If the patient is hemodynamically stable, the bowel anastomosis can be performed using either a hand-sewn or stapled technique. A hand-sewn anastomosis may be performed in an end-to-end fashion in either one or two layers, as long as the bowel diameters are approximately equal. Alternatively, a side-to-side (functional end-to-end) or end-to-side hand-sewn anastomosis may be performed. There is no difference in leak rate between single and double layer anastomoses [6, 7]; this can be left to surgeon preference. A single layer anastomosis or the inner layer of a two layer anastomosis can be performed with either a running transmural technique or using interrupted sutures. We prefer to use monofilament absorbable suture, often 2-0 or 3-0 polydioxanone (PDS®) suture (Ethicon, Cincinnati OH). It is critical to take full thickness bites to prevent anastomotic breakdown or leakage as the submucosal layer of the small bowel provides strength to the anastomosis [1]. The outer layer of suture closure is performed in an interrupted Lembert fashion using braided permanent suture, typically 3-0 silk suture.

Stapled anastomoses are typically faster than hand-sewn and are associated with equivalent rates of clinically evident leakage, morbidity, and post-operative mortality [8, 9]. The proximal and distal segments of bowel are aligned in a side-to-side fashion and two silk sutures are placed, one at the staple line and the other more distally, to temporarily secure the two segments in proper alignment (Fig. 19.2). Small enterotomies are then made on the anti-mesenteric side of each segment near the resection edges. A linear stapling device (e.g. GIA stapler) of either 60 or 80 mm is then inserted with one arm through each enterotomy (Fig. 19.3). After confirming that the mesenteries of the bowel segments are outside of the stapling device, it is closed and fired creating a large enteroenterostomy. The stapler is removed and an Army Navy retractor can be used to inspect the luminal staple line for hemostasis. If the patient is on therapeutic anticoagulation, a running monofilament absorbable suture can be placed along the luminal staple line to reinforce the area and assure hemostasis (Fig. 19.4). The common channel enterotomy can then be closed using a hand-sewn technique as above or by firing across the enterotomy with a stapler (either a TA or GIA stapler) (Fig. 19.5). Some surgeons choose to oversew the staple lines with interrupted Lembert braided permanent sutures to create a second layer (Fig. 19.6). Most surgeons place one or more braided sutures distally to reinforce the end of the staple line where the two bowel segments diverge. Depending on its size, the mesenteric defect can then be closed using either running or interrupted braided absorbable sutures, taking care not to injure the blood vessels running through the mesentery (Fig. 19.7).