the needle track in highly contaminated visceral organs. The author prefers to begin these two inverting lines with a Lembert stitch which helps to begin tissue inversion with the first stitch. Subsequent bites are more readily inverted after the Lembert stitch is placed. The suture line is continued taking alternating 5 mm bites of tissue, 3 mm away and parallel to the incision line. Once the needle exits the bite, it is passed directly across the incision and another similar parallel bite of tissue is taken. This suture line is repeated until the incision is closed. The suture strand is pulled firmly to create inversion and to reduce suture exposure on the serosal surface.
3.5.3 Lembert
This interrupted or continuous pattern results in aggressive inversion of hollow visceral edges (Figure 3.5). It may be used to help bury considerable eversion of mucosa. The needle penetrates through serosa and muscularis and purchases submucosa about 8–10 mm away from the incision edge and exits 3–4 mm from the wound margin on the same side. After the needle passes over the incision, it penetrates 3–4 mm from the wound margin and exits about 8–10 mm away from the incision. The further away from the incision the needle passes, the more inversion is formed. When placing continuous inverting suture lines, the surgeon must be aware of the location of the cut edge at all time. As the cut edge inverts when the line is tightened, there is a tendency to take bites progressively further from the visceral wound edge which can result in an undesirable deep inverted stump of tissue at the end of the suture line.
3.5.4 Parker–Kerr Oversew
This continuous inverting pattern is used to “blind end” a tubular organ such as bowel or uterine stumps (Figure 3.6). To reduce contamination and aid in needle purchase, a large hemostatic clamp is first placed perpendicular to the long axis of the tubular organ. Any remaining organ tissue extending past the jaws of the clamp is removed. Starting at either the mesenteric or antimesenteric surface, a loose continuous Cushing suture pattern is placed catching 3–4 mm of bowel wall with each needle bite and running at least 3 mm from the edge of the clamp. Once the loose Cushing pattern is complete, the jaws of the clamp are partially opened releasing the incised bowel edges, while the suture end with the needle is slowly tensioned away from the side closest to the clamp hinge. The clamp is removed and the suture line is tensioned from both sides to completely invert the stump edges. The needle is then reversed and a Lembert pattern is placed and tied to the original free suture end to form a leak‐proof double inverted stump.
3.6 Special Supplementary Patterns: Purse‐String
This suture pattern is intended to close a hollow organ opening or body aperture, such as the anal opening, or around a tube entrance in viscera (Figure 3.7). It is often utilized around the anal opening to prevent fecal contamination during perineal surgery, and to create a seal around a feeding tube placed in hollow viscera, as in a gastrostomy tube procedure. As the suture is placed around the site, tension on the suture end will tighten the continuous pattern much like a purse being pulled together at its neck with a string. The suture pattern is begun with parallel 3–4 mm bites of tissue about 3–5 mm away from the opening or cut edge. Each successive bite is advanced no more than 2–3 mm from the exit site of the last purchase. This forms a circular pattern around the centrally located opening. At the end of the pattern, both beginning and ending suture strands are in close apposition to each other. The strands are pulled firmly to form a tight cuffed rim of tissue around the tube