The handsewn anastomosis after colon resection due to colonic
M. G. Pramateftakis•G. Vrakas•P. Hatzigianni•
T. Tsachalis•I. Matzoros•E. Christoforidis•
D. Raptis•G. Roidos•C. Lazaridis
Published online: 4 August 2010
? Springer-Verlag 2010
the handsewn single-layer interrupted extramucosal anas-
tomosis following colon cancer.
Patients and methods
In the period between 1989 and
2009, 276 intestinal anastomoses were fashioned following
colon resection using single-layer interrupted extramucosal
The mean hospital stay was 8.2 days. Twenty-
three patients had postoperative complications, and the
total morbidity was 8.3%. Seven anastomotic leakages
occurred (2.5%). The mortality rate was 2.5%.
The single-layer anastomosis with inter-
rupted extramucosal sutures after colon resection is safe
The purpose of our study is to present the results of
Colon resection ? Single-layer anastomosis ?
During the last decades, a variety of techniques, materials
and devices has been successfully applied for the con-
struction of an intestinal anastomosis. The method that has
proven to be successful in most situations is the single-
layer appositional extramucosal anastomosis. Kanellos 
and Matheson et al.  describe the technique for clinical
use that has become widely accepted, with reported leak-
age rates in the region of 2%. The safety and efficacy of an
intestinal anastomosis, however, is evaluated by its com-
plication rate and particularly by the incidence of anasto-
motic leakage [3–6].
The purpose of our study is to present the results of the
handsewn single-layer interrupted extramucosal anasto-
mosis following colon cancer.
Patients and methods
Between 1989 and 2009, 276 patients (144 men and 132
women) with colorectal cancer underwent surgical treat-
ment by resection and anastomosis involving the colon and
rectum. The mean age of the patients was 65.5 years (range
30–86 years). The resections were performed under cura-
tive intent in 238 (86.2%) patients, while in the remaining
38 (13.8%), the resections were palliative.
In 258 (93.5%) patients, the operations were accom-
plished under elective setting, with full mechanical and
antibiotic bowel preparation. Perioperative antibiotics
(second-generation cephalosporin and metronidazole) were
administered, with the initial dose given immediately
before surgery and continued for 24-h postoperatively.
Low molecular weight heparin was also administered for
deep vein thrombosis prophylaxis. In 18 (6.5%) patients,
the surgical procedures were performed under emergency
setting. However, these patients underwent a one-stage
surgical intervention. All the patients underwent handsewn
single-layer interrupted extramucosal anastomosis with 3/0
They were 94 (34.1%) right colectomies, 8 (2.9%)
laparoscopic right colectomies, 10 (3.6%) transverse
colectomies, 21 (7.6%) left colectomies, 109 (39.5%)
M. G. Pramateftakis (&) ? G. Vrakas ? P. Hatzigianni ?
T. Tsachalis ? I. Matzoros ? E. Christoforidis ? D. Raptis ?
G. Roidos ? C. Lazaridis
4th Surgical Department, Aristotle University of Thessaloniki,
Antheon 1, 55236 Panorama, Thessaloniki, Greece
Tech Coloproctol (2010) 14 (Suppl 1):S57–S59
sigmoidectomies, 3 (1.1%) laparoscopic sigmoidectomies,
8 (2.9%) high anterior resections, 7 (2.5%) low anterior
resections, 7 (2.5%) subtotal colectomies, 1 (0.4%) total
colectomy, 5 (1.8%) palliative ileo-transverse anastomoses
and 3 (1.1%) palliative ileo-sigmoid anastomoses.
Anastomotic leakage was defined as any clinical evi-
dence of leakage that required surgical or conservative
intervention. Clinical signs of anastomotic leakage inclu-
ded postoperative fever/tachycardia, septicemia, abdominal
pain, fecal drainage from the wound or generalized peri-
tonitis. Diagnosis of the leakage was based on clinical
features, serum blood investigations and abdominal CT
scan. Postoperative death was defined as any death within
30 days of the operation.
The technique for the appositional end-to-end extra-
mucosal anastomosis is well described by I. Kanellos ,
and the principles described therein can be applied to all
but the most extreme situations. The handsewn anasto-
mosis in all cases was fashioned by single-layer technique
using interrupted extramucosal 3/0 Vicryl sutures. Care
was taken to include the submucosal and serosal layers in
each bite, but not the mucosa. Sutures were placed 4 mm
apart and 4 mm deep as far as possible. On completion of
the posterior line of the anastomosis, the sutures were tied
by non-constricting knots using five throws with the first
two in the same direction to facilitate controlled tightening,
whereupon all the sutures were cut except for the corner
sutures. Then, the bowel ends were turned over and the
same process was repeated for the anterior line in order to
complete the anastomosis. The corner sutures were tied
after the completion of the anterior line in order to identify
easier the bowel wall layers at the corners. It should be
noted that in all cases, meticulous care was taken to ensure
good blood supply to the cut ends of bowel and complete
lack of tension on the anastomosis.
The mean hospital stay was 8.2 days (range 4–28). Most of
the postoperative complications were minor ones, while the
overall postoperative morbidity was 8.3% (23 patients).
The most common complication detected was wound
infection that occurred in 6 patients. One of them devel-
oped wound dehiscence requiring re-suturing. Three
patients developed wound lymphorrhea, which was man-
aged conservatively. Additionally, 3 patients developed
prolonged ileus (defined as lack of bowel function for more
than 4 days).
Following a total of 276 intestinal anastomoses, clini-
cally evident anastomotic leakage occurred in 7 patients
(2.5%). One post transverse colectomy, one post left
colectomy, four post sigmoidectomies and one post
anterior resection. There were no specific features in these
patients that would have identified them at being at high
risk of anastomotic dehiscence.
There were seven deaths (2.5%) [3 due to anastomotic
dehiscence, 2 due to heart failure, 1 due to superior mes-
enteric artery embolism and 1 due to generalized
Anastomotic leakage continues to be the leading cause of
postoperative morbidity and mortality following intestinal
surgery. Thus, a baseline intestinal leakage rate can be
expected in any series of cases despite improvements in
Accordingly, in order to create a safer anastomosis, a
variety of intestinal anastomotic techniques have been
described in the literature. Among these techniques, hand-
sutured anastomosis is a well-established technique and
may be accomplished in a variety of methods. These
include single-layer or multiple-layer techniques, using
interrupted or continuous sutures of a multiplicity of suture
Over the years, the interrupted extramucosal anasto-
motic method has been widely accepted and represents one
of the most widely used techniques for restoring bowel
continuity. Leslie et al.  reported a clinical leakage rate
of 0.2% using this anastomotic technique. However, Burch
et al.  claimed that the anastomotic technique that has
proven successful in most situations is the two-layer
anastomosis using interrupted sutures for the outer inverted
seromuscular layer and a running absorbable suture for the
transmural inner layer.
When comparing continuous with interrupted anasto-
motic methods, it is certainly possible to create an ischemic
continuous anastomosis by applying too much tension
while following the suture. According to this, the imme-
diate concern after continuous suture is the narrowing of
the anastomosis due to the purse-string phenomenon .
The interrupted extramucosal anastomosis has been the
technique of choice for the restoration of large bowel
continuity in our practice. The leakage rate of 2.5% com-
bined with the reporting leakage rate of similar studies, and
the fact that there have been no postoperative anastomotic
strictures in our study, confirms the safety and low com-
plications rate of this technique.
There is also much debate in the literature regarding the
performance of stapled versus handsewn anastomosis .
Over the last years, the role of stapling devices in gastro-
intestinal surgery has been extensively studied.
The morbidity rate after colon and intraperitoneal rec-
tum resection is reported to be as high as 37% . In our
S58Tech Coloproctol (2010) 14 (Suppl 1):S57–S59
study, the overall postoperative morbidity rate was 8.3%. Download full-text
Additionally, the reported mortality rate after colorectal
anastomoses ranged between 2.4 and 3.6% [1–3]. In our
study, we demonstrated a morbidity rate of 2.5%.
In conclusion, the single-layer anastomosis with inter-
rupted extramucosal sutures after colon resection is safe
Conflict of interest
of interest related to the publication of this article.
The authors declare that they have no conflict
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