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Principles of Bowel Anastomosis with Videos

Milestones in the history of intestinal anastomosis

Intestinal anastomosis has been successfully performed for more than 150 years using a variety of techniques and suture materials. Major milestones in the development of this technique are:

Lembert : Seromuscular suture technique for bowel anastomosis in 1826

Kocher : Utilised a two-layer anastomosis. First a continuous all-layer suture using catgut, then an
inverting continuous (or interrupted) seromuscular layer suture using silk

Halsted : Favoured a one layer extramucosal closure, it was felt to cause the least tissue necrosis or
luminal narrowing. This technique has now become widely accepted.

Currently accepted technique for intestinal anastomosis

Of these, the method that has proven successful in most situations and in the hands of most surgeons has been the two-layer anastomosis using interrupted silk sutures for an outer inverted seromuscular layer and a running absorbable suture for a transmural inner layer.

The only appreciable shortcoming of the two-layer technique is that it is somewhat tedious and time-consuming to perform. Recently, several reports have appeared advocating a single-layer continuous anastomosis using monofilament plastic suture.

Single layer continuous extramucosal closure has now become widely accepted.

A single-layer continuous anastomosis can be constructed in significantly less time and with a similar rate of complications compared with the two-layer technique. It also costs less than any other method and can be incorporated into a surgical training program without a significant increase in complications.

Single Layer , Extramucosal, Interrupted- End to End bowel anastomosis (simulation)





Side to side bowel anastomosis (simulated)



Difference between Extramucosal Technique and Seromuscular Suture Technique

The extramucosal suture must include the submucosa as this has a high collagen content and is the most stable suture layer in all sections of the gastrointestinal tract.

Suture Materials used in Intestinal Anastomosis

Catgut and silk have been replaced by synthetic, usually absorbable, polymers.

The suture materials should be of 2/0–3/0 size and made of an absorbable polymer, which can be braided (e.g. polyglactin), or monofilament (e.g. polydioxanone), mounted on an atraumatic round-bodied needle. 

Suture bites should be approximately 3–5 mm deep and 3–5 mm apart depending on the thickness of
the bowel wall.

Stay sutures are put to avoid the need for tissue forceps. They are important for displaying the bowel
ends and in accurate alignment of the bowel and the placement of the sutures.

Important Considerations while doing Bowel Anastomosis

In cases of major size discrepancy of size of bowel end to be anastamosed, a side-to-side or end-to-side anastomosis is done.

In cases of minor size discrepancy, Cheatle split (making a cut into the antimesenteric border) may
help to enlarge the lumen of distal, collapsed bowel and allow an end-to-end anastomosis to be fashioned.

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