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Two layer technique (classical teaching)

1. Full-thickness "all coats" continous suture - catches strong submucosa
2. Seromuscular interrupted suture (Lembert stitch)

- Achieves inversion (low likelihood of anastamotic leakage)
- Inner layers haemostatic but prone to stangulation

Single layer technique (modern teaching)

1. Interrupted seromuscular extramucosal suture on round-bodied needle

- Minimal damage to vascular plexus
- may cause less tissue trauma

Stapled

1. Linear: creates side-to-side anastamosis
   • Inserts 4 parallel linear rows and cuts in the middle
2. Circular:
   • Unites bowel end-to-end

- Reduced anastamotic leakage
- Increased strictures

Tissue Glue

Suspection of leakage

1. Unexplained pyrexia
2. Tachycardia
3. Prolonged ileus
4. GI contents in drain 

Aim:

1. Permanently establish flow
2. Avoid intimal disruption and turbulence
   • Pass needle within outwards
   • Smooth intimal suture line
   • Eversion of anastamosis 

Use non-absorbable suture

- Everted anastamosis (provides intact endothelial surface, low risk of thrombus)

Complications

1. Bleeding / leakage / pseudoaneurysm
2. Stenosis
3. Thrombosis
4. Distal embolism 

Blood supply
Tension-free
Good approximation
No distal obstruction