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49 Anastomoses R.DAVID ROSINBackgroundThe experience of bowel surgery until the latter part of the nineteenth century was limited to dealing with protruding intestine following abdominal injury usually sustained during wars. If a laceration of the bowel was encountered attempts were made to repair it using the jaws of ants (described by Sushruta and Albucasis) or by suturing (Celsus). Probably the first surgeon to describe a suture made from animal gut was Albucasis. In Salerno, Italy, between the twelfth and thirteenth centuries, it was advised that if a piece of bowel had to be repaired it should be done over a stent of elder wood or animal trachea. Alternatives for dealing with injured intestine were to suture it to the abdominal wall to create a fistula or do nothing and let nature take its course. The latter management was frequently considered safer.For centuries, no attempt was made to define the process of healing of the gastrointestinal tract. However, in 1812, Travers reported that intestinal wounds healed as a result of ‘adhesive inflammation’ binding down the peritoneal (‘serosal’) coat. Fourteen years later Lembert des-cribed a suturing technique in which serosa apposition was obtained.As a consequence of the adoption of the Listerian. principles of wound care and antiseptic surgery (Chapter 1) (together with general anaesthesia) surgeons in the second half of the nineteenth century began to perform laparotomies with the express purpose of resecting a piece of intestine and subsequently restoring continuity. Gastrointestinal surgery expanded rapidly and with it various methods of suturing the bowel together. All were modifications of Lembert’s basic principles and were reviewed by Senn in 1893. A year earlier Murphy introduced his button but an adverse report appeared in the surgical literature citing colocolic anastomotic stricture which resulted in the patient’s death.In 1893, Senn advised two-layer interrupted anastomoses. His suture was of fine aseptic silk applied with ordinary sewing needles. Halsted favoured a one-layer anastomosis without penetration of the lumen. In contrast, Connell in 1903 strongly recommended a single layer of interrupted sutures which passed through all coats of the bowel and with the knots ligated intraluminally. Kocher also suggested an all-coats suture technique in two layers using catgut and silk. In 1907 Kerr and Parker used a temporary suture to close the bowel whilst the permanent sutures were inserted; once the anastomosis was completed these preliminary sutures were removed. Shoemaker and Remkin (1928) performed end-to-end anastomoses over narrow crushing clamps.In 1922 Halsted described a closed colorectal technique in which the bowel was crushed, ligated and divided at the resection margins. Next submucosal buttress sutures joined the two ends of the bowel and finally an instrument with a knife blade was passed per rectum through the anastomotic diaphragm to divide the two Sutures which had closed the lumen: the forerunner of our contemporary stapling devices. Stapling techniques have been ‘reinvented’ recently.The closed method of anastomosis has been replaced by the open method for four major reasons (Table 49.1):