3.4.3 Patterns to Reduce Excess Mucosal Eversion
After gastric and intestinal incision, it is common that muscle fibers within the wall contract, causing retraction and spasm. The underlying loosely attached mucosa aggressively everts and rolls over the incised edge of intestine or stomach. When simple interrupted or simple continuous sutures are placed while the mucosa is remains everted, true apposition of intestinal layers cannot be attained. Everted mucosa is caught between the incised edges. Intestinal healing in this instance is slowed, when compared to accurately aligned intestinal layers. Excess mucosal eversion also lowers leak pressure of the repair and may increase the incidence of adhesion formation. The Gambee and modified Gambee patterns help reduce mucosal eversion.
3.4.3.1 Gambee
In the Gambee pattern on the first side, the needle is inserted 3–4 mm away from the cut edge of serosa directly through the full‐thickness wall of the intestine into the lumen (Figure 3.1a). The needle is backed up just enough to advance and pierce the middle of the cut surface of the everted mucosal edge. The second purchase on the opposite side begins with the needle inserted in the cut edge of the everted mucosa down into the lumen of the bowel. The needle is then advanced and driven full thickness directly from the bowel lumen to the serosa, catching 3–4 mm of wall. The advantage of this suture over the modified Gambee stitch (below) is that since the needle pierces the bowel wall full thickness, a good purchase of submucosa is guaranteed to be included with each needle bite.
3.4.3.2 Modified Gambee
In this suture pattern, the needle penetrates the serosa, muscularis, and submucosa, but the everting mucosal layer is not incorporated (Figure 3.1b). On the opposite side a mirror image of the needle purchase is taken; the needle incorporates the submucosa, muscularis, and serosa only. When the suture is pulled snuggly, the mucosa is buried within the lumen. This pattern can be used as a simple interrupted pattern or in a continuous fashion. Caution should be taken when considering this pattern. The downside to this modification is that the serosa and muscularis layers may be included, but because mucosal eversion hides the incised bowel edge, either the submucosa may not be included or too small of purchase if this layer is included, rendering the suture line susceptible to premature dehiscence (Kieves et al. 2014).
3.4.3.3 Luminal Interrupted Vertical Mattress Pattern
During intestinal anastomosis and other tubular anastomoses, occasionally the deep side of the bowel edges are difficult to mobilize and expose. In this instance, surgeons may elect to use vertical mattress suture patterns placed within 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.
