Anastomotic Construction

  • Steven R. HuntEmail author
  • Matthew L. Silviera


This chapter summarizes the various techniques for common abdominal and pelvic anastomoses. General principles of anastomotic construction are summarized, including a review of the basic anastomotic types, techniques, equipment, and common problems leading to anastomotic complications. Controversial issues such as treatment of mesenteric defects, anastomotic drainage, and fecal diversion are presented. This chapter contains detailed descriptions for the creation of simple and complex anastomoses. The rationale and creation of various fecal reservoirs are explained. Finally, troubleshooting techniques for various intraoperative complications are discussed.


Anastomotic construction Hand-sewn anastomosis Anastomotic drainage Fecal diversion Neorectal reservoir Anastomotic salvage 

Supplementary material

Video 9.1

Extracorporeal assessment of the left colon prior to anastomosis using indocyanine green (ICG) (MP4 130,196 kb)

Video 9.2

Proctoscopic anastomotic view of a colorectal rectal anastomosis (MP4 260,584 kb)


  1. 1.
    Moran BJ. Stapling instruments for intestinal anastomosis in colorectal surgery. Br J Surg. 1996;83(7):902–9.PubMedGoogle Scholar
  2. 2.
    Ceraldi CM, et al. Comparison of continuous single layer polypropylene anastomosis with double layer and stapled anastomoses in elective colon resections. Am Surg. 1993;59(3):168–71.PubMedGoogle Scholar
  3. 3.
    Everett WG. A comparison of one layer and two layer techniques for colorectal anastomosis. Br J Surg. 1975;62(2):135–40.PubMedGoogle Scholar
  4. 4.
    Fielding LP, et al. Anastomotic integrity after operations for large-bowel cancer: a multicentre study. Br Med J. 1980;281(6237):411–4.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Reichel K, Rauner P, Guthy E. Clinical and experimental evaluation of single and double layer entero anastomosis. Chirurg Gastroenterol. 1975;9:461–7.Google Scholar
  6. 6.
    Slieker JC, et al. Systematic review of the technique of colorectal anastomosis. JAMA Surg. 2013;148(2):190–201.PubMedGoogle Scholar
  7. 7.
    Andersen E, Sondenaa K, Holter J. A comparative study of polydioxanone (PDS) and polyglactin 910 (Vicryl) in colonic anastomoses in rats. Int J Colorectal Dis. 1989;4(4):251–4.PubMedGoogle Scholar
  8. 8.
    Foresman PA, Edlich RF, Rodeheaver GT. The effect of new monofilament absorbable sutures on the healing of musculoaponeurotic incisions, gastrostomies, and colonic anastomoses. Arch Surg. 1989;124(6):708–10.PubMedGoogle Scholar
  9. 9.
    Bubrick MP, et al. Prospective, randomized trial of the biofragmentable anastomosis ring. The BAR Investigational Group. Am J Surg. 1991;161(1):136–42. discussion 142–3.PubMedGoogle Scholar
  10. 10.
    Corman ML, et al. Comparison of the Valtrac biofragmentable anastomosis ring with conventional suture and stapled anastomosis in colon surgery. Results of a prospective, randomized clinical trial. Dis Colon Rectum. 1989;32(3):183–7.PubMedGoogle Scholar
  11. 11.
    Hardy Jr TG, et al. A biofragmentable ring for sutureless bowel anastomosis. An experimental study. Dis Colon Rectum. 1985;28(7):484–90.PubMedGoogle Scholar
  12. 12.
    Pahlman L, et al. Randomized trial of a biofragmentable bowel anastomosis ring in high-risk colonic resection. Br J Surg. 1997;84(9):1291–4.PubMedGoogle Scholar
  13. 13.
    Seow-Choen F, Eu KW. Circular staplers versus the biofragmentable ring for colorectal anastomosis: a prospective randomized study. Br J Surg. 1994;81(12):1790–1.PubMedGoogle Scholar
  14. 14.
    Thiede A, et al. Overview on compression anastomoses: biofragmentable anastomosis ring multicenter prospective trial of 1666 anastomoses. World J Surg. 1998;22(1):78–86. discussion 87.PubMedGoogle Scholar
  15. 15.
    Kim HR, et al. Early surgical outcomes of NiTi endoluminal compression anastomotic clip (NiTi CAC 30) use in patients with gastrointestinal malignancy. J Laparoendosc Adv Surg Tech A. 2012;22(5):472–8.PubMedGoogle Scholar
  16. 16.
    D’Hoore A, et al. COMPRES: a prospective postmarketing evaluation of the compression anastomosis ring CAR 27()/ColonRing(). Colorectal Dis. 2015;17(6):522–9.Google Scholar
  17. 17.
    Masoomi H, et al. Compression anastomosis ring device in colorectal anastomosis: a review of 1,180 patients. Am J Surg. 2013;205(4):447–51.PubMedGoogle Scholar
  18. 18.
    Jafari MD, et al. Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study. J Am Coll Surg. 2015;220(1):82–92.e1.Google Scholar
  19. 19.
    Jesus EC et al. Prophylactic anastomotic drainage for colorectal surgery. Cochrane Database Syst Rev 2004; (4): CD002100.Google Scholar
  20. 20.
    Urbach DR, Kennedy ED, Cohen MM. Colon and rectal anastomoses do not require routine drainage: a systematic review and meta-analysis. Ann Surg. 1999;229(2):174–80.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Merad F, et al. Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. French Association for Surgical Research. Surgery. 1999;125(5):529–35.PubMedGoogle Scholar
  22. 22.
    Rondelli F, et al. To drain or not to drain extraperitoneal colorectal anastomosis? A systematic review and meta-analysis. Colorectal Dis. 2014;16(2):O35–42.PubMedGoogle Scholar
  23. 23.
    Cabot JC, et al. Long-term consequences of not closing the mesenteric defect after laparoscopic right colectomy. Dis Colon Rectum. 2010;53(3):289–92.PubMedGoogle Scholar
  24. 24.
    Causey MW, Oguntoye M, Steele SR. Incidence of complications following colectomy with mesenteric closure versus no mesenteric closure: does it really matter? J Surg Res. 2011;171(2):571–5.PubMedGoogle Scholar
  25. 25.
    Rullier E, et al. Risk factors for anastomotic leakage after resection of rectal cancer. Br J Surg. 1998;85(3):355–8.PubMedGoogle Scholar
  26. 26.
    Bertelsen CA, et al. Anastomotic leakage after anterior resection for rectal cancer: risk factors. Colorectal Dis. 2010;12(1):37–43.PubMedGoogle Scholar
  27. 27.
    Platell C, Barwood N, Makin G. Clinical utility of a de-functioning loop ileostomy. ANZ J Surg. 2005;75(3):147–51.PubMedGoogle Scholar
  28. 28.
    Chow A, et al. The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Colorectal Dis. 2009;24(6):711–23.PubMedGoogle Scholar
  29. 29.
    Pokorny H, et al. Predictors for complications after loop stoma closure in patients with rectal cancer. World J Surg. 2006;30(8):1488–93.PubMedGoogle Scholar
  30. 30.
    Chen TA. Loop ileostomy or loop colostomy: which one is better for fecal diversion? Int J Colorectal Dis. 2012;27(1):131–2.PubMedGoogle Scholar
  31. 31.
    Nurkin S, et al. The role of faecal diversion in low rectal cancer: a review of 1791 patients having rectal resection with anastomosis for cancer, with and without a proximal stoma. Colorectal Dis. 2013;15(6):e309–16.PubMedGoogle Scholar
  32. 32.
    Tan WS, et al. Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg. 2009;96(5):462–72.PubMedGoogle Scholar
  33. 33.
    Shiomi A, et al. Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis of 1,014 consecutive patients. J Am Coll Surg. 2015;220(2):186–94.Google Scholar
  34. 34.
    Chude GG, et al. Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study. Hepatogastroenterology. 2008;55(86–87):1562–7.PubMedGoogle Scholar
  35. 35.
    Matthiessen P, et al. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg. 2007;246(2):207–14.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Ulrich AB, et al. Diverting stoma after low anterior resection: more arguments in favor. Dis Colon Rectum. 2009;52(3):412–8.PubMedGoogle Scholar
  37. 37.
    Guenaga KF et al. Ileostomy or colostomy for temporary decompression of colorectal anastomosis. Cochrane Database Syst Rev 2007; (1): CD004647.Google Scholar
  38. 38.
    Goulder F. Bowel anastomoses: the theory, the practice and the evidence base. World J Gastrointest Surg. 2012;4(9):208–13.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Leung TT, et al. Comparison of stapled versus handsewn loop ileostomy closure: a meta-analysis. J Gastrointest Surg. 2008;12(5):939–44.PubMedGoogle Scholar
  40. 40.
    Choy PY et al. Stapled versus handsewn methods for ileocolic anastomoses. Cochrane Database Syst Rev 2011; (9): CD004320.Google Scholar
  41. 41.
    Liu Z, et al. Ileocolonic anastomosis after right hemicolectomy for colon cancer: functional end-to-end or end-to-side? World J Surg Oncol. 2014;12:306.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Carnuccio P, Jimeno J, Pares D. Laparoscopic right colectomy: a systematic review and meta-analysis of observational studies comparing two types of anastomosis. Tech Coloproctol. 2014;18(1):5–12.PubMedGoogle Scholar
  43. 43.
    Tarta C, Bishawi M, Bergamaschi R. Intracorporeal ileocolic anastomosis: a review. Tech Coloproctol. 2013;17(5):479–85.PubMedGoogle Scholar
  44. 44.
    Hallbook O, et al. Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection. Ann Surg. 1996;224(1):58–65.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Hida J, et al. Indications for colonic J-pouch reconstruction after anterior resection for rectal cancer: determining the optimum level of anastomosis. Dis Colon Rectum. 1998;41(5):558–63.PubMedGoogle Scholar
  46. 46.
    Neutzling CB et al. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2012; (2): CD003144.Google Scholar
  47. 47.
    Baker JW. Low end to side rectosigmoid anastomosis; description of technique. Arch Surg. 1950;61(1):143–57.PubMedGoogle Scholar
  48. 48.
    Bryant CL, et al. Anterior resection syndrome. Lancet Oncol. 2012;13(9):e403–8.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Bloemen JG, et al. Long-term quality of life in patients with rectal cancer: association with severe postoperative complications and presence of a stoma. Dis Colon Rectum. 2009;52(7):1251–8.PubMedGoogle Scholar
  50. 50.
    Lange MM, van de Velde CJ. Faecal and urinary incontinence after multimodality treatment of rectal cancer. PLoS Med. 2008;5(10):e202.PubMedPubMedCentralGoogle Scholar
  51. 51.
    Keighley MR, Matheson D. Functional results of rectal excision and endo-anal anastomosis. Br J Surg. 1980;67(10):757–61.PubMedGoogle Scholar
  52. 52.
    Lazorthes F, et al. Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum. Br J Surg. 1986;73(2):136–8.PubMedGoogle Scholar
  53. 53.
    Parc R, et al. Resection and colo-anal anastomosis with colonic reservoir for rectal carcinoma. Br J Surg. 1986;73(2):139–41.PubMedGoogle Scholar
  54. 54.
    Dehni N, et al. Long-term functional outcome after low anterior resection: comparison of low colorectal anastomosis and colonic J-pouch-anal anastomosis. Dis Colon Rectum. 1998;41(7):817–22. discussion 822–3.PubMedGoogle Scholar
  55. 55.
    Joo JS, et al. Long-term functional evaluation of straight coloanal anastomosis and colonic J-pouch: is the functional superiority of colonic J-pouch sustained? Dis Colon Rectum. 1998;41(6):740–6.PubMedGoogle Scholar
  56. 56.
    Kusunoki M, et al. Function after anoabdominal rectal resection and colonic J pouch--anal anastomosis. Br J Surg. 1991;78(12):1434–8.PubMedGoogle Scholar
  57. 57.
    Lazorthes F, et al. Late clinical outcome in a randomized prospective comparison of colonic J pouch and straight coloanal anastomosis. Br J Surg. 1997;84(10):1449–51.PubMedGoogle Scholar
  58. 58.
    Ortiz H, et al. Coloanal anastomosis: are functional results better with a pouch? Dis Colon Rectum. 1995;38(4):375–7.PubMedGoogle Scholar
  59. 59.
    Seow-Choen F, Goh HS. Prospective randomized trial comparing J colonic pouch-anal anastomosis and straight coloanal reconstruction. Br J Surg. 1995;82(5):608–10.PubMedGoogle Scholar
  60. 60.
    Portier G, Platonoff I, Lazorthes F. Long-term functional results after straight or colonic J-pouch coloanal anastomosis. Recent Results Cancer Res. 2005;165:191–5.PubMedGoogle Scholar
  61. 61.
    Hida J, et al. Long-term functional changes after low anterior resection for rectal cancer compared between a colonic J-pouch and a straight anastomosis. Hepatogastroenterology. 2007;54(74):407–13.PubMedGoogle Scholar
  62. 62.
    Harris GJ, Lavery IC, Fazio VW. Function of a colonic J pouch continues to improve with time. Br J Surg. 2001;88(12):1623–7.PubMedGoogle Scholar
  63. 63.
    Brown CJ, Fenech DS, McLeod RS. Reconstructive techniques after rectal resection for rectal cancer. Cochrane Database Syst Rev 2008; (2): CD006040.Google Scholar
  64. 64.
    Hida J, et al. Functional outcome after low anterior resection with low anastomosis for rectal cancer using the colonic J-pouch. Prospective randomized study for determination of optimum pouch size. Dis Colon Rectum. 1996;39(9):986–91.PubMedPubMedCentralGoogle Scholar
  65. 65.
    Lazorthes F, et al. Prospective, randomized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis. Dis Colon Rectum. 1997;40(12):1409–13.PubMedGoogle Scholar
  66. 66.
    Hallbook O, Sjodahl R. Anastomotic leakage and functional outcome after anterior resection of the rectum. Br J Surg. 1996;83(1):60–2.PubMedGoogle Scholar
  67. 67.
    Hallbook O, Johansson K, Sjodahl R. Laser Doppler blood flow measurement in rectal resection for carcinoma--comparison between the straight and colonic J pouch reconstruction. Br J Surg. 1996;83(3):389–92.PubMedGoogle Scholar
  68. 68.
    Ramirez JM, et al. Colonic J-pouch rectal reconstruction--is it really a neorectum? Dis Colon Rectum. 1996;39(11):1286–8.PubMedGoogle Scholar
  69. 69.
    Hida J, et al. Comparison of long-term functional results of colonic J-pouch and straight anastomosis after low anterior resection for rectal cancer: a five-year follow-up. Dis Colon Rectum. 2004;47(10):1578–85.PubMedGoogle Scholar
  70. 70.
    Furst A, et al. Colonic J-pouch vs. coloplasty following resection of distal rectal cancer: early results of a prospective, randomized, pilot study. Dis Colon Rectum. 2003;46(9):1161–6.PubMedGoogle Scholar
  71. 71.
    Fazio VW, et al. A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers. Ann Surg. 2007;246(3):481–8. discussion 488–90.PubMedPubMedCentralGoogle Scholar
  72. 72.
    Z’Graggen K, et al. A new surgical concept for rectal replacement after low anterior resection: the transverse coloplasty pouch. Ann Surg. 2001;234(6):780–5. discussion 785–7.PubMedPubMedCentralGoogle Scholar
  73. 73.
    Ho YH, et al. Comparison of J-pouch and coloplasty pouch for low rectal cancers: a randomized, controlled trial investigating functional results and comparative anastomotic leak rates. Ann Surg. 2002;236(1):49–55.PubMedPubMedCentralGoogle Scholar
  74. 74.
    Pimentel JM, et al. Transverse coloplasty pouch and colonic J-pouch for rectal cancer--a comparative study. Colorectal Dis. 2003;5(5):465–70.PubMedGoogle Scholar
  75. 75.
    Huber FT, Herter B, Siewert JR. Colonic pouch vs. side-to-end anastomosis in low anterior resection. Dis Colon Rectum. 1999;42(7):896–902.PubMedGoogle Scholar
  76. 76.
    Machado M, et al. Similar outcome after colonic pouch and side-to-end anastomosis in low anterior resection for rectal cancer: a prospective randomized trial. Ann Surg. 2003;238(2):214–20.PubMedPubMedCentralGoogle Scholar
  77. 77.
    Machado M, et al. Functional and physiologic assessment of the colonic reservoir or side-to-end anastomosis after low anterior resection for rectal cancer: a two-year follow-up. Dis Colon Rectum. 2005;48(1):29–36.PubMedGoogle Scholar
  78. 78.
    Ho YH, Tan M, Seow-Choen F. Prospective randomized controlled study of clinical function and anorectal physiology after low anterior resection: comparison of straight and colonic J pouch anastomoses. Br J Surg. 1996;83(7):978–80.PubMedGoogle Scholar
  79. 79.
    Furst A, et al. Neorectal reservoir is not the functional principle of the colonic J-pouch: the volume of a short colonic J-pouch does not differ from a straight coloanal anastomosis. Dis Colon Rectum. 2002;45(5):660–7.PubMedGoogle Scholar
  80. 80.
    Ho YH, et al. Small colonic J-pouch improves colonic retention of liquids – randomized, controlled trial with scintigraphy. Dis Colon Rectum. 2002;45(1):76–82.PubMedGoogle Scholar
  81. 81.
    Baik SH, et al. Hand-sewn coloanal anastomosis for distal rectal cancer: long-term clinical outcomes. J Gastrointest Surg. 2005;9(6):775–80.PubMedGoogle Scholar
  82. 82.
    Laurent A, et al. Colonic J-pouch-anal anastomosis for rectal cancer: a prospective, randomized study comparing handsewn vs. stapled anastomosis. Dis Colon Rectum. 2005;48(4):729–34.PubMedGoogle Scholar
  83. 83.
    Smith S, et al. The efficacy of intraoperative methylene blue enemas to assess the integrity of a colonic anastomosis. BMC Surg. 2007;7:15.PubMedPubMedCentralGoogle Scholar
  84. 84.
    Beard JD, et al. Intraoperative air testing of colorectal anastomoses: a prospective, randomized trial. Br J Surg. 1990;77(10):1095–7.Google Scholar
  85. 85.
    Davies AH, et al. Intra-operative air testing: an audit on rectal anastomosis. Ann R Coll Surg Engl. 1988;70(6):345–7.PubMedPubMedCentralGoogle Scholar
  86. 86.
    Kwon S, et al. Routine leak testing in colorectal surgery in the Surgical Care and Outcomes Assessment Program. Arch Surg. 2012;147(4):345–51.PubMedPubMedCentralGoogle Scholar
  87. 87.
    Ricciardi R, et al. Anastomotic leak testing after colorectal resection: what are the data? Arch Surg. 2009;144(5):407–11. discussion 411–2.Google Scholar
  88. 88.
    Hanna MH, Vinci A, Pigazzi A. Diverting ileostomy in colorectal surgery: when is it necessary? Langenbecks Arch Surg. 2015;400(2):145–52.Google Scholar
  89. 89.
    Kamal T, et al. Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection? Colorectal Dis. 2015;17:160.Google Scholar
  90. 90.
    Li VK, et al. Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure? Surg Endosc. 2009;23(11):2459–65.Google Scholar
  91. 91.
    Rombeau JL, Collins JP, Turnbull Jr RB. Left-sided colectomy with retroileal colorectal anastomosis. Arch Surg. 1978;113(8):1004–5.PubMedGoogle Scholar
  92. 92.
    Deloyers L. Suspension of the right colon permits without exception preservation of the anal sphincter after extensive colectomy of the transverse and left colon (including rectum). Technic -indications- immediate and late results. Lyon Chir. 1964;60:404–13.PubMedGoogle Scholar

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Authors and Affiliations

  1. 1.Section of Colon and Rectal Surgery, Division of General Surgery, Department of Surgery, Barnes Jewish HospitalWashington University School of MedicineSt. LouisUSA

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