Parker-Kerr Stitch
The Parker-Kerr stitch is a classical two-layer inverting closure for the stump of a hollow viscus, named for E. M. Parker and H. H. Kerr, who published their intestinal-anastomosis method in 1908.[6] In urinary diversion, hand-sewn two-layer closure, including Parker-Kerr, is described for the proximal end of an ileal conduit; other reservoir designs use different closures according to their configuration.[3][4]
The described pattern places a continuous inverting Cushing-type suture over a clamp holding the divided end, withdraws the clamp while drawing the suture to invert the stump, and reinforces the closure with a seromuscular Lembert layer. A Cushing pattern takes bowel wall without entering the lumen; it is not a full-thickness baseball or Connell stitch.[5]
Indications in GU Reconstruction
- Closing the proximal end of an ileal conduit when a hand-sewn inverted end closure is chosen; this is separate from the Bricker-versus-Wallace ureteroenteric anastomosis choice.[3][4]
- Closing another divided bowel end in an appropriate reconstruction, provided the anatomy, perfusion and planned ureteral or pouch openings permit this closure.
- An alternative to a stapled end closure when a hand-sewn closure is selected; irradiated or thickened bowel needs individual viability and tissue-quality assessment.
The technique is independent of stapler supply and remains a useful hand-sewn option. Its choice in redo or resource-limited surgery is a technical judgment, not a proven superior outcome in those settings.
Technique
Setup
- Identify the planned division line on the isolated bowel segment. If a GIA stapler divided the conduit, excise the proximal staple line before hand-sewn two-layer closure.[4] For a clamp-assisted closure, clamp and divide the end to be closed.
- A bowel clamp or forceps placed across the bowel end to be preserved, with the bowel divided alongside it. The jaw type and compression depend on tissue and operative plan; an atraumatic Doyen is one option.[5]
- The clamp serves as the scaffolding over which the inverting stitch is placed
Inner inverting layer — the "over-the-clamp" Cushing stitch
- Select an appropriate suture and needle for the bowel wall and application.
- Place a running Cushing-type, inverting suture over the clamp, from one corner of the stump to the other. Its bites engage bowel wall and submucosal holding tissue without passing into the lumen.[5]
- Leave the suture loose while completing the row. Withdraw the clamp carefully while drawing on the suture ends and guiding the stump inward to appose serosa; avoid tearing or excessive inversion.[5]
- Secure the first layer according to the selected continuous-suture sequence before or while returning with the reinforcing layer.
Outer reinforcing layer — Lembert stitch
- Place a second Lembert seromuscular inverting layer over the primary line; operative descriptions include a continuous return row, while an interrupted row is a technical variation.[5]
- Inspect the closure for perfusion, secure inversion and any gap or leak appropriate to the reconstruction.
See Bowel Anastomosis for the broader two-layer hand-sewn anastomotic framework. General operative and bowel-anatomy context is available in the cited atlases; the named step sequence above is attributed to the more specific technical descriptions.[1][2]
Key Technical Pearls
- Clamp selection. Choose the instrument according to bowel condition.
- Cushing-stitch spacing. Take evenly spaced bites that purchase the submucosa without luminal penetration or excessive tissue strangulation; adjust bite size to the wall and available tissue.
- Clamp removal timing. Draw the first row gradually as the clamp withdraws and assist inversion; excessive tension can damage the bowel.
- Confirm inversion before the outer layer. The mucosa should be fully invaginated with serosa-to-serosa apposition visible externally.
- Assess the completed reconstruction. Inspect perfusion and apposition; irrigation or leak assessment can be performed through a suitable opening when feasible, without assuming that a future ureteroenteric site should be cannulated before construction.[4]
Limitations
- Hand-sewn closure requires additional suturing steps, and operative time varies with the reconstruction and tissue.
- Suitable bowel control is needed during suturing and careful clamp withdrawal.
- Not a primary anastomotic technique. It closes one end and does not join two lumens
- Bowel viability and wall thickness matter. Avoid excessive compression, tight inversion or poorly perfused tissue
Comparison with Alternatives
| Closure | Role | Speed | Bowel demand |
|---|---|---|---|
| Parker-Kerr | Hand-sewn two-layer inverting stump closure | Requires two rows | Tissue suitable for inversion |
| Stapled closure (TA / GIA) | Stapled end-closure | Device-dependent | Requires suitable bowel and staple-line assessment |
| Connell + Lembert two-layer | Hand-sewn full-thickness first row plus outer inverting row | Two rows | Luminal entry differs from Cushing |
| Purse-string | Selected small stump or lumen closure | Case-dependent | Must match lumen and tissue quality |
| Hand-sewn single-layer | Alternative closure pattern | One row | Site- and tissue-dependent |
Staplers commonly close bowel ends, while two-layer hand-sewn conduit-end closure remains described in operative teaching.[3][4] One urinary diversion text notes that a nonabsorbable staple line at the conduit end may lead to stone formation.[3] The choice in irradiated, thickened or redo bowel requires individual assessment of viable tissue, perfusion and the planned reconstruction.
History
E. M. Parker and H. H. Kerr published Intestinal anastomosis without open incisions by means of basting stitches in 1908.[6] A 1909 case report describes their Cushing-type basting stitch over clamps with inversion on withdrawal.[7] The stump-oversew pattern that carries their names applies the same clamp, Cushing-stitch and Lembert principle.
See Also
References
1. Zollinger RM Jr, Ellison EC. Zollinger's Atlas of Surgical Operations. 9th ed. McGraw-Hill; 2010.
2. Skandalakis JE, Colborn GL, Weidman TA, et al. Skandalakis' Surgical Anatomy. Paschalidis Medical Publications; 2004.
3. DeCastro GJ, Large MC, Steinberg GD. Urinary Diversions and Reconstructions, section 25A: Cutaneous Urinary Diversions. Ileal-conduit construction and Fig. 25A.1.
4. Urinary Diversions and Neobladders. NCBI Bookshelf; ileal-conduit technique.
5. British Small Animal Veterinary Association. Suture patterns and surgical knots, Fig. 22.13: Parker–Kerr oversew. Species-specific technical depiction of Cushing-over-clamp and Lembert-oversew; human application described separately in refs. 3–4.
6. Parker EM, Kerr HH. Intestinal anastomosis without open incisions by means of basting stitches. Bull Johns Hopkins Hosp. 1908;19:132–137. Bibliographic listing.
7. Breckinridge SD. Intestinal resection with end-to-end anastomosis by Parker-Kerr method: recovery. JAMA. 1909;52:1107. doi:10.1001/jama.1909.25420400033002f.