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Peritoneal Onlay Patch Buttress as a Salvage
Technique to Improve Enterotomy Repair
Surgical repair of an enterotomy remains a cornerstone
practice of the general surgeon. Uncomplicated partial-
thickness enterotomies are easily managed by serosal
reapproximation. More complicated enterotomies can
be repaired primarily; when the defect is too large
and there is sufficient bowel length, a resection and
reanastomosis may be indicated. In yet more complex
circumstances, the general surgeon may encounter an
abdomen in which these time-tested techniques are
unable to be used and additional, less well-described
techniques are necessary for satisfactory repair. We
present one such technique in which a peritoneal onlay
patch was used to buttress a primary full-thickness re-
pair completed under tension and with extremely friable
tissue.
The patient is a 63-year-old man who underwent
orthotopic liver transplant for decompensated liver
disease related to postnecrotic cirrhosis secondary to
hepatitis B, hepatitis C, and alcohol. His immediate
postoperative course was complicated by bile peritonitis,
which on further surgical exploration was found to be
secondary to a leak at the common bile duct anastomosis.
After débridement there was insufficient length to attempt
a duct-to-duct repair and biliary drainage was performed
by means of a Roux-en-y hepaticojejunostomy. The
patient tolerated the procedure without additional
complications and was discharged. He returned ap-
proximately one month later with evidence of free in-
traperitoneal air, was surgically explored, and found to
have a small enterotomy at the Roux limb that was
repaired primarily in a two-layered fashion. At the time
of this operation, he was noted to have substantial intra-
abdominal adhesions that had fixed the colon anteriorly
and superiorly to the surface of the liver as well as sub-
stantial small bowel adhesions distal to the jejunojejunal
Address correspondence and reprint requests to Jordan E. Fishman,
M.D., M.P.H., 150 Bergen Street, Suite E-401, Newark, NJ 07101-
1709. E-mail: fishmajo@njms.rutgers.edu.
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anastomosis of the hepaticojejunostomy. His initial
postoperative course was uneventful; however, 16
days after the repair, he manifested new signs of
intra-abdominal sepsis and required urgent explora-
tion. Although our original repair was intact, the pa-
tient had developed a second enterotomy distal to both
the Roux limb and the jejunojejunal anastomosis that
we attributed to the friable tissue and the tension
placed on the jejunojejunal anastomosis from the prior
repair. An attempt was made to close the new enterotomy
primarily; however, the single-layer repair was under
tension and there was insufficient tissue laxity to com-
plete a two-layer closure. Three options were discussed
but each proved infeasible. First, there was insufficient,
readily available jejunum to attempt a resection and
reanastomosis. Second, the omentum was fixed and
trapped between bowel loops and therefore not mobi-
lized for fear of causing additional enterotomies. This
excluded an omental patch. Third, there was no mo-
bility in the surrounding bowel. Consequently, we were
unable to cover the defect with a serosal patch. We
elected to harvest a 4-cm · 2-cm peritoneal patch that
we placed over the primary repair and secured in
a tension-free fashion by continuous 5-0 Prolene to
overlay our primary repair and serve as a buttress
(Fig. 1). We placed the peritoneum with the anatomic
peritoneal surface facing away from the repair in the
so-called ‘‘smooth side out’’ fashion. The patient’s
abdomen was closed and he was returned to the
surgical intensive care unit. Five days after this re-
pair, he developed an enteric leak distal to the onlay
patch repair, was made comfort care, and died two
weeks later.
Prior animal work demonstrates the effectiveness of
the peritoneal patch in preventing leaks if used as
a buttress for surgical anastomoses when placed in the
‘‘smooth side out fashion.’’1 Early clinical enthusiasm
for this practice was tempered by a subsequent clinical
trial in which the use of a free peritoneal patch as an
anastomosis buttress was associated with increased
stricture formation.2 Current clinical interest in the
peritoneal patch technique has been directed toward the