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The Next Era in GI Surgery BioDynamixTM,[object Object],Anastomosis,[object Object],The Colon Ring,[object Object],USE OF THE,[object Object],ColonRingTM,[object Object],Clinical Training Team,[object Object]
2,[object Object],ColonRingTM,[object Object],Purse String Notch,[object Object],Plastic Anvil Ring,[object Object],Locking Spring,[object Object],10,[object Object],9,[object Object],11,[object Object],Detachable Anvil Head Assembly,[object Object],12,[object Object],Anvil Shaft,[object Object],8,[object Object],Piercing Trocar,[object Object],7,[object Object],Operating Knob,[object Object],5,[object Object],13,[object Object],Cutting Trigger,[object Object],Grasping Notch,[object Object],6,[object Object],1,[object Object],Colon RingTM,[object Object],2,[object Object],ColonRing™ Housing,[object Object],3,[object Object],Applier,[object Object],4,[object Object],Cutting Handle,[object Object]
Use of the Colon RingTM in Colon Surgery,[object Object]
OR Protocol,[object Object],Procedural Limitations:,[object Object],No anastomosis should be placed proximal to the ileocecal valve.,[object Object],At present, there is no piercing ancillary trocar to push through a stapled proximal stump.,[object Object],The ColonRingtm should not be used in anyone with a known allergy to nickel.,[object Object]
Surgical Technique,[object Object]
Surgical Technique,[object Object]
Surgical Technique,[object Object]
Surgical Technique,[object Object]
Surgical Technique,[object Object]
Surgical Technique,[object Object]
OR Staff Instructions,[object Object]
OR Staff Instructions,[object Object]
Colon RingTM Approved Procedures,[object Object],Right Hemicolectomy w/Ileocolic Anastomosis,[object Object],Only if already being done, or if already using circular stapler for anastomosis,[object Object],Leave distal colonic segment open,[object Object],Introduce ring applier through open end,[object Object],Piercing trocar to pass thru colon ~5 cm distal to open bowel end,[object Object],Alternately, pass applier proximally through distal colotomy,[object Object],Anvil in distal ileum (side),[object Object],Form anastomosis and check visually,[object Object],Close proximal colon with linear stapler or sutures,[object Object],Consider buttressing anastomosis with absorbable sutures,[object Object],Transverse or Segmental Resections w/Colocolonic Anastomosis,[object Object],Rarely done,[object Object],As above, or end-to-end through colotomy,[object Object]
Colon RingTM Approved Procedures,[object Object],Left Colectomy/Hemicolectomy w/Colocolonic Anastomosis,[object Object],Will usually require proximal enterotomy for insertion of applier with anvil placed distally, especially for anastomoses above 20-23 cm,[object Object],Sigmoidectomy w/Colorectal Anastomosis,[object Object],Anterior and Low Anterior Resections w/Colorectal Anastomosis,[object Object],Total Colectomy w/Ileorectal Anastomosis,[object Object],Proctocolectomy w/Ileoanal Anastomosis,[object Object],J-Pouch,[object Object],Ileal,[object Object],Colonic,[object Object],Closure of Colostomy w/Colocolonic or Colorectal Anastomosis,[object Object],If anastomosis above 20-23 cm, may require proximal enterotomy,[object Object],Closure of Hartmann Procedure w/Colorectal Anastomosis,[object Object]
Bubble Test Precautions,[object Object],Precautions in Bubble Testing,[object Object],When preparing to use a bubble test for verification of intact colorectal anastomosis, it is advisable to assure that there be no trapped extraluminal air under the rectal segment (while instilling warm saline solution) which, if present, could be forced from under the rectum and would appear to be a positive indication of an anastomotic or peri-anastomotic leak when the rectal segment is distended with air.,[object Object],Gently moving the rectum side-to-side or up-and-down may allow for any trapped extraluminal air to escape.,[object Object],Care should be taken not to place tension on the anastomotic area during the post-anastomotic period which might cause serosal tearing due to the rigidity of the compression ring anastomosis.,[object Object]
Bubble Test Precautions,[object Object],Precautions in Bubble Testing,[object Object],Sufficient air should be introduced within the rectal vault, while closing off the proximal sigmoid segmentto prevent proximal bowel distention, so that there is a significant pressure gradient sufficient to demonstrate the presence of any anastomotic or peri-anastomotic leak.,[object Object],Methylene blue may be instilled rectally in a further attempt to demonstrate a potential leak if so desired.  Although lack of visualizing intra-abdominal methylene blue is not conclusive evidence of the absence of an anastomotic or peri-anastomotic leak, it would certainly suggest integrity of the bowel.,[object Object]
Bubble Test Interpretation,[object Object],Interpretation of Bubble Testing,[object Object],Bubbles which are of small to moderate size and flow only for 1-2 seconds and which cannot be demonstrated repeatedly with additional air insufflation are more likely to represent trapped extraluminal air from under the rectum.,[object Object],Bubbles which are extremely small and are contained in a steady stream, especially if they are repeatedly demonstrable, are more likely to represent a tiny leak.,[object Object],Bubbles of small to moderate size which are free-flowing, fairly persistent, and demonstrable on repeated testing may likely indicate a significant leak.,[object Object],By carefully turning the anastomosed bowel while insufflating additional air rectally, it is frequently possible to localize the site of any tiny or significant leak.,[object Object]
Treatment of Leaks,[object Object],Treatment of Apparent Anastomotic or Peri-Anastomotic Leaks,[object Object],If, after careful testing and cautious evaluation of any perceived bubbles, it is deemed likely that the bubbles were a result of trapped extraluminal air behind the rectum, nothing further need be done if the surgeon is comfortable with the anastomosis and peri-anastomotic area.,[object Object],If it is deemed likely that a tiny leak might be present (more likely from a "dog-ear" than from the anastomosis), but further testing cannot demonstrate either a localized site of the leak or any prolonged persistenceof that leak, it may be appropriate to do nothing further if the surgeon has confidence in his anastomosis and peri-anastomotic area.  A soft silicone drain might be advantageous in this situation.,[object Object]
Treatment of Leaks,[object Object],Treatment of Apparent Anastomotic or Peri-Anastomotic Leaks,[object Object],If there appears to be a tiny leak and the involved site appears to involve one or both "dog-ears," it may be sufficient to cautiously suture that site with a 3-0 or 4-0 suture of choice, with or without interposition of fatty tissue, and retest for a persistent leak.  If none persists, nothing further need be done other than drainage, if desired.  If a persistent leak is present, diversion might be considered.,[object Object],If a significant leak is determined to be present, suture repair, including interposition of fatty tissue, may be consideredif it is felt likely that the leak can be locally controlled.  Alternately, reconstruction of the anastomosis or diversion should be considered as deemed appropriate by the surgeon.,[object Object]

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Combined 16 clinical training--use of colon_ring

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