Out of the pub, round the back, into the pub, and take a pull”: Revisiting an inverting continuous bowel anastomosis technique employing counteraction

Author : Warunika Jayasena, Sunil Siri Pathamanathan, Steven Due, Harjit Singh

Abstract : Purpose: To revisit a new surgical technique for inverting continuous bowel anastomosis and a descriptive literature review on current techniques. Approach / Results: Literature review identified that clinical context was a critical factor when selecting hand-sewn vs stapled bowel anastomosis, with more than 300 variations currently described worldwide.(1-5) Key principles for a robust anastomosis has consistently included– a tension free, well perfused inverting suture line. Continuous full thickness bowel anastomosis ensures inversion of the suture line. Inverting suture techniques include the Connell (6) , Lembert (7) or more recently interlocking method(8). The described anastomosis technique allows inversion with countertraction for the anterior inner suture layer of a two layered side to-side bowel anastomosis. A useful mnemonic for the direction of the lead suture is “Out of the pub (Figure 1a), round the back (Figure1b), into the pub (Figure 1c), and take a pull (Figure1d)”. In our current practice this has resulted in a robust suture with low anastomotic leak rate. Implications: This counter traction bowel anastomosis technique adds to current literature. It allows a consistent inversion of the suture line, that ensures a robust anastomosis and should be considered in all gastrointestinal surgeon’s repertoire post further studies.

Keywords : Bowel anastomosis technique, general surgery.

Conference Name : International Symposium on Surgical Techniques and Innovations (ISSTI-26)

Conference Place : Brisbane, Australia

Conference Date : 13th Feb 2026