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This Concept Map, created with IHMC CmapTools, has information related to: Anastamosis Procedure, Step 20: The abdominal layers should be closed with absorbable suture using a simple continuous pattern. The skin should be closed with non-absorbable suture with a a tension suture patterns such as a cruciate or horizontal mattress. ???? Step 21: Proper post-op care should be done at the incision site., Step 4: Use the simple interrupted suture and double ligate and transect the arcadial mesenteric vessels from the cranial mesenteric artery that supplies the damaged segment of intestine. ???? Step 5: Double ligate the terminal arcade vessels within the mesenteric fat at the points of intestinal transection., Step 3: Assess the tissue viability and determine the amount of bowel that needs to be resected using color, palpation and the "pinch test", which is pinching a section of bowel to see if a peristaltic wave can be initiated. ???? Step 4: Use the simple interrupted suture and double ligate and transect the arcadial mesenteric vessels from the cranial mesenteric artery that supplies the damaged segment of intestine., Step 10: Make the oblique incision so that the antimesenteric border is shorter than the mesenteric border. If necessary trim the everted mucosa with Metzenbaum scissors just before beginning the end-to-end anastomosis. ???? Step 11: Place simple interrupted sutures through all layers of the intestinal wall and angle the needle so the serosa is engaged slightly further from the edge than the mucosa, which helps prevent muscosal evertion., Step 9: If the luminal diameters are not equal, use a perpendicular incision across the intestine with the larger diameter and an oblique incision (45 to 60 degrees) across the intestine with the smaller luminal diameter to help correct size disparity and allow the lumens on both sides to line up correctly. Failure to do so will result in leakage of intestinal contents. ???? Step 10: Make the oblique incision so that the antimesenteric border is shorter than the mesenteric border. If necessary trim the everted mucosa with Metzenbaum scissors just before beginning the end-to-end anastomosis., Step 2: Exteriorize and isolate the afflicted intestine by packing with moistened towels or laparotomy sponges. ???? Step 3: Assess the tissue viability and determine the amount of bowel that needs to be resected using color, palpation and the "pinch test", which is pinching a section of bowel to see if a peristaltic wave can be initiated., Step 17: After suture placement, inspect the anastomosis and check for leakage as performed for enterotomies. This is a subjective test because all anastomoses can leak if enough pressure is applied. Place additional sutures if leakage occurs. ???? Step 18: The mesenteric defect should be closed with a simple interrupted or continuous pattern of 4-0 PDS or Maxon on a swagedon taper needle. DO NOT penetrate or damage the arcadial vessel near the defect., Step 8: Transect the intestine with either a scalpel blade or Metzenbaum scissors along the outside of the forceps. Make the incision either perpendicular or oblique to the long axis of the intestine. Use a perpendicular incision at each end if the luminal diameters are equal in size. ???? Step 9: If the luminal diameters are not equal, use a perpendicular incision across the intestine with the larger diameter and an oblique incision (45 to 60 degrees) across the intestine with the smaller luminal diameter to help correct size disparity and allow the lumens on both sides to line up correctly. Failure to do so will result in leakage of intestinal contents., Step 19: The abdomen should be thoroughly lavaged with warm saline and the anastomotic site before abdominal closure. ???? Step 20: The abdominal layers should be closed with absorbable suture using a simple continuous pattern. The skin should be closed with non-absorbable suture with a a tension suture patterns such as a cruciate or horizontal mattress., Step 14: Appose intestinal ends by placing a simple interrupted suture at the mesenteric border to prevent intestinal dehiscence. It may be necessary to dissect some of the mesenteric fat for proper visualization. ???? Step 15: Place a second suture at the antimesenteric border approximately 180 degrees from the first suture, dividing the suture line into halves. If the luminal diameters are of equal diameter, space additional sutures between the first two sutures approximately 2 mm from the edges and 2 to 3 mm apart. If minor disparity exists between lumen sizes, space sutures around the larger lumen slightly further apart than the sutures in the intestine with the smaller lumen., Step 12: Tie each suture carefully to appose all layers of the intestine with the knots located extraluminally. A simple continuous pattern is used. ???? Step 13: Do not pull sutures too tight, as this will cause a purse-string effect, which may compromise intestinal lumen diameter leading to stenosis or obstruction., Step 7: Place either crushing (Carmalts) or noncrushing (Doyens) forceps across each end of the afflicted bowel segment. It does not matter which forceps is used as the area being crushed is being removed. ???? Step 8: Transect the intestine with either a scalpel blade or Metzenbaum scissors along the outside of the forceps. Make the incision either perpendicular or oblique to the long axis of the intestine. Use a perpendicular incision at each end if the luminal diameters are equal in size., Step 11: Place simple interrupted sutures through all layers of the intestinal wall and angle the needle so the serosa is engaged slightly further from the edge than the mucosa, which helps prevent muscosal evertion. ???? Step 12: Tie each suture carefully to appose all layers of the intestine with the knots located extraluminally. A simple continuous pattern is used., Step 1: Make an abdominal incision for exploration of the abdomen. This is typically from xphoid to pubis. ???? Step 2: Exteriorize and isolate the afflicted intestine by packing with moistened towels or laparotomy sponges., Step 16: To correct luminal disparity that cannot be accommodated by first angling the incision or by suture spacing, resect a small wedge (1 to2 cm long and 2 mm wide) with Metzenbaum scissors from the antimesenteric border of the intestine with the smaller luminal size. This will enlarge the perimeter of the stoma, giving it an oval shape. ???? Step 17: After suture placement, inspect the anastomosis and check for leakage as performed for enterotomies. This is a subjective test because all anastomoses can leak if enough pressure is applied. Place additional sutures if leakage occurs., Intestinal Resection and Anastamosis ???? Step 1: Make an abdominal incision for exploration of the abdomen. This is typically from xphoid to pubis., Step 6- Gently milk chyme from the lumen of the intestinal segment and occlude the lumen at both ends of the segment to minimize spillage of intestinal contents. ???? Step 7: Place either crushing (Carmalts) or noncrushing (Doyens) forceps across each end of the afflicted bowel segment. It does not matter which forceps is used as the area being crushed is being removed., Step 13: Do not pull sutures too tight, as this will cause a purse-string effect, which may compromise intestinal lumen diameter leading to stenosis or obstruction. ???? Step 14: Appose intestinal ends by placing a simple interrupted suture at the mesenteric border to prevent intestinal dehiscence. It may be necessary to dissect some of the mesenteric fat for proper visualization., Step 18: The mesenteric defect should be closed with a simple interrupted or continuous pattern of 4-0 PDS or Maxon on a swagedon taper needle. DO NOT penetrate or damage the arcadial vessel near the defect. ???? Step 19: The abdomen should be thoroughly lavaged with warm saline and the anastomotic site before abdominal closure., Step 15: Place a second suture at the antimesenteric border approximately 180 degrees from the first suture, dividing the suture line into halves. If the luminal diameters are of equal diameter, space additional sutures between the first two sutures approximately 2 mm from the edges and 2 to 3 mm apart. If minor disparity exists between lumen sizes, space sutures around the larger lumen slightly further apart than the sutures in the intestine with the smaller lumen. ???? Step 16: To correct luminal disparity that cannot be accommodated by first angling the incision or by suture spacing, resect a small wedge (1 to2 cm long and 2 mm wide) with Metzenbaum scissors from the antimesenteric border of the intestine with the smaller luminal size. This will enlarge the perimeter of the stoma, giving it an oval shape.