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One centimeter openings are created using ultrasonic dissection in the antimesenteric border of the bowel for insertion of the stapler between the two holding sutures (Fig. 10.21). The bowel wall is grasped and the dissector used to create a full thickness injury which then can be spread in such a manner as to enter the bowel lumen. The dissector provides for good hemostasis in almost every case. The ultrasonic dissector is removed and a linear stapler with a 60 mm cartridge of 2.5 mm staples inserted. We prefer to cannulate these openings with what we call the "pop and drop" technique (Fig. 10.22). The closed stapler jaws is advanced just into each opening simultaneously. "Popping" open the lever on the heel of the stapler will then cause the jaws to "pop" open, retracting the enterotomy sites simultaneously so that the stapler can be easily advanced. It is important to maintain back tension toward the surgeon with the left hand grasper attached to the holding suture. If the stapler will not advance easily into the lumen, this can be facilitated by lifting the stapler anteriorly towards the abdominal wall to prevent it from becoming entrapped posteriorly within the bowel lumen. If the staple jaws can be visualized within the bowel lumen anteriorly then it is often easier to advance the stapler. The assistant's holding suture can also be moved toward the surgeon during this process in order to facilitate pulling the bowel over the stapling device. Once the stapler is clearly identified to be intraluminal from several angled views, the stapler is closed and fired. The intraluminal anastomosis should be briefly inspected but hemostasis is usually excellent. A third Endo stitch suture of 2.0 Surgidac is then placed in the midportion between the previously placed sutures and all three are held anteriorly in such a way that they can be amputated with a firing of the 60 mm cartridge of 2.5 mm staples to close the small bowel enterotomy (Fig. 10.23). To accomplish this, the stapler is introduced into the abdominal cavity and the trajectory and approximation of the stapler is examined and ensured by retraction on the stay sutures. The surgeon is responsible only for the medial holding suture while the assistant's left hand instrument is placed on the middle suture and the right hand instrument placed on the lateral suture. If the GIA stapler takes a sharp anterior/posterior trajectory, it may be necessary to simply lift the surgeon's suture anteriorly and let the other sutures hang free until the last possible moment in positioning the GIA. One must be very careful to avoid amputating too much during this step since this may obstruct the anastomosis. It also is important to note that the knife blade which cuts between the staple lines is not at the anterior-most margin of the stapler, but is rather down the middle of the cartridge where it is marked by a slot on the side of the staple cartridge device. The goal is to have the stay suture knots just visible within the jaws of the instrument. To ensure this the medial location of the stapler for closure is positioned first followed by the lateral tip. With the U.S. Surgical stapler, tissue gap control allows the surgeon to reposition tissue at the farthest extent (tip) of the stapler's jaw even though the device is closed. This allows us to manipulate the tissue and decrease the amount amputated laterally without losing the important proximal positioning that was obtained. Ideally, a very small rim of tissue is amputated to just include the previously tied three sutures knots. This tissue specimen is then removed through a 12 mm trocar and discarded.

The anastomosis and enterotomy closure sites are inspected with particular attention to the medial corner where the two staple lines intersect. We have occasionally found small defects in the staple line at this area even though the enterotomy

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