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Bowel resection techniques

Bowel resection techniques
Literature review current through: Jan 2024.
This topic last updated: Mar 29, 2022.

INTRODUCTION — Bowel resection and anastomosis is one of the most common and important procedures performed by general surgeons. The ability to perform a successful bowel anastomosis in a variety of fashions is required.

The basic techniques of open and laparoscopic bowel resection and anastomosis are described in this topic. Additional techniques of gastrointestinal surgery are discussed elsewhere:

Esophagectomy (see "Surgical management of resectable esophageal and esophagogastric junction cancers")

Gastrectomy (see "Partial gastrectomy and gastrointestinal reconstruction" and "Total gastrectomy and gastrointestinal reconstruction" and "Laparoscopic gastrectomy for cancer")

Bariatric surgery (see "Laparoscopic Roux-en-Y gastric bypass" and "Laparoscopic sleeve gastrectomy")

Colectomy (see "Overview of colon resection" and "Surgical resection of primary colon cancer" and "Right and extended right colectomy: Open technique" and "Left colectomy: Open technique" and "Minimally invasive techniques: Left/sigmoid colectomy and proctectomy" and "Restorative proctocolectomy with ileal pouch-anal anastomosis: Laparoscopic approach")

Proctectomy (see "Radical resection of rectal cancer" and "Surgical treatment of rectal cancer" and "Abdominal perineal resection (APR): Open technique")

In addition, other topics discuss the management of common gastrointestinal problems that may lead to a bowel resection, such as:

Perforation (see "Overview of gastrointestinal tract perforation")

Obstruction (see "Management of small bowel obstruction in adults" and "Large bowel obstruction")

SURGICAL ANATOMY — The bowel wall is comprised of four layers: the mucosa, submucosa, muscularis propria, and serosa. The submucosa is the "strength" layer of the anastomosis and must be included in every suture pass (figure 1).

The vascular supply to the bowel is via the mesentery. The superior mesenteric artery gives rise to the arcuate system that supplies the vasa recta of the small intestine. The arcades are simple and primary in the proximal jejunum but increase in complexity in the more distal portions of the intestine. The vasa recta arise from the most peripheral arcades and do not intercommunicate (figure 2). This configuration leaves the antimesenteric borders of the bowel at the highest risk for ischemia, especially if reconstructions are not centered on them.

If an anastomosis is constructed off to one side of the bowel, there will be a shorter distance for the blood supply to reach the mesenteric aspect of the anastomosis. However, the blood supply to the antimesenteric aspect of the anastomosis must travel a considerably longer distance over the antimesenteric border of the bowel. That puts the antimesenteric aspect of the anastomosis at a much higher risk of ischemia (figure 3). For this reason, we suggest centering side-to-side and side-to-end anastomoses on the antimesenteric border of the bowel, rather than off to one side, whenever possible, to minimize ischemia. (See 'Open resection' below.)

MATERIALS — An intestinal resection can be performed using either a surgical instrument (knife or scissors) or a stapler to transect the bowel and either a vessel-sealing device or sutures to cut and ligate the mesentery. The subsequent bowel anastomosis can be carried out using sutures (handsewn), staplers, or a combination of both.

Suture types — Practically speaking, surgeons may select any type of suture, so long as they adhere to the essential tenets of anastomoses (see 'General principles' below). There is no proven advantage of one suture type over another for a successful anastomosis.

The ideal suture would provide adequate tensile strength throughout the healing process while minimizing local tissue reaction. Individual suture characteristics vary, but generally speaking, the typical absorbable sutures used for bowel anastomoses maintain tensile strength for two to three weeks and are absorbed by hydrolysis after two to three months. Nonabsorbable sutures maintain their tensile strength throughout the entire healing process.

Common brands of braided absorbable sutures include Vicryl and Polysorb. A criticism of braided sutures is damage due to tissue drag. Common brands of monofilament absorbable sutures include Monocryl, Biosyn, PDS, and Maxon. Monofilament sutures traverse tissue with minimal drag, though their tendency to slip requires additional knots when compared with braided sutures.

Common nonabsorbable sutures include silk, nylon, and polypropylene. The benefits and drawbacks to these braided and monofilament sutures are the same as their absorbable counterparts. However, silk has an additional drawback of potentially acting as a nidus of infection due to its braided nature.

Sutures used in abdominal surgery are further discussed in another topic. (See "Principles of abdominal wall closure", section on 'Sutures'.)

Staplers — There are three standard types of surgical staplers used for bowel resection and reconstruction:

Transverse anastomosis (TA) staplers are typically noncutting straight staplers that lay down several rows of staples. After stapling with a TA stapler, the specimen needs to be transected with scissors or a scalpel.

Linear staplers, most commonly referred to as gastrointestinal anastomosis (GIA) staplers, are similar to the TA staplers but have an additional cutting mechanism for transection. Several rows of staples are placed on either side of the cut.

End-to-end anastomosis (EEA) staplers are circular cutting staplers that place several rows of staples on both cut ends as well.

While the individual staples are almost always made of titanium, staplers come in a variety of configurations and lengths for open and laparoscopic procedures. Staplers can also accommodate different cartridges to handle different tissue thickness. Cartridges are preloaded with staples and color coded by the manufacturer to indicate the height of the staples. Typical staple heights range from 2 mm for thin, vascular tissue (eg, mesentery) to 4.1 mm for thick tissue (eg, inflamed bowel/colon). The typical staple height used for the majority of bowel resection/anastomosis procedures is 3.5 mm. GIA staplers typically come with different staple lengths of 30, 45, and 60 mm.

Electrosurgical devices — In the past, mesenteric division was accomplished by cutting and suture ligating the blood vessels. In contemporary practice, many surgeons use electrosurgical devices to expedite mesenteric division. Such devices save time by sealing the ends of blood vessels and cutting them with a single application. Commonly used devices include advanced bipolar devices and ultrasound desiccation devices. (See "Instruments and devices used in laparoscopic surgery", section on 'Electrosurgery'.)

OPEN RESECTION — The techniques described here may be used for the entire gastrointestinal tract. The choice of resection and reconstruction techniques is at the surgeon's discretion based on the clinical situation.

General principles — Attention to detail helps ensure success. The essential tenets for a successful bowel anastomosis include [1]:

Good blood supply – Blood supply is mostly judged subjectively, though some adjuncts are available (eg, Doppler, ICG, etc). Brisk or pulsatile bleeding in the cut edge of the bowel suggests adequate perfusion. The absence of such may lead the surgeon to extend the resection margins.

Absence of tension – Care must be taken to ensure that no tension is placed on the anastomosis. Adequate mobilization of the proximal and distal ends of the reconstruction makes setting up the anastomosis easier and prevents undue tension postoperatively. Continual tension causes ischemia, which will lead to a failed anastomosis.

Meticulous technique – Careful tissue manipulation and meticulous technique during the reconstruction are paramount. Meticulous technique demands mucosal inversion, ensuring equal progression on both sides of the anastomosis when suturing, and careful tissue handling.

Resection — Once the pathologic area is identified, sterile towels should be placed in the wound, protecting it from spillage that may occur during the procedure. The proposed segment for resection should include the pathologic area while minimizing the margins of resection to preserve length. Angle the line of transection somewhat obliquely so that the mesenteric edge is longer than the antimesenteric edge (figure 4). This ensures a robust blood supply to the antimesenteric aspect of the anastomosis, which is at highest risk of ischemia.

Bowel transection can be accomplished with a linear stapler. When using a stapler, pinch the mesentery under the proposed line of transection to thin it. While protecting the bowel with a thumb, the surgeon tents out the thinned mesentery with the tip of the index figure. Make a small mesenteric defect using electrocautery. Insert one jaw of the stapler through this defect, or guide it through with a hemostat (figure 5). Assemble and fire the stapler. Repeat for the opposite margin. Transect the mesentery using an electrosurgical device or by clamping and tying. (See 'Electrosurgical devices' above.)

When a stapler is not used, noncrushing bowel clamps are placed on both sides of the pathologic area and oriented slightly oblique to the bowel, favoring the antimesenteric border. The bowel is then transected sharply with a scalpel. The ends of the specimen are usually also controlled with bowel clamps (crushing or noncrushing) before transection to prevent spillage of enteric contents (figure 6). After bowel transection, mesenteric division is performed in the same manner as previously described.

Type of anastomosis — Following bowel resection, an anastomotic procedure is required to reestablish gastrointestinal continuity unless an ostomy is planned. The ability to perform each of the following reconstructions is required of the general surgeon. Proficiency in these techniques allows the surgeon to adapt the planned reconstruction to the clinical situation. Adaptability is key to a successful surgeon (figure 7).

End-to-end — These are "physiologic" in that they replicate normal gut motility. They are constructed by orienting the cut ends of both loops of bowel end-to-end.

End-to-side — Typically used when there is a size mismatch between the bowel loops to be anastomosed (ie, enterocolostomy or following small bowel obstruction with significant proximal distension). Care should be taken to anastomose the end of one loop of bowel into the side of another at the antimesenteric border (small bowel) or one of the taeniae (colon). Sewing to the antimesenteric border minimizes ischemia, while sewing to the taeniae adds strength to the reconstruction and avoids diverticula when present.

Side-to-side — Most commonly used with linear stapled anastomoses. The bowel loops can be oriented side by side or in an overlapping configuration (figure 7). The common enterotomy can be closed either by a TA stapler or handsewn (single or double layer).

Handsewn anastomosis — The author's preference is to perform handsewn single-layer anastomoses with continuous absorbable sutures.

To perform a handsewn end-to-end anastomosis, the staple lines sealing the ends of the bowel to be anastomosed are first completely excised. A stay suture is placed through the antimesenteric border of both ends of the bowel (figure 8). This helps align the ends and allows the surgeon to keep track of appropriate suture travel.

Two absorbable sutures are placed next to each other through the mesenteric border of both ends of the bowel (figure 8). The ends of the two sutures are then tied together. Each suture is then run toward the antimesenteric border of the bowel, with one suture anastomosing the back wall of the bowel while the other one anastomoses the front wall of the bowel (figure 8). Care must be taken to take full-thickness bites ensuring mucosal inversion along the mesentery as this area is more difficult to visualize than the remaining bowel wall. Inserting the needle on the serosa deeper than the mucosal exit site helps invert the mucosa. Once the two sutures meet on the antimesenteric border of the bowel and are tied, the stay suture is removed.

Not to detract from the description of the technique above, but the starting and ending points of the running absorbable sutures can be varied. Some surgeons prefer to start at the antimesenteric border and sew toward the mesenteric border (typically because they prefer to sew toward rather than away from themselves), while others prefer to start somewhere between the mesenteric and antimesenteric borders on the back wall and end at the same location on the front wall. As long as the anastomosis is completed as a full circle, any technique is sound.

The assistant pinches the bowel lumen on both sides of the anastomosis to prevent narrowing the reconstruction while the surgeon ties the two completed running sutures together at the antimesenteric border (figure 9). The anastomosis is then leak checked by gently squeezing both ends of the anastomosis to ensure no enteric spillage (figure 9). Small leaks can be fixed by additional interrupted sutures; larger leaks should prompt repeat construction of the anastomosis.

Seromuscular Lembert sutures can be used to buttress the anastomosis as a second layer. However, no compelling evidence has shown that this is superior to a single-layer reconstruction. On the contrary, the seromuscular sutures could in theory create an ischemic area (figure 10).

The anastomosis can also be constructed with interrupted sutures. A stay suture is placed at the antimesenteric border of both ends of the bowel for alignment and orientation. Full-thickness interrupted sutures are then placed to approximate the edges of the bowel wall, taking care to ensure mucosal inversion. Seromuscular Lembert sutures may also be used here to buttress the anastomosis. Again, it is left to surgeon discretion since there is no evidence to support this added step.

Whether to close the mesenteric defect is left to the discretion of the surgeon. There is a theoretical risk of internal hernia when the mesenteric defect is left open, but conflicting evidence exists regarding the benefit of closure. Suture closure of the mesenteric defect should avoid ligation of additional mesenteric vasculature that may compromise the anastomotic blood supply.

Linear stapled anastomosis — Following the same bowel resection described above (see 'Resection' above), side-to-side stapled reconstructions start with sharply removing a portion of the staple line near the antimesenteric border if a stapler has been used to transect the bowel. This also allows bowel viability to be assessed; brisk bleeding from the cut edge implies adequate perfusion for the reconstruction.

The gastrointestinal anastomosis (GIA) stapler is then introduced into each end of the bowel. Cartridge length is left to the surgeon's discretion, but the author typically utilizes a 60 mm load when performing a stapled anastomosis. Using one hand, the bowel is manipulated so that the antimesenteric borders of the bowel are included in the jaws of the stapler as they close (figure 11). This helps ensure that the anastomosis is perfectly centered on the antimesenteric border of the bowel, which maximizes perfusion. (See 'Surgical anatomy' above.)

The stapler is closed and bowel inspected to ensure that no other intra-abdominal contents have been inadvertently caught by the stapler. Once this is confirmed, a reinforcing silk "crotch" stich may be placed at the distal end of the anastomosis as this area is subject to the most tension (figure 11). The stapler is then fired. It is then removed and the newly created common channel is inspected for hemostasis with a ring forceps. Interrupted sutures can be used to control larger bleeders from the staple line, though most oozing will be self-limited.

The author typically uses a braided absorbable suture to close the common enterotomy in an interrupted fashion. Full-thickness bites are used, taking care to invert the mucosa. The staple lines should be offset to minimize the potential ischemic area (figure 11). If electing to staple the common enterotomy closed, a transverse anastomosis (TA) stapler is typically used. Allis clamps are used to align the common enterotomy in the TA stapler with the linear staple lines offset. The TA stapler is fired, then transected sharply with scissors or a scalpel.

End-to-end stapled anastomosis — End-to-end stapled reconstructions are typically used for colorectal or upper gastrointestinal anastomoses. If the stapled end-to-end anastomosis is to be used for a colorectal anastomosis, the patient must be in the lithotomy position. Resection is completed as previously described (see 'Resection' above). Care should be taken to mobilize the bowel sufficiently on either side of the resection. This will help visualization and reduce tension on the reconstruction. End-to-end anastomosis (EEA) sizers are sequentially placed through the anus to determine the largest size of stapler that the patient's anatomy will accommodate.

Once an appropriately sized circular stapler has been selected, the anvil of the stapler is introduced into the proximal end of the bowel by removing the staple line if present. A purse-string suture is used to close the lumen around the anvil. Alternatively, some situations will call for the anvil to be brought out of the sidewall of the bowel, creating an end-to-side anastomosis with the EEA stapler (ie, Baker-type anastomosis). When this is planned, a conical tip is attached to the anvil and used to pierce the taenia of the colon or antimesenteric border of the small bowel. No purse string is required in this configuration, but the bowel lumen must be closed after the anvil has been inserted with a linear stapler or sutures.

After the anvil is readied for anastomosis, the assistant advances the EEA stapler through the anus. The stapler is positioned in a manner that would provide the least amount of tension on the anastomosis. The EEA stapler is then opened, which advances the guidepost to pierce the bowel wall. The anvil is attached to the guidepost after ensuring there is no twist of the proximal bowel. The stapler is then closed, which retracts the guidepost along with the anvil toward the rectus, thus approximating the two bowel ends. Once the stapler is adequately closed, it is fired and removed through the anus, and the two anastomotic "donuts" are inspected. Two complete "donuts" imply a satisfactory anastomosis, though a leak test is still required. Incomplete "donuts" warrant additional inspection to ensure a complete anastomosis.

Typically, a rigid proctoscope or flexible sigmoidoscope is used to inspect the staple line of a stapled colorectal anastomosis. After circumferential inspection, a leak test is often performed by instilling saline into the pelvis, compressing the proximal colon, and gently insufflating air through the scope. Air bubbles in the pelvis indicate a leak. Small leaks may be repaired with interrupted sutures. Larger leaks require taking down the anastomosis for recreation (figure 12).

LAPAROSCOPIC RESECTION — Port placement will vary depending on the procedure performed, whether the anastomosis planned is intra- or extracorporeal, and surgeon preference.

Laparoscopic resection with intracorporeal anastomosis — Once the pathologic area is identified, a laparoscopic linear stapler is used to transect the bowel proximal and distal to the area. An electrosurgical device is then used to transect the mesentery of the resected segment. A small portion of the staple line is removed from the antimesenteric border of each end of bowel, and a fresh load of linear stapler is introduced. The bowel is gently manipulated onto the stapler so that the antimesenteric border will form the anastomosis. Some gentle pressure to close the stapler without locking it into place can be used to assist with the manipulation. Once the stapler is closed, the bowel is inspected to ensure no other intra-abdominal contents are inadvertently caught in the stapler. The stapler is then fired.

The laparoscopic stapler is reloaded with a new staple cartridge and the common enterotomy arranged with the staple lines offset. The stapler is then fired again to close the common enterotomy.

Laparoscopic resection with extracorporeal anastomosis — The resection is carried out intracorporeally in the same manner as described above or by externalizing the proposed segment to resect as previously described in the open section. Once the surgeon is ready for reconstruction, the bowels are grasped at the staple line with locking laparoscopic bowel graspers. Access to the peritoneum is obtained either by making a new incision or by extending a port site incision long enough to place a small wound protector. After the wound protector is in place, a handheld retractor is used to visualize the bowel. The previously placed graspers are used to deliver the bowel into the wound. Once the ends of the bowel are accessible in the wound, the reconstruction is performed in an open manner of the surgeon's choosing. (See 'Open resection' above.)

Intra- versus extracorporeal bowel anastomosis has been studied most extensively in laparoscopic right colon resection. Intracorporeal anastomosis was associated with more favorable patient outcomes in some studies [2,3]. Several randomized trials also found faster return of bowel function or fewer complications with intracorporeal anastomosis, but not shorter hospital stay [4-6]. No differences were noted in the rate of anastomotic leak.

OUTCOMES — Various bowel reconstructive techniques have been compared with one another, and in general there is no compelling evidence that one technique is superior to others:

Handsewn single- and double-layer anastomoses have been compared in a 2012 Cochrane review of seven small trials [7]. There was no significant difference in anastomotic failure, morbidity, and mortality rates. Single-layer anastomosis was faster, but only by a mean difference of 11 minutes (95% CI -16.37 to -5.97; two studies).

Handsewn and stapled anastomoses have been compared in a number of studies and trials since the introduction of surgical staplers in the 1970s. The best evidence came from a trial of over 1000 patients who underwent gastrointestinal anastomoses [8]. The incidence of clinical leaks was similar between the two groups (sutured 3.2 percent, stapled 4.7 percent), while the incidence of radiological leaks was higher in the sutured group (12.2 versus 4.1 percent). Other patient outcomes were comparable.

These data would suggest that operative technique should be tailored to the specific clinical circumstance and surgeon's discretion. Operative times are subject to surgeon familiarity with the technique. When the surgeon is comfortable with both handsewn and stapled reconstructions, operative times should not vary significantly.

SPECIAL CONSIDERATIONS

Size mismatch — On occasion the surgeon will encounter a significant size mismatch between the bowel loops that need to be anastomosed. Options include end-to-side and side-to-side reconstructions.

However, an end-to-end anastomosis is still feasible even in the face of a size mismatch. Smaller size mismatches can be compensated by differential suture travel on each side of the bowel. Larger mismatches can be accommodated with a Cheatle slit, which is a small incision made longitudinally on the antimesenteric border of bowel of the smaller caliber (figure 13). This will effectively augment the circumference of the smaller-caliber bowel to permit an end-to-end anastomosis.

Emergency bowel surgery — Trauma and emergency general surgery patients are often at increased risk for anastomotic leak due to bowel wall edema, size mismatch between adjacent loops, or bowel wall friability. Although there is no high-quality evidence to guide the choice of techniques due to a lack of randomized trials, many trauma and acute care surgeons prefer the handsewn technique for small bowel anastomoses due to its precision. However, stapled resections have the advantage of lesser time utilization and should be considered in damage control situations.

Published data in 2001 associated stapled anastomoses with higher leak and intra-abdominal abscess rates compared with handsewn anastomoses for trauma and emergency general surgery patients [9]. A 2017 study of bowel resection in this population reported equivalent anastomotic failure rates (12.5 percent overall) and operative time between the handsewn and stapled techniques, despite the fact that surgeons preferentially performed handsewn anastomoses in sicker patients [10].

Ileocolic anastomosis — An ileocolic anastomosis is commonly required for right-sided colon cancer, Crohn disease, or other indications. The anastomosis can be performed with a side-by-side stapled technique or one of the suture techniques (end-to-end, end-to-side, or side-to-side ileum-to-colon).

In a 2011 Cochrane review of seven trials, stapled anastomoses were associated with fewer leaks compared with handsewn anastomoses (odds ratio 0.48, 95% CI 0.24-0.95) [11]. In subgroup analysis, the advantage of stapled anastomosis was found for cancer patients (odds ratio 0.28, 95% CI 0.10-0.75) but not for noncancer patients. However, a newer retrospective Danish study of 1414 patients showed anastomotic leak rates of 5.4 and 2.4 percent in the stapled and handsewn groups, respectively (p = 0.004) [12].

The literature on ileocolic resection performed for Crohn disease is more varied, but most evidence also seems to favor a stapled ileocolic anastomosis or suggest equipoise; no evidence favors a sutured end-to-end anastomosis [1,13,14]. The choice of a procedure for Crohn disease is further complicated by the concern for recurrences and is further discussed in another topic. (See "Surgical management of Crohn disease", section on 'Anastomotic technique'.)

Colorectal anastomosis — Handsewn and stapled colorectal anastomoses have been compared in a 2012 Cochrane review of nine trials [15]. There was no significant difference in the anastomotic failure rate regardless of the level of anastomosis (13 percent for both), though operative time was longer for the handsewn group (weighed mean difference -7.6 minutes, 95% CI -12.9 to -2.2 minutes) and stricture rate was higher for the stapled group (8 versus 2 percent). Thus, the choice is made based on the clinical situation and surgeon discretion.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Bowel obstruction".)

SUMMARY AND RECOMMENDATIONS

Bowel resection and anastomosis is one of the most common and important procedures performed by general surgeons. The ability to perform a successful bowel anastomosis in a variety of fashions is required. (See 'Introduction' above.)

Blood is supplied to the bowel wall from the mesentery through a vascular arcade. To minimize ischemia, side-to-side and side-to-end anastomoses should be centered on the antimesenteric border of the small bowel, rather than off to one side, whenever possible. (See 'Surgical anatomy' above.)

The essential tenets of a successful bowel anastomosis include good blood supply, no tension, and meticulous techniques. So long as these criteria are met, successful bowel anastomoses can be constructed regardless of the technique used. (See 'General principles' above.)

A bowel resection can be performed using either a surgical instrument (knife or scissors) or a stapler to transect the bowel and either a vessel-sealing device or sutures to ligate and divide the mesentery. (See 'Resection' above.)

Following bowel resection, an anastomosis is required to reestablish gastrointestinal continuity unless an ostomy is planned. Bowel anastomoses can be configured as end to end, end to side, or side to side. Proficiency in all allows the surgeon to adapt the planned reconstruction to the clinical situation. Adaptability is key to a successful surgeon. (See 'Type of anastomosis' above.)

Laparoscopic bowel resection can be performed with intra- or extracorporeal anastomosis. (See 'Laparoscopic resection' above.)

In general, the anastomotic failure (leak) rate is similar between single- and double-layer handsewn anastomoses, between sutured and stapled small bowel anastomoses, and between sutured and stapled colorectal anastomoses. Thus, the choice can be made based on the clinical situation and surgeon discretion. (See 'Outcomes' above and 'Colorectal anastomosis' above.)

When there is a significant size mismatch between the bowel loops, a Cheatle slit to the antimesenteric border of the smaller-caliber bowel can allow for an end-to-end anastomosis. Alternatively, side-to-side or end-to-side anastomoses can be constructed. (See 'Size mismatch' above.)

  1. Goulder F. Bowel anastomoses: The theory, the practice and the evidence base. World J Gastrointest Surg 2012; 4:208.
  2. Wu Q, Jin C, Hu T, et al. Intracorporeal Versus Extracorporeal Anastomosis in Laparoscopic Right Colectomy: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2017; 27:348.
  3. Ricci C, Casadei R, Alagna V, et al. A critical and comprehensive systematic review and meta-analysis of studies comparing intracorporeal and extracorporeal anastomosis in laparoscopic right hemicolectomy. Langenbecks Arch Surg 2017; 402:417.
  4. Allaix ME, Degiuli M, Bonino MA, et al. Intracorporeal or Extracorporeal Ileocolic Anastomosis After Laparoscopic Right Colectomy: A Double-blinded Randomized Controlled Trial. Ann Surg 2019; 270:762.
  5. Vignali A, Bissolati M, De Nardi P, et al. Extracorporeal vs. Intracorporeal Ileocolic Stapled Anastomoses in Laparoscopic Right Colectomy: An Interim Analysis of a Randomized Clinical Trial. J Laparoendosc Adv Surg Tech A 2016; 26:343.
  6. Bollo J, Turrado V, Rabal A, et al. Randomized clinical trial of intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy (IEA trial). Br J Surg 2020; 107:364.
  7. Sajid MS, Siddiqui MR, Baig MK. Single layer versus double layer suture anastomosis of the gastrointestinal tract. Cochrane Database Syst Rev 2012; 1:CD005477.
  8. Suturing or stapling in gastrointestinal surgery: a prospective randomized study. West of Scotland and Highland Anastomosis Study Group. Br J Surg 1991; 78:337.
  9. Brundage SI, Jurkovich GJ, Hoyt DB, et al. Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial. J Trauma 2001; 51:1054.
  10. Bruns BR, Morris DS, Zielinski M, et al. Stapled versus hand-sewn: A prospective emergency surgery study. An American Association for the Surgery of Trauma multi-institutional study. J Trauma Acute Care Surg 2017; 82:435.
  11. Choy PY, Bissett IP, Docherty JG, et al. Stapled versus handsewn methods for ileocolic anastomoses. Cochrane Database Syst Rev 2011; :CD004320.
  12. Nordholm-Carstensen A, Schnack Rasmussen M, Krarup PM. Increased Leak Rates Following Stapled Versus Handsewn Ileocolic Anastomosis in Patients with Right-Sided Colon Cancer: A Nationwide Cohort Study. Dis Colon Rectum 2019; 62:542.
  13. Simillis C, Purkayastha S, Yamamoto T, et al. A meta-analysis comparing conventional end-to-end anastomosis vs. other anastomotic configurations after resection in Crohn's disease. Dis Colon Rectum 2007; 50:1674.
  14. McLeod RS, Wolff BG, Ross S, et al. Recurrence of Crohn's disease after ileocolic resection is not affected by anastomotic type: results of a multicenter, randomized, controlled trial. Dis Colon Rectum 2009; 52:919.
  15. Neutzling CB, Lustosa SA, Proenca IM, et al. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2012; :CD003144.
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