A handsewn small bowel anastomosis can be created end to end or side to side. When creating a side to side anastomosis, the planned enterotomy site on each limb of bowel is identified. The backwall is created first, just lateral to the planned enterotomy sites- it would be very challenging to access this portion of the anastomosis after creating the inner layer. The back layer is followed by inner layers of absorbable suture. My personal preference is Vicryl, but PDS can also be used. Finally, the anterior outer seromuscular layer of silk is created. 

​

• Posterior outer layer of interrupted 3-0 Silk Limbert sutures

• Posterior inner layer of interrupted 3-0 Vicryl sutures

• Anterior inner layer of Connell with 3-0 Vicryl

• Anterior outer layer or interrupted 3-0 Silk Limbert sutures

• Inner layer of absorbable sutures and outer seromuscular layer of silk.

Two different depictions of side to side anastomoses (1,2).​

​

1. Rao SD. Small Intestine, In: Snapshots in Gastroenterology. Jaypee Brothers Medical Publishers (P) Ltd. 2016.

2. Rao SD. Pre- and Postoperative Management in Midgut (Small Bowel) Surgery, In: Gastrointestinal Surgery Step by Step Management. Jaypee Brothers Medical Publishers (P) Ltd. 2005.