Principles of Successful Intestinal Anastomosis

Technical Factors

- Adequate blood supply

- Tension-free
- Minimize fecal contamination
- Accurate apposition of bowel ends
- Inverted edges
- Ensure patency
- Adequate resection margin
- Closure of mesenteric defects
- Avoid distal obstrcution
- Protection of anastomosis (e.g by loop ileostomy)

Patient-Related Factors

− Malnourished

− Chronic steroid use

− Diabetes mellitus

− Malignancy, prior chemoradiation

− Hypotension/Shock

− Emergency surgery
1. Hand Sewn Technique
 Suture Material
o Ideal suture is one that elicits little to no inflammatory response while
maintaining strength of the anastomosis during the lag phase of healing
 Continuous versus Interrupted
o No significant difference
 Single-layer versus Double-layer
o No difference in leak rates

Most surgeons adopt an interrupted single-layer serosubmucosal technique as the

gold standard using an absorbable suture.

2. Staple Technique
 Various stapling devices
 Staples come in various width, height, distance between staples
 Each designed for specific tissues
 Open and laparoscopic uses
 Made of titanium – minimal tissue reaction
 Non-magnetic – MRI compatiable

Hand sewn Staple

- Low cost - Expensive
- Longer operating time - Shorter operating time
- Learning curve - Easy to learn
- Surgeon experience - Little variability
- Great variability - Easier in less accessible areas (e.g AP
resection)
- Malfunctioning of device/Misfiring

3. Sutureless Compression Anastomosis

 Tissue glue
 Compression rings : e.g Valtrac BAR (Biofragmentable Anastomosis Ring)
Examples of Staplers

1. Transverse Anastomosis (TA) Stapler

o 2 staggered rows of staples

o Does not cut

2. Gastrointestinal Anastomosis (GIA) Stapler

o 2 double rows of staples

o Simultaneously cuts in between the rows

3. End-to-end Anastomosis (EEA) circular stapler

o Double rows of staples in circle

o Tissue cut within the circle of staples with cylindrical knife