Resection

Objective 4: Variation in technique for resection

In this section we discuss various aspects of resection, and preparing the bowel ends for anastomosis

Significant variation exists between cases, and surgeons, and there is no strong evidence to suggest that one resection technique is superior.

We hope that the videos below raise some questions about resection and anastomosis, as well as highlight some common considerations that might be of benefit.

The video below discusses where surgeons might perform resection of the specimen and then anastomosis, or anastomosis and then resection of the specimen:

The next video is a discussion between surgeons about situations where they have performed resection before or after anastomosis:

Other aspects to consider around the time of the resection include:

• Oversewing of the stumps: there is no evidence to suggest additional oversewing of the stapled ends of the bowel is of benefit or of harm, but this may be preferred by some surgeons.

Related paper: The impact of stapling technique and surgeon specialism on anastomotic failure after right-sided colorectal resection: an international multicentre, prospective audit.

• Anatomical configuration of bowel for anastomosis (isoperistaltic vs antiperistatic): there is no evidence to one configuration is superior to the other with regard to anastomotic leak in randomised studies.

Related paper: Isoperistaltic versus antiperistaltic ileocolic anastomosis. Does it really matter? Results from a randomised clinical trial (ISOVANTI)

Evidence from 2015 ESCP audit data

• Side to side anastomosis was the most common configuration for stapled ileocolic anastomoses in the 2015 ESCP audit.
• Over 25 different configurations and techniques were used in total in this dataset, with over 90% of surgeons using the 4 most common variations.
• Of note there was a disproportionately high rate of anastomotic leak in the rarer anastomotic configurations, compared to those most commonly used.
• This may represent technically challenging operations, where perhaps formation of an end stoma would have been preferable, or perhaps unusual variations

Harmonisation of practice using consensus of colorectal surgeons worldwide may help to reduce unnecessary variation and improve patient outcomes 

The next video is a discussion between surgeons about the use of stay sutures to increase stability of the anastomotic configuration before starting an anastomosis: