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Original article
The interrupted serosubmucosal anastomosis – still the goldstandard
A. Leslie* and R. J. C. Steele*
*Department of Surgery and Molecular Oncology, University of Dundee, Dundee, UK
Received 8 July 2002; accepted 19 December 2002
Abstract
Background The single-layer appositional serosub-
mucosal anastomosis is a well established technique and
appears to have a favourable record. Over a 15-year
period the senior author of this paper has performed or
directly supervised 553 anastomoses using this technique.
This report describes the results of these operations, the
results of stapled anastomoses carried out during the
same period and discusses the utility of the handsewn
technique.
Methods From August 1986 to July 2001, 553 intes-
tinal anastomoses in 550 patients were fashioned using
single-layer, interrupted serosubmucosal 3 ⁄ 0 braided
polyamide and 131 anastomoses in 131 patients were
performed using a circular anastomosing stapler.
Results One anastomotic leakage occurred in the
group of patients whose anastomosis was handsewn
(0.2%) and 11 leaks occurred in those who had a stapled
anastomoses (8.4%). The mortality rate in each group was
similar (2% and 2.3%, respectively). There were no deaths
attributable to anastomotic dehiscence in either group.
Conclusion In this prospectively audited series of 553
handsewn anastomoses the leakage rate was 0.2%. These
results compare favourably with other published series
and continue to support a single layer of interrupted
serosubmucosal sutures as the gold standard for anasto-
moses involving the large or small bowel.
Keywords Serosubmucosal anastomosis, stapled anasto-
mosis, technique
Introduction
The concept of using the submucosal layer of the bowel
to hold stitches for a sound anastomosis was first
introduced by William Halsted in his publication of
1887 [1], but this described work in dogs, and there is no
evidence that Halsted ever applied his findings to man. It
fell to Matheson in Aberdeen, working from the 1960s to
the 1990s, to develop the technique for clinical use [2],
and the extramucosal, appositional, interrupted sero-
submucosal anastomosis has become widely used, with
reported leakage rates in the region of 2% [3,4].
Since 1986 the senior author of this paper has
employed this technique for all anastomoses involving
the large and small bowel with the exceptions of upper
gastrointestinal surgery, where a continuous sero-
submucosal technique was used [5], and low rectal
anastomoses, where stapling devices were employed. This
report describes the results of a continuous series of
operations carried out between August 1986 and July
2001 in four different centres either by, or under the
direct supervision of, the senior author with a view to
assessing the utility of the interrupted serosubmucosal
anastomosis. It represents an update of a previous report
[6], but on this occasion we have included all stapled low
anastomoses carried out by the same surgeon in order to
provide a complete picture of anastomosis-related mor-
bidity. It should be emphasized, however, that the
indications for sutured and stapled anastomoses in this
series were quite separate in that the stapled approach was
reserved for the lower anterior resections. This report
therefore should not be seen as a direct comparison of the
two techniques.
Patients and methods
Patients
Over a 15-year period 553 anastomoses involving the
large or small bowel in 550 patients (252 male, 298
Correspondence to: Ms A Leslie, Department of Surgery and Molecular Oncology,
University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK.
E-mail: a.leslie@dundee.ac.uk
362 � 2003 Blackwell Publishing Ltd. Colorectal Disease, 5, 362–366
female) were fashioned using the interrupted sero-
submucosal technique. During the same period 131
anastomoses involving the colon and rectum in 131
patients (71 male, 60 female) were performed using a
circular anastomosing stapler. Both elective and emer-
gency cases are included in this series, and there are no
exclusions. The types of procedures, indications for
operation and complications are given in Tables 1 and
2. The term ‘Anterior Resection’ is used to describe
restorative excision of lesions at or below the recto-
sigmoid junction; an anastomosis at the pelvic brim is not
included in this category. Anastomotic leakage was
defined as any clinical evidence of leakage that led to
intervention, resulted in a prolonged hospital stay or was
diagnosed at postmortem. Post-operative death was
defined as death within 30 days of surgery.
A mid-line incision was used in all operations apart
from five laparoscopically assisted right hemicolectomies
and one laparoscopically assisted low anterior resection.
Peri-operative single-dose intravenous antibiotic prophy-
Table 1 Details of 553 single-layer interrupted serosubmucosal anastomoses in 550 patients.
Operation Indication No. of cases Complications and comments
Right hemicolectomy Cancer 109 1 death – MI. 1 anastomotic leak
Crohns’ disease 55 5 performed laparoscopically
Trauma 5
Ischaemia 2
Extended Right hemicolectomy Cancer 34 1 death – MI
Ischaemia 2
Colocutaneous fistula 1 1 death – whole gut ischaemia
Left hemicolectomy Cancer 31 2 deaths – MI & respiratory failure
Diverticular disease 1
Sigmoid colectomy Cancer 106 2 deaths – MI & PE
Diverticular disease 6 1 death – respiratory failure
Anterior Resection Cancer 48
Reversal of Hartmann’s Cancer 20 1 small bowel fistula
Diverticular disease 8
Trauma 3
Closure of loop colostomy – 11
Closure of loop ileostomy – 50
Subtotal colectomy & ileorectal anastomosis Cancer 10 2 deaths – adhesions & aspiration
FAP 5
Crohns’ disease 4
Constipation 3
Small bowel resection Crohns’ disease 16 1 death – MSOF
Trauma 6
Involved in colonic tumour 4
Ischaemia 3
Meckel’s diverticulitis 3
Gall stone ileus 3
Primary tumour 2
Involved in diverticular disease 2
MI, myocardial infarction; PE, pulmonary embolism; MSOF, Multi-system organ failure; TME, Total Mesorectal Excision.
Operation Indication No. of cases
Complications
and comments
High anterior resection Cancer 27 1 anastomotic leak
Low anterior resection &
TME with defunctioning
stoma
Cancer 104 3 deaths – 2 MI,
1 pneumonia
& respiratory failure.
10 anastomotic leaks
Table 2 Details of 131 stapled anasto-
moses in 131 patients.
A. Leslie & R. J. C. Steele Interrupted serosubmucosal anastomosis
� 2003 Blackwell Publishing Ltd. Colorectal Disease, 5, 362–366 363
laxis (cephalosporin and metronidazole) was used rou-
tinely and at the end of the procedure the peritoneal
cavity was lavaged with tetracycline solution or more
latterly, cephalosporin solution. The fascial incision was
closed with No.1 polydioxanone suture (PDS�: Ethicon,
Edinburgh, UK), and the skin was closed using a variety
of techniques.
Anastomotic technique
The technique for the appositional serosubmucosal
anastomosis is well described by Matheson in two
photographic colour atlases of right and left hemicolec-
tomy [7,8], and the principles described therein can be
applied to all but the most extreme situations. In all cases
in the present series a single layer of interrupted 3 ⁄ 0braided polyamide (NurulonR, Ethicon) was used for its
tying properties which allow controlled ‘snugging’ of the
knot on the second throw (Fig. 1). Care was taken to
include the submucosal and serosal layers in each suture,
but the mucosa was deliberately avoided (Fig. 2); sutures were placed an estimated 4 mm apart and 4 mm deep as
far as possible.
For mobile anastomoses, two corner sutures were
placed between the mesenteric and antimesenteric bor-
ders of both bowel ends and placed under tension by
means of the weight of Mayo’s artery forceps. A middle
suture was then placed exactly half way between the
corner sutures and again held with an artery forceps to aid
accurate placement of the remaining sutures which were
inserted towards the operator and held by the assistant.
On completion of the first side of the anastomosis the
sutures were tied by hand to ensure a snug but
nonconstricting knot, using, in the majority of cases, five
throws with the first two in the same direction to facilitate
controlled tightening. With the exception of the corners,
all the sutures were then cut to leave 4 mm long tails, the
bowel ends turned over, and the process repeated to
complete the anastomosis. It should be noted that the
corner sutures were not tied until the second line of
sutures had been inserted; this makes for easier identifi-
cation of the bowel wall layers at the corners.
For anastomoses that could not be turned over
(usually colorectal after sigmoid colectomy or high
anterior resection), the sequence of events was different
although the same basic principles of placement and tying
of the sutures were applied. Firstly, stay sutures were
placed through the serosubmucosal layers of the colon
equidistant between the mesenteric and antimesenteric
borders, and then through the rectum in the same
positions, all four being held by Mayo’s artery forceps.
The two corner sutures were then placed in the same
place and direction as the stay sutures, i.e. through the
serosubmucosal layer of the colon parallel to the cut edge
Figure 1 Tying the serosubmucosal suture, showing (a) the first
throw and (b) the second throw, both in the same direction to
form a slip knot. This is then locked with three further throws.Note the sutures placed approximately four millimetres apart and
four millimetres deep, and the degree of tension applied.
Figure 2 Insertion of the serosubmucosal suture, avoiding the
mucosa.
Interrupted serosubmucosal anastomosis A. Leslie & R. J. C. Steele
364 � 2003 Blackwell Publishing Ltd. Colorectal Disease, 5, 362–366
(not through it) about 4 mm from it, and then through
the rectal wall in the same way. This manoeuvre turns the
corners of the colon and rectum in when the sutures are
eventually tied, resulting in a neat result and making
placement of the adjacent sutures easier.
Once the corner sutures were inserted they were held
by Crile’s artery forceps which were hung over the edge
of the wound. A centre suture was then placed between
the midpoints of the posterior layers of the colon and
rectum and held by a further Crile’s forceps. Working
towards the operator, sutures were then inserted along
the posterior layers of the colon and rectum, each suture
being held in a forceps which was threaded in turn on to a
forceps holder to avoid tangling the threads. The corner
sutures were not held in the forceps holder. To facilitate
definition of the bowel layers, it was found to be helpful
for the assistant to hold up the previously inserted suture
under a slight degree of tension, and for the operator to
hold the centre or corner suture under similar tension
with a pair of tissue forceps. Once the posterior layer was
complete, the sutures in the forceps holder were held up,
the stay sutures removed, and the colon slid down to the
rectum. Each of the sutures was then tied, taking care to
tie the corner sutures square in order to turn the corners
in. After cutting all the sutures except the corners, the
anterior layer of sutures was then inserted and tied in a
similar fashion. For this anastomosis it has been found to
be useful to use the curved Heaney or Stratte needle
holder to obtain the correct angle of the needle.
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.
Results
Following a total of 684 intestinal anastomoses, clinically
evident anastomotic leakage occurred in 12 patients
(1.8%). One leak occurred in the group of patients whose
anastomosis was fashioned using the interrupted sero-
submucosal technique (0.2%) and 11 occurred in the
group in whom a stapled anastomosis was performed
(8.4%). There were no specific features in these patients
that would have identified them at being at high risk of
anastomotic dehiscence.
There were a total of 14 deaths (2.1%): 11 in the
handsewn anastomosis group (2%) and three in the
stapled anastomosis group (2.3%). The cause of each
death is given in Tables 1 and 2. There were no deaths
associated with anastomotic dehiscence. In the handsewn
anastomotic group one patient developed a small bowel-
cutaneous fistula after reversal of a Hartmann’s operation;
this closed spontaneously. There were no other major
complications in either group.
Discussion
Published leakage rates after intestinal anastomosis are
highly variable. For example, in a recent meta-analysis of
13 randomised trials of handsewn vs stapled anastomosis
in colorectal surgery the clinical leakage rate for hand-
sewn varied from 0 to 10% and for stapled from 0 to 12%
[9]. Results from trials may not reflect experience
throughout the country, however, but owing to lack of
comprehensive prospective audit it is difficult to estimate
a reasonable average figure. Perhaps the most accurate
published data come from the Wales ⁄ Trent Audit, carried
out in 1992–93, which reported a 4% leakage rate after
colonic anastomosis and 8% after rectal anastomosis [10].
In this consecutive, prospectively audited series of 553
hand sewn anastomoses the leakage rate was 0.2%, a
figure which compares very well with any other large
published series, and, as far as we can tell, the national
average. There is little recent relevant literature other
than the meta-analysis referred to above, but a trial
comparing single-layer continuous with two layer inter-
rupted techniques published last year reported leakage
rates of 1.5% and 3.1%, respectively [11].
It has to be recognized that there is no universally
accepted and validated definition of anastomotic leak [12],
and this makes comparison of different series difficult.
However, the definition we adopted is in line with that
proposed by the UK Surgical Infection Study Group in
1991 [13], and we are confident that no clinically signi-
ficant event related to anastomotic leakage was missed.
Despite an impression that the interrupted sero-
submucosal anastomosis has become widely accepted
there are surprisingly few publications describing the
results of this technique. In Matheson’s own series,
published in 1985 [3], the leakage rate in 206 large
bowel intestinal anastomoses was 1.5%. Also in 1985
Errett et al. [14] described a 1.2% leak rate in 250 large
bowel anastomoses, and in the series reported by Carty
et al. [4] in 1991 it was 2.2% in 500 colorectal anastomoses.
Kingsnorth et al. [15] reported on a small heterogeneous
series in which they used both the open serosubmucosal
technique as described in this paper and a closed method.
They found the open method to be satisfactory with only
one leak out of 26 anastomoses, but the closed method was
associated with a leakage rate of 6.8% in 44 patients.
In our series of 553 handsewn anastomoses, one
clinically evident leak occurred in 1990. This was in a
27-year-old-man who had undergone a right hemicol-
ectomy for obstructing Crohn’s disease while on high-
dose steroids and cyclosporin. It is difficult to be sure
whether or not the therapy contributed to the leak, but
at re-laparotomy for peritonitis on day 2, the leakage
was traced to a single suture site. It was evident that
A. Leslie & R. J. C. Steele Interrupted serosubmucosal anastomosis
� 2003 Blackwell Publishing Ltd. Colorectal Disease, 5, 362–366 365
the suture had become untied, and from that time we
changed our policy to using five throws on every suture
as opposed to the three originally taught by Matheson.
The randomised trials comparing stapling with hand-
sewn anastomotic technique have not shown any differ-
ence in leakage rate [9], and the same is true of most trials
comparing one handsewn technique with another
[11,16–18]. It is likely therefore that the care with which
an anastomosis is carried out is more important than the
specific technique employed. There is no doubt, however,
that leakage rates can be kept very low by the interrupted
serosubmucosal technique, and while minimizing isch-
aemia by gentle apposition of the tissues may play a role,
we believe that the careful identification of the bowel
layers and the attention to detail demanded by the
technique ensures a sound result.
Although meticulous technique is clearly important,
anatomical location has a significant effect, and it is well
known that the low rectal anastomosis, particularly when
it is performed less that 5 cm from the anorectal junction
[19], is prone to leakage. This is borne out by our
experience of an 8.4% leak rate with the stapled anasto-
mosis after total mesorectal excision despite liberal use of
defunctioning stomas. Given the results of the random-
ised trials [9] these relatively poor results are not likely to
be due to stapling. This would be very difficult to prove
however; we have carried out moderately low rectal
anastomoses using the serosubmucosal technique, but
after total mesorectal excision we have found this to be
impossible, and the only way a manual anastomosis could
be achieved in this situation would involve the transanal
coloanal method. Although this technique has been used
after low anterior resection for cancer [20], it has never
been formally compared to a stapled anastomosis, and as
it would necessitate mucosectomy, it might have dele-
terious effects on function as experienced by some in
ileoanal pouch formation [21].
In conclusion, with the exception of low anterior
resection of rectum, leakage after intestinal anastomosis
can be virtually eliminated by the careful, standardized
use of a well-established technique. We commend the
interrupted serosubmucosal anastomosis as developed by
Matheson to all surgeons, particularly those who have an
interest in colorectal surgery.
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