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Anastomosis by Invagination:
Intestinal
A Historical Review of a "New" Technic with
Controlled Study of Its Potential
BERNARD S. LINN,* M.D., TERRY M. REISMAN,** M.D.,
ROGER W. YURT,*"* B.S., HIRAM C. POLK, JR.,t M.D.
From the Department of Surgery, University of Miami School of Medicine,
Miami, Florida
IN 1812, Travers 17 reported, "the union fully used but never widely acclaimed.
of a divided bowel requires the contact of Most users of the technic have been enthu-
the cut extremities in their entire circum- siastic about and more than a few have
ference." Thus peritoneal continuity and claimed the procedure as their own dis-
bowel healing became synonomous. How- coveries. Clinical use of the procedure out-
ever, around the turn of the century, Hal- dates its experimental research history.
sted5 emphasized the importance of the Moore and Forrest-Hamilton 1" reported
submucosa in intestinal anastomosis. It is that Sonnenburg, in Berlin, first used an
surprising that this did little, at that time end-to-end ileo-colic anastomosis, before
or later, to alter the orthodox end-to-end the turn of the century. Unfortunately, he
procedure. Investigators have repeatedly never published his results and Maylard,10
explored other methods in attempts to re- unaware of Sonnenburg's discovery, prac-
duce operative time and improve func- ticed the same technic in Scotland around
tional results. In fact, Da Costa 2 stated 1910. In their procedure, ileum was invagi-
that some 250 methods had been described nated into a longitudinal incision in the
for doing anastomoses. It is obvious, how- colon. Again in Germany, in 1923, Goepel 4
ever, that most of these deviations from described successful use of the technic and
the time-honored procedure were met with later challenged a claim by Babcock' to
controversy or doubt. technic priority. Babcock's report, in 1926, was the
The telescoping or invaginating first known American use of invagination
is one such method that has been success- anastomoses. He reported 10 partial gas-
Submitted for publication August 11, 1967. trectomies by means of telescopic anasto-
* Associate Chief of Staff for Research & Edu- moses, in which duodenum was turned
cation, Veterans Administration Hospital, Assistant into the open end of the gastric stump.
Professor of Surgery, University of Miami, School For almost 20 years, the technic lay
of Medicine, Miami, Florida. Miami, Florida. dormant. Then Pringle,14 an army surgeon,
** Jackson Memorial Hospital, developed a procedure for fast and simple
* ** Biomedical Engineering. of that
f Assistant Professor of Surgery, University repair of war injuries. Pringle wrote
Miami, School of Medicine, Miami, Florida. he knew of no earlier accounts of this
This project was supported in part by 8200 method but acknowledged that his access
Research funds from Veterans Administration, to the literature was impossible at the time.
Washington, D. C.
393
LINN, REISMAN, 'Y(URT AND POLK Annals of Surgery
394 March 1968
He called his operation "a method of end- invagination process dates back to 1963,
to-end anastomosis of small intestines." when we began experimental studies on
In 1951, Kimbarovskij,6 described a large and small bowel anastomosis. In an
"new" method of intestinal anastomosis earlier report by Linn et al.,7 an evaluation
whereby 4-5 cm. of small intestine was was made between large and small bowel
introduced into colon lumen in an attempt adhesive invagination and conventional
to reproduce the equivalent of an ileo- control procedures. We concluded that, al-
cecal valve. Two years later, Moore and though the experimental procedure was
Forrest-Hamilton,"l of England, refuted his faster and safer, precise evaluation of the
claim, referring him to the Maylard-Son- invagination technic was hampered by fac-
nenburg history. tors related to the use of adhesives. In ad-
Other clinical descriptions of large bowel dition, there had been questions concern-
anastomoses followed in which Prioleau 13 ing the need for mucosal dissection. For
and Ferrara3 used the technic for rectosig- these reasons, the present study was un-
moid anastomoses. Although they reported dertaken to evaluate the use of suture in-
success, they cautioned against rectosig- vagination with and without mucosal dis-
moid invagination, except in the presence section for large and small bowel anasto-
of dense scar tissue resulting from chronic moses.
inflammation in the rectal stump. Method
To our knowledge, the first experimental Twenty-four mongrel dogs weighing 10
studies of this method were those of Mc- to 15 Kg. were randomly assigned to one
Caughan 12 who reported axial enteren- of two groups. In the first group anasto-
terostomy successfully performed on 11 moses were performed on proximal and
dogs in 1954. After preparing cuffs, de- distal small intestine; in the second group
nuded proximally of the seromucular layer anastomoses were performed on proximal
and distally of the mucosal layer, he tele- and distal large intestines. The experimen-
scoped the ends of the intestines and tal procedures of invagination alone (IA)
united them by a continuous stitch. He and invagination with dissection of distal
concluded this was a simple, safe, and bowel mucosa (ID) were compared with
rapid method of anastomosis. the standard end-to-end procedures (C).
In 1965, Shrum and his associates 15 in- The project was designed so that each ani-
vestigated the fate of the telescoped seg- mal would have two anastomoses per-
ment of ileum in ileocolostomies in 20 formed during the same operation, either
dogs. A segment from the ileo-colic junc- an experimental and a control or two ex-
tion was later excised for gross and micro- perimentals. Procedures were alternated
scopic examination, and continuity was re- within each group so that each type of
established by the same experimental pro- anastomosis was performed as many times
cedure. They found that the segments proximally as distally. A total of 48 proce-
decreased in size and eventually were com- dures were done: 16 IA, 16 ID, and 16 C.
pletely covered by ileal mucosa. They were Animals scheduled for small bowel anas-
encouraged enough to employ the proce- tomoses received only water for 48 hours
dure in 13 patients. They concluded the preoperatively. Dogs scheduled for large
experimental method was superior to the bowel operations also received two enemas
conventional end-to-end procedure. and 8 Gm. of neomycin during this preop-
Although the invagination method ap- erative period. Pentobarbital anesthesia and
peared, in these studies, to be superior, midline incisions were used. Fluids were
data comparing test animals with controls given intravenously at the time of opera-
had been lacking. Our own interest in the
Volume 167 ANASTOMOSIS BY INVAGINATION
Number 3 INTESTINAL 395
FIG. 1. Experimental invagination technics.
tion and one day postoperatively. Diets stay suture for the IA, or from the place-
were progressively advanced to regular ment of the first approximation suture for
chow. Dogs were individually caged until the control.
the passage of the first postoperative stool. Animals were sacrificed on the 28th post-
Penicillin (600,000 units) and streptomycin operative day. Anastomoses were removed
(0.25 Gm.) were administered parenterally for gross and microscopic examination. On
for five days postoperatively. gross examination, they were rated as good
Details of the ID procedure are shown in if there were no evidence of leak, stricture,
Figure 1. After bowel transection, extra- or significant adhesions. A rating of fair
luminal fat and vessels were first dissected was assigned if there were either stricture
from the terminal inch of the bowel to be or adhesions. A rating of poor was reserved
invaginated. One inch of mucosal lining for any evidence of leak. On microscopic
was then dissected from the distal bowel. examination, the presence or absence of
A temporary stay suture was used to pull inflammation, accumulation of polymor-
proximal into distal bowel. Interrupted No. phonuclear leukocytes or edema fluid was
4-0 silk sutures were used for the serosa. noted. In addition, continuity was rated as
Details of the IA follow the same technic good if mucosa and muscle were present in
with the exception that no mucosa was dis- all parts of the bowel wall, fair if either
sected. Conventional anastomoses for the nucosa or muscle were present, and poor
controls were done by the standard two if there were gaps of both muscle and mu-
layer end-to-end procedure. cosa. To statistically evaluate the degree of
All procedures were carefully timed, be- stricture, the circumferences of the anasto-
ginning with the dissection of the mucosa motic line and of bowel one inch proxi-
for the ID, the placement of the temporary mally were measured and a ratio of the de-
Annals of Surgery
396 LINN, REISMAN, YURT AND POLK March 1968
TABLE 1. Results ofSmall and Large Bowel Anastomoses Performed
Small Bowel (24) Large Bowel (24)
IA ID C IA ID C
Malfunction 1 0 0 0 0 0
Operative time
Mean average (min.) 16 18 46 11 14 36
Standard deviation 4 1.5 ±2.7 4±4.7 ±4.1 ±4.6 ±7.9
Gross appearance
Good 4 7 8 5 7 7
Fair 3 1 0 3 1 1
Poor 1 0 0 0 0 0
A/P ratio
Mean 0.78 0.81 0.90 0.82 0.87 1.00
Standard deviation ±.12 ±.08 4.16 ±.90 ±.05 4.07
Microscopic appearance*
Continuity
Good 2 2 5 6 3
Fair 2 0 5 2 1 4
Poor 1 0 0 0 0 0
Inflammation
Absent 3 3 2 0 0 0
Present 4 5 5 8 8 8
* N = < 8 cases where sections could not be prepared for examination.
gree of stricture computed (hereafter re- two sutures of the IA anastomosis had torn
ferred to as the A/P ratio). through the serosa leaving a gaping hole.
Other data for analysis included clinical The C anastomosis was still intact.
courses of the animals judged by weight There were no significant weight changes
changes, complications, bowel cultures, in any animal. All animals had a return of
bowel functions, and deaths. Finally all normal bowel function within 2 or 3 days
data were subjected to analysis of variance after operation. Intestinal cultures taken
on an IBM 7040 computer in which large during the anastomotic procedure were
and small bowel series and IA, ID, and C negative in all but two of the small bowel
procedures were compared. Differences sig- series and positive in all of the large bowel
nificant at p < 0.01 by F ratio and T test series.
between means are reported. Anastomotic Time: The most significant
Results result was found in comparison of opera-
tive time. The C anastomoses always re-
Findings are presented in terms of clini- quired two to three times longer than the
cal function, operative time, and anasto- invagination technic. Differences between
motic appearance. Results are summarized length of time were highly significant (p
in Table 1. > 0.001).
Clinical Function: One animal in the Anastomotic Appearance: There were
small bowel series with an IA-C anasto- few differences between the ratings of the
mosis died on the 12th day after operation. controls and ID, in terms of gross appear-
On postmortem examination, 400 cc. of ance. The IA, however, were more fre-
dark fluid and early adhesions were found quently rated as only fair and one (that
throughout the peritoneal cavity. One or dehisced on the 14th day) was rated poor.
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