International Journal of Surgery 7 (2009) 31–35

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International Journal of Surgery

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A comparison of three single layer anastomotic techniques

in the colon of the rat
A. Krasniqi a, b, *, L. Gashi-Luci a, b, S. Krasniqi b, M. Jakupi b, Sh. Hashani a, b,
D. Limani a, b, I.A. Dreshaj c
a
University Clinical Centre of Kosova, Department of Abdominal Surgery, Prishtina, Kosovo
b
University of Prishtina, Faculty of Medicine, Prishtina, Kosovo
c
Biomedical Research Center, Case Western Reserve University, Cleveland, OH, USA

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Although intestinal anastomoses are mainly made by staplers, manual anastomoses are still
Received 5 September 2008
in use worldwide. In previous studies, single layer anastomosis has shown better results compared to
Accepted 2 October 2008
double layer techniques.
Available online 18 October 2008
Purpose: To test experimentally some aspects of three different single layer anastomotic techniques in
Keywords: order to identify advantages and disadvantages of each.
Intestinal anastomosis Material and methods: The study was done on Sprague Dawley rats. Animals were randomly divided into
Surgical technique four groups. Three experimental groups consisted of 21 animals each, and the fourth sham group con-
Healing process tained 10 animals. By 7 animals of each group were sacrificed on the 4th and the rest of 14 animals on the
Intraperitoneal adhesions 7th postoperative day. In all groups the resected distal part of the colon was anastomosed using Halsted,
Gambee and Gambee–Halsted technique. To evaluate each specific technique the following were used:
postoperative complication frequency, biomechanical measurements, adhesion density, condition of
intestinal lumen and histological parameters of the healing process.
Results: The complication frequency was not significantly different between the tested techniques. The
average bursting pressure and tensile strength were higher on both the 4th and 7th postoperative days
with the Gambee technique. In the colon segments removed on the 4th postoperative day 97% of
pressure induced ruptures occurred in the anastomotic line, whereas on the 7th postoperative day 76% of
ruptures occurred about 1 cm distal to the anastomotic line.
Conclusion: The Gambee technique had significantly better biomechanical and histological results
compare to the other two anastomotic techniques. Adhesion density was significantly lower in the
control group (p < 0.001).
Ó 2008 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction Anastomotic technique represents an important chain of successful

Intestinal anastomosis is a basic procedure in gastrointestinal
surgery. There is still interest in research on intestinal anastomosis
because failed anastomosis is associated with high morbidity and
mortality rates.1,2 Although intestinal anastomosis has been prac-
ticed for centuries, there still exist among the surgeons different
opinions about the preferred type of anastomotic technique. In
developed countries intestinal anastomosis is mainly performed by
staplers, however, manual anastomoses are still in use worldwide.3
* Correspondence to: Avdyl Krasniqi, University Clinical Center of Kosova, Depart-
ment of Abdominal Surgery, 10000 Prishtina, Kosovo. Tel.: þ381 38557588, þ381
38224667, þ37744507776 (mobile); fax: þ381 38512231.
E-mail address: dr_krasniqi2001@yahoo.com (A. Krasniqi).
healing of anastomosis.4 Although double layer anastomosis is
preferred by many surgeons, in our previous studies and studies of
other authors, single layer anastomosis has shown better results.5–8
The aim of this study was to test experimentally some important
aspects of three different single layer anastomotic techniques in
order to identify advantages and disadvantages of each.
2. Material and methods
The research was done on Sprague Dawley rats of both genders.
Animals were randomly divided into four groups. The experimental
(three) groups consisted of 21 animals each, whereas the fourth
sham operated group contained 10 animals (Table 1). All animals
underwent surgical procedure under general anaesthesia induced
by intraperitoneal administration of ketamine HCl (Animal Health,

1743-9191/$ – see front matter Ó 2008 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijsu.2008.10.005
32 A. Krasniqi et al. / International Journal of Surgery 7 (2009) 31–35
Table 1
General characteristics of animals.
Group Type of Group size Gender
Anastomosis ratio F:M
I Halsted 21 10:11
II Gambee 21 10:11
III Gambee/Halsted 21 7:14
IV Sham operated 10 5:5
Total 73 32:41
Fort Dodge, USA) 70 mg/kg and xylazine (The Butler Company,
Columbus, Ohio) 7 mg/kg. The inferior midline laparotomy and
resection of distal colon were performed in all animals of the
experimental group. The continuity of colon was reestablished with
end to end anastomosis according to Halsted in the first group,
according to Gambee in the second group and with combined
Gambee–Halsted techniques in the third group (the posterior wall
was anastomosed according to Gambee and the anterior wall
according to Halsted). All anastomoses were done with sutures PDS
II 6.0 (Ethicon, Inc.). In the sham operated animals inferior midline
laparotomy and closure of abdominal wall similarly to other groups
were performed without resection of colon. After surgery animals
were left on ‘‘ad libitum’’ water and food. In each experimental
group 7 animals were sacrificed on the 4th and, 14 others on the 7th
postoperative day. Local intraperitoneal findings were checked, and
adhesions dissected carefully. After the identification of anasto-
mosis, a 5 cm segment of colon with the anastomosis in the middle
was resected.
To evaluate the results the following were used: postoperative
complication frequency, biomechanical measurements, adhesion
density, status of intestinal lumen and histological parameters of
healing process.
Postoperative complications included microperforation, dehis-
cence, stenosis of anastomosis, per secundum healing of laparotomy,
incisional hernias and density of intraperitoneal adhesions. As
stenotic anastomoses were arbitrarily considered those where the
lumen upstream from anastomosis was twice larger than that
downstream the anastomosis. The endoluminal status was evalu-
ated by the degree of mucosal necrosis, oedema of anastomotic line
and measurement of circumference of anastomotic line (Fig. 1).
Adhesion density was graded from 0 to 4 according to Knightly
et al.9 (Fig. 2). To test anastomotic strength, the bursting pressure
Fig. 1. Endoluminal macroscopic view of anastomotic line; Halsted, Gambee and Gambee–Halsted.
(BP) and tensile strength (TS) were measured. Bursting pressure
was measured in vitro on a 5 cm segment of colon with the anas-
Average tomosis in the middle. An infusion pump driven at constant speed
weight (gr) inflated 2 mL/min of saline with methylene blue until the colonic
298 segment ruptured. Pressure change was registered digitally and
302 graphically by Buxco, Biosystem XA, Buxco Electronics, Inc. The BP
286
was marked by an abrupt drop in the pressure curve as well as by
291
294 the methylene blue appearance in the bathing medium. A
longitudinally resected 0.7 cm wide colon strip containing the
anastomotic line was used for measurement of minimal tensile
strength. Minimal tensile strength was tested by dynamometer
(Harvard Apparatus, Model 906, Millis, Massachusetts, USA) moving
at a constant speed of 10 mm/min and measured by Validyne, Model
MC1-3-871 (Engineering Corporation, Northridge, California, USA).
The start of the drop in the tension curve (initial breakage) was
marked as TS. Cellular and architectural parameters of anastomotic
healing were scored according to the semi-quantitative method
modified by Verhofstad et al.10 Statistical analysis of results was
done using t test and Mann-Whitney sum rank test provided in the
Sigma Stat 2000 software.
3. Results
The complication frequency was similar in both of the first two
groups. However, in all groups complications were related to the
abdominal wall rather than to the healing process of the
anastomosis. There was no anastomotic dehiscence. Most often
encountered complications consisted of ‘‘per secundum’’ healing of
the abdominal wall, intraperitoneal adhesions and incisional
hernias. The average bursting pressure and tensile strength were
higher in the Gambee group (Table 2) compare to the other two
groups. On the 7th postoperative day the rupture induced by
increase in the intraluminal pressure in 76% of cases occurred
approximately 1 cm distal to the anastomotic line, 69% of cases on
the antemesocolic side. On the 4th postoperative day 97% of
ruptures occurred on the anastomotic line. The biomechanical
parameters (BP, TS) were significantly higher in all groups on the
7th than on the 4th postoperative day (p < 0.001).
Histological evaluation showed that anastomoses done by the
Gambee technique in almost all parameters such as anastomotic
necrosis, polymorphonuclear cells infiltration, edema, epithelial
recovery and repair of submucosal-mucosal layer demonstrated
 A. Krasniqi et al. / International Journal of Surgery 7 (2009) 31–35 33

Fig. 2. Adhesion density grades: 0 - no adhesions (a), 1-one easy dissectible adhesion (b), 2 - moderately extended adhesions without intestinal lifting (c), 3 - adhesions extended
between intestine and parietal peritoneum (d) and 4 – extensive adhesions attached to the large and the small bowel as well as the parietal peritoneum.

a better score, closer to ideal healing (Fig. 2). Also, macroscopic Halsted technique. The study was focused on the following aspects:
evaluation indicated that on the anastomotic line mucosa was endoluminal and extra luminal macroscopic appearance of the
abridged better with less local edema in the Gambee technique anastomotic line, perianastomotic adhesion density, the bursting
group (Fig. 3). pressure and the tensile strength of the anastomosis and histo-
logical changes during the early phase of healing.
4. Discussion There have been numerous clinical and experimental studies
done on surgical techniques and the healing process of intestinal
This study was undertaken to experimentally compare some anastomosis.1–14 Traditionally, two main surgical sutures have been
aspects of the most commonly used single layer anastomotic used to perform manual intestinal anastomosis: double and single
techniques such as Halsted, Gambee and combined Gambee– layer sutures.1,2 Although nowadays the intestinal anastomoses are
mainly made by staplers, training of surgeons on manual anasto-
mosing is still very much needed, especially in developing
Table 2 countries. There are different preferences among the surgeons
Biomechanical parameters, Knightly score and overall complication frequency. regarding the use of surgical techniques for creating the intestinal
Type of Bursting Tensile Strength Knightly Overall anastomosis. The majority of studies uniformly favor single layer in
anastomosis Pressure (g/mm of strip) score complication preference to double layer anastomoses.5–9,12,13 The single layer
(mmHg) frequency (%) anastomosis was first described by William.14 Since then, different
Halsted 141.5 112.6 1.25 14.2 single layer anastomotic techniques have been invented.1,12–18
Gambee 147.6 127.7 1.25 14.2
Connell described his continuous inverting suture in 1892.1 Single
Gambee–Halsted 130.6 111.2 1.11 4.7
layer continuous suture was reported later on by many authors.11–13
34 A. Krasniqi et al. / International Journal of Surgery 7 (2009) 31–35
Fig. 3. Hematoxylin-eosin stained sections of anastomosis: 0 – minimal necrosis and edema, normal PMN, macrophage, and lymphocytic celullarity; 3 – extensive necrosis and
other cellular changes.
In 1951 Gambee designed a stitch that apposed both the serosa and
the mucosa, forming a single layer anastomosis.1,15 All of these
techniques in essence create inverted intestinal anastomosis. They
differ in using either interrupted or continuous sutures and whole
intestinal wall thickness sutures or extra mucosal sutures. There are
only few comparative studies that favor particular single layer
anastomosis.
In the present study, we focused on some aspects of the healing
process of intestinal anastomosis in the period between days 3 and
7 which is characterized by restoration of the matrix accumulation
and the strength.19 Therefore, we sacrificed the animals on post-
operative days 4 and 7.
Endoluminally, the macroscopic appearance of anastomotic
line was quite similar in specimens of all groups on the 4th
postoperative day, however on the 7th postoperative day, in the
Gambee group was found less edema in the anastomotic line and
better mucosal coverage compared to other two groups (Fig. 1).
This probably was due to, better apposition of intestinal layers,
less narrowing of the lumen and a smaller amount of strangulated
tissue.20,21 Another aspect analyzed in our study was the density
of intraperitoneal adhesions. The density of the intraperitoneal
adhesions was quantified according to Knightly et al.,9 from grade
0 to 4 (Fig. 2). Our results showed that there was not a significant
difference in the intraperitoneal adhesion development depending
on the type of anastomosis neither on the day of animal sacrifice.
However, we found a statistically significant difference compared
to the sham operated group (p < 0.001). DeCherney and diZer-
ega,22 Ellis,23 and Holdahl et al.24 also reported that adhesions are
present more often in anastomosis and potentially are caused by
the contamination of the peritoneal area, sutures as foreign
material and ischemic changes of the intestine in the anastomotic
region.22–24
Bursting pressure and tensile strength were significantly higher
in the 7th compared to the 4th postoperative day in all groups
(p < 0.001, p < 0.005, p < 0.005). A significant increase of the
biomechanical parameters of the anastomotic line between post-
operative days 3 and 7 has been demonstrated in other studies as
well.18,19,25 Seifert et al.19 have found a significant increase of
vascular and perfusion areas in anastomotic region 7 days after
surgery. They have confirmed the importance of angiogenesis and
other concomitant changes that increase the strength of anasto-
mosis after the first 3 days. The rapid increase of strength in
anastomotic line on the 7th postoperative day,19 even higher than in
an intact colon, is also supported by the fact that 76% of ruptures in
our experiment occurred approximately 1 cm downstream the
anastomotic line, whereas, on the 4th postoperative day 97% of
ruptures occurred on the anstomotic line.
Cellular and architectural parameters of the anastomotic healing
were evaluated on hematoxylin-eosin stained sections. We have
adopted the method modified by Verhofstad et al.,10 where ‘‘ideal
healing’’ is scored with 0 on the scale from 0 to 3 (Fig. 3). Analyzed
changes, such as presence of necrosis, polymorphonuclear infiltra-
tion, edema, epithelial recovery and repair of submucosal-muscular
layer, have shown that Gambee technique histologically was closer
to the ‘‘ideal healing’’ compare to the other two techniques.
The results of present study indicate that the Gambee technique
has shown better biomechanical and histological parameters on
both, the 4th and the 7th postoperative days compared to the two
other techniques tested in this study.
Conflicts of interest
None declared.
Funding
Research was partly funded by the Department of Science, Ministry
of Education, Science and Technology of Kosovo.
Ethical approval
Project was approved by Scientific Council and Ethical Committee
of Faculty of Medicine, University of Prishtina, Prishtina Kosovo;
December 2001.
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