V Vol. 22, No.
3 March 2000
CE Refereed Peer Review
FOCAL POINT
★ Single-layer, approximating
suture patterns are currently
recommended for end-to-end
intestinal anastomosis in small
animal surgery.
KEY FACTS
■ The modern era of intestinal
surgery began in the early
1800s.
■ The fundamental doctrines of
intestinal anastomosis were
established in human surgery
by the beginning of the 20th
century and are still practiced
today.
■ In the 1950s, it was proven that
serosal inversion is not necessary
for the healing of intestinal
wounds.
■ Approximating anastomosis
techniques were first described
in the 1960s and first appeared
in the veterinary literature in the
1970s.
■ The human surgical literature
generally classifies intestinal
anastomoses as inverting or
everting and largely ignores
the concept of end-to-end
approximation of cut intestinal
layers.
Historical Perspective
of Intestinal
Anastomosis in
Veterinary Surgery
University of Illinois
Bradley R. Coolman, DVM, MS
Nicole Ehrhart, VMD, MS
Sandra Manfra Marretta, DVM
ABSTRACT: Information on intestinal anastomosis in the veterinary surgical literature before
the 1940s is scarce. To understand the current methods advocated for suturing intestinal
wounds in animals, it is important to study the modern history of human intestinal surgery.
Single-layer, approximating suture patterns are currently recommended for intestinal wound
closure in veterinary surgery. Approximating suture patterns typically cause mucosal eversion
and would be classified as everting patterns in the human literature.
B
efore the 19th century, surgical treatment of intestinal wounds was rarely
successful and elective surgical procedures involving the gastrointestinal
(GI) tract were not attempted. Early in the first century AD, Celsus
recorded attempts to suture the intestine but spoke disparagingly of its use.1 In
87 AD, Abulkasem recommended using the jaws of large ants to unite intestinal
wounds.1 He also referred to catgut made from the intestines of sheep as suture
material.1
The oldest reported intestinal suturing technique is the glover’s suture.1 Senn
used a picture from a 1739 surgical textbook to illustrate the technique (Figure
1). The glover’s suture was a simple continuous stitch in which the ends, instead
of being tied, were left long and pulled externally through the abdominal
wound. The suture was intended to approximate the intestinal wound and was
used to prevent leakage of intestinal contents and to keep the injured intestine in
close contact with the external wound. If the patient survived, the suture was
pulled from the wound in 5 to 9 days when the intestine was “healed.”1
Other ancient surgical methods involved the use of a few large-diameter su-
tures; use of bone, trachea, or wood stents; or attempts to invaginate the cut
ends of intestine.1 Most surgeons advised bringing the visceral wound in close
contact with the external wound and holding the intestine in position with one
Compendium March 2000 Small Animal/Exotics

or two large sutures through the Dupuytren, his mentor.4,5 Nev-

mesentery or the intestinal wall ertheless, in an 1893 review of
(Figure 2).1 The intent of these intestinal surgery, Senn stated
techniques was to use the peri- that Lembert’s technique and
toneum to seal the wound or to practices represented a sudden
form an “artificial anus,” especial- shift from ancient to modern
ly in complete transverse lac- methods and that Lembert’s
erations of the intestine. These principle of using the serous
methods stemmed from clinical coat to procure early and per-
observations of several patients manent adhesions would never
who survived complete transverse be rejected.1
“fatal” intestinal wounds that Lister (1867) is credited with
spontaneously adhered to the ex- another important discovery in
ternal wound and formed en- the advancement of intestinal
terostomies.1 surgery: asepsis.5 Lister advocat-
As late as 1818, prominent sur- Figure 1—Glover’s suture. (From Senn N: Enteror- ed the use of aseptic suture ma-
geons commonly stated that su- rhaphy: Its history, technique, and present status. terial and the principles of anti-
turing the intestine was very dan- JAMA 21:215–235, 1893) septic surgery. Although the
gerous.1 The mortality rate was concept of aseptic technique
higher for patients who had in- initially met with resistance and
testinal wounds sutured than for was slow to catch on, in 1893
those whose intestinal wounds Senn gave credit for the rapid
were left to heal naturally. success of intestinal surgery to
Lister’s methods, which helped
MODERN HISTORY reduce the incidence of septic
Current principles of intestinal peritonitis and surgical wound
surgery originated in the early infection.1
19th century. In 1812, Travers In 1883, Czerny modified
first reported that the entire cir- Lembert’s technique into a two-
cumference of cut extremities of layer, inverting anastomosis,
a divided intestine needed to be which became widely used in
in contact to heal properly.2 Un- the 20th century. 6 In 1887,
like his contemporaries, Travers Halsted reported the impor-
used a small, round sewing nee- tance of the submucosal layer in
dle to place multiple full-thick- Figure 2—Large suture passed through the mesen- suturing GI wounds (Figure 3).7
tery and surrounding the intestine. (From Senn N:
ness silk sutures at close intervals Enterorrhaphy: Its history, technique, and present He stated that a delicate thread
to prevent leakage of ingesta and status. JAMA 21:215–235, 1893) of submucosa was considerably
to increase the mechanical stronger and better able to hold
strength of the anastomosis. He a stitch than was a coarse shred
emphasized the importance of uniform apposition and of the entire thickness of the muscular and serous
stated that the type of suture used was a secondary con- coats.7 Halsted advocated a single-layer closure and em-
2
cern as long as the contact was secure. Travers knotted phasized the importance of surgical technique and
the sutures, cut the threads short, and did not fasten asepsis for successful intestinal healing. In 1892, Con-
the intestine to the abdominal wall. He reported suc- nell introduced a single-layer, continuous inverting su-
cessful healing of intestinal anastomoses in dogs with ture pattern.8 The major advantages of Connell’s tech-
2
his mucosal appositional (everting) technique. nique were the speed of the operation and reduction of
In 1826, Lembert reported that serosa-to-serosa con- the number of knots left in the wound.8
tact of the divided intestine, achieved by inverting su- That same year, Murphy described the use of an inter-
ture patterns, was necessary for intestinal healing.3 Lem- locking metallic button (Figure 4) designed to create a
bert’s technique became a fundamental principle of sutureless, inverting, end-to-end intestinal anastomosis.9
intestinal surgery, and he became known as the founder After the ends of the intestine had healed sufficiently,
of modern intestinal surgery.1 However, Lembert him- the inverted cuff of tissue would slough and the button
self gave credit for the idea of serosal apposition to and necrotic tissue would pass with the feces. Murphy’s

PRINCIPLES OF INTESTINAL SURGERY ■ ASEPSIS ■ TWO- VS. SINGLE-LAYER CLOSURE

Small Animal/Exotics Compendium March 2000

button was widely used by sur- resort (i.e., when it was the only
geons around the turn of the 20th hope to save a patient’s life).14 The
century. In a 1923 review, Kerr textbook described use of an in-
detailed the development of in- verting Lembert pattern to per-
testinal surgery and identified the form end-to-end small intestinal
Murphy button as being one of anastomosis and mentioned vari-
the most brilliant contributions ous mechanical devices, such as
ever made to surgery.10 Kerr also the Murphy button, that require
claimed that this device advanced no sutures. McCunn admitted
intestinal surgery more than did that, in his experience with en-
any other factor.10 Nevertheless, terorrhaphy, the results were not
Murphy’s button was largely re- good, although there had been
placed by hand-sewn intestinal some successes.14
anastomosis techniques in human Figure 3—Passage of the needle through the intesti- The second edition of Canine
patients by the 1920s.10 nal wall into the submucosal coat. (From Halsted Surgery (1949) described the Par-
By the beginning of the 20th WS: Circular suture of the intestine—An experi- ker-Kerr technique (a closed, sin-
century, about 250 methods for mental study. Am J Med Sci 94:436–461, 1887) gle-layer, inverting end-to-end
intestinal suturing had been de- intestinal anastomosis) as such a
scribed and the fundamental doc- theoretically perfect method that,
trines of intestinal anastomosis when executed precisely, there
were firmly established. 10 These can be little reason for failure.15
principles included: (1) apposing This reference is probably the
the serosal surfaces of the intes- reason that most veterinary
tine around the full circumference surgery textbooks from the
using an inverting suture tech- 1950s and 1960s recommended
nique, (2) including the tough the technique.16–21 The fifth edi-
submucosa in the suture bites, tion of Canine Surgery (1965) il-
(3) performing the anastomosis lustrated an open, single-layer,
in an environment free of con- inverting small intestinal anasto-
tamination and trauma, (4) using mosis technique in addition to
aseptic surgical technique, (5) the Parker-Kerr method.20
maintaining adequate blood sup-
ply to tissue, and (6) avoiding IMPORTANT ADVANCES
tension on the anastomosis. 1,10 In 1951, Gambee described
These basic tenets are still consid- a single-layer, inverting tech-
ered the cardinal principles of in- nique for intestinal anastomosis
testinal anastomosis in human (Figure 5).22 He reported good
surgery.11,12 results with the technique and
challenged the practice of dou-
EARLY VETERINARY Figure 4—The Murphy button, which was designed ble-layer closure in the GI tract,
to create a sutureless intestinal anastomosis. (From
REPORTS which was widely used in hu-
McCunn J: Hobday’s Surgical Diseases of the Dog
Information on surgical treat- and Cat, ed 4. Baltimore, Williams & Wilkins, man surgery. Gambee stated
ment of intestinal diseases in the 1941, pp 180–213; with permission) that each suture placed must
small animal veterinary literature have a definite purpose or else
is generally lacking before the not be used.23 Gambee’s work
1940s. The first edition of Canine Surgery was published established the value of single-layer intestinal closure;
in 1939.13 No description of how to perform intestinal however, many prominent surgeons continued to use
anastomosis was given; readers were told to proceed double-layer closures.
based on their training and experience and were directed The first challenges to Lembert’s principles of inver-
to human surgical texts for additional information.13 sion and serosal contact also appeared in the 1950s.24–26
In a 1941 small animal surgery textbook, McCunn In the following years, numerous reports that studied
stated that the prognosis is always grave for enterorrha- various inverting and everting suture patterns for en-
phy in the dog.14 He advocated intestinal surgery as a last teroanastomosis appeared.27–40 Much of this research

BASIC TENETS ■ PARKER-KERR TECHNIQUE ■ SINGLE-LAYER INVERTING TECHNIQUE

Compendium March 2000 Small Animal/Exotics

was performed in dogs. The re- amount of lumen narrowing,

sults of these studies varied wide- omental adhesions, and mural fi-
ly and often had contradicting brosis was smallest with the ap-
conclusions. However, by the end positional crushing pattern and
of the 1960s, it was firmly estab- greatest with the everting pattern.
lished that the intestine would In 1973, DeHoff and co-
heal adequately without inversion workers compared single-layer
and serosal contact. inverting, everting, and approx-
The earliest descriptions of evert- imating jejunal anastomoses in
ing intestinal anastomoses in the puppies.53 They stated that the
veterinary literature appeared in goal of the approximating tech-
the 1960s.27,41,42 In 1968, Ott and nique is gentle apposition of
colleagues compared single-layer, the anastomosed edges and that
inverting anastomosis with evert- the cut intestine may invert, ev-
ing anastomosis in the small in- ert, or approximate when brought
testine of 100 dogs.33 They con- into apposition.53 The illustra-
Figure 5—The Gambee suture technique, an ap-
cluded that the everting technique tions in their article clearly showed
proximating method described as a single-layer, in-
was stronger and was associated verting suture pattern.22,23 (From Orsher RJ, Rosen mucosal eversion at the anasto-
with less compromise of the lu- E: Small intestine, in Slatter D [ed]: Textbook of moses, and they reported that
men diameter and fewer compli- Small Animal Surgery, ed 2. Philadelphia, WB Saun- eversion of the mucosa was evi-
cations. ders Co, 1993, pp 593–612; with permission) dent in histologic examination
In 1968, Poth and Gold de- of all approximating anasto-
scribed a “new technique” for in- moses. They concluded that, 1
testinal anastomosis (Figure 6).43 month after surgery, the ap-
They stated that it seemed more proximating technique had low-
reasonable to approximate the er morbidity and produced less
severed intestine by true end-on scar tissue formation at the an-
reconstruction rather than invert- astomosis than did the inverting
ing or everting the intestinal wall.43 or everting techniques.
They reported that the end-on, In 1976, Reinertson com-
simple interrupted suture was the pared three patterns for equine
simplest possible stitch and advo- Figure 6—Poth and Gold’s crushing appositional jejunal anastomosis: a modified
suture. (From Orsher RJ, Rosen E: Small intestine,
cated a crushing technique, which in Slatter D [ed]: Textbook of Small Animal Surgery, Gambee appositional suture, a
cut through all layers except the ed 2. Philadelphia, WB Saunders Co, 1993, pp simple interrupted everting su-
submucosa. Despite this recom- 593–612; with permission) ture, and a double-row invert-
mendation, relatively few reports ing suture.54 He reported that
in the human surgical literature the inverting technique had
discuss approximating suturing techniques,31,43–46 and minimal adhesions but predisposed the patient to in-
approximating methods of intestinal anastomosis are testinal obstruction. The everting technique avoided lu-
not mentioned in current human surgery textbooks.12,47–48 minal compromise but predisposed the intestine to
leakage and had increased adhesions, which led to ex-
APPROXIMATING HAND-SEWN ANASTOMOSIS tramural fibrosis that limited intestinal extensibility.
In contrast to the human literature, most published The modified Gambee technique resulted in near-nor-
reports in the recent veterinary literature involve ap- mal lumen diameter, minimal adhesions, and adequate
proximating, end-to-end techniques for intestinal anas- strength and thus was deemed safe and effective for
tomosis. Simple interrupted approximating anastomo- end-to-end intestinal anastomosis in horses.54
sis has become the technique of choice for end-to-end The reports of Bennett, DeHoff, and Reinertson and
anastomosis in small animal surgery.49–51 their colleagues seem to be responsible for establishing
The first report in the veterinary literature discussing the single-layer, interrupted, approximating technique
approximating intestinal anastomosis appeared in for end-to-end intestinal anastomosis in veterinary
1970.52 Bennett and Zydeck52 compared single-layer ev- surgery. It is interesting that the everting technique
erting, inverting, and appositional crushing end-to-end used by Reinertson54 is identical to the approximating
jejunal anastomoses in six dogs and concluded that the technique used by DeHoff and coworkers.53 It should

EVERTING ANASTOMOSIS ■ APPROXIMATING ANASTOMOSIS ■ MODIFIED GAMBEE TECHNIQUE

Small Animal/Exotics
also be pointed out that the Gambee suture tech-
nique,22 which Reinertson considered an appositional
suture, is considered to be an inverting pattern in the
human literature.
In the middle 1970s, the single-layer, interrupted,
end-to-end approximating technique for intestinal
anastomosis first appeared in small animal surgery text-
books.55,56 In addition to the new approximating tech-
niques, these texts describe traditional inverting, evert-
ing, and double-layer techniques for intestinal closure.
In 1981, Ellison reviewed techniques for end-to-end
intestinal anastomosis in dogs.57 He pointed out the
difficulty in avoiding some degree of mucosal eversion
when either a crushing or noncrushing approximating
pattern is used and cautioned that, as a result, modifi-
cation of healing like that associated with everting pat-
terns may occur.57 He concluded that, with proper sur-
gical technique, any anastomotic suture pattern could
be used successfully in the canine intestine but that ap-
proximating patterns offer the least compromise of lu-
men diameter and early superior healing.
In 1982, Ellison and colleagues58 compared simple
interrupted approximating, simple interrupted crush-
ing, and simple continuous approximating techniques
for end-to-end intestinal anastomosis in dogs. In all
techniques, the needle passage excluded the mucosa in
an attempt to minimize eversion. However, these re-
searchers reported that 65% of the simple interrupted
approximating anastomoses had mucosal eversion; 62%
of the simple interrupted crushing anastomoses had
mucosal eversion or tissue overlap; and 38% of the sim-
ple continuous approximating anastomoses had ever-
sion, inversion, or tissue overlap.58
In 1982, Bellenger was the first to report results of
experimental appositional anastomosis of the jejunum
in cats.59 He compared single-layer inverting and sin-
gle-layer appositional patterns in six cats. He concluded
that the inverting technique caused substantially more
luminal impingement than did the appositional tech-
nique and that the histologic continuity of layers was
superior to that associated with the appositional meth-
od. The primary complications were intestinal obstruc-
tion in two of six inverting anastomoses and leakage in
one of six appositional anastomoses.59
In 1983, Bone and coworkers compared simple inter-
rupted crushing and noncrushing approximating anas-
tomoses in the canine jejunum.60 They reported that
neither suture pattern produced consistent mucosal ap-
position, which varied from inverted to apposed to ev-
erted. The histologic illustrations in this report clearly
showed eversion of the mucosa and healing of the anas-
tomoses by bridging fibroplasia.60
These studies of end-to-end intestinal anastomosis
APPOSITIONAL ANASTOMOSIS ■ STAPLING DEVICES ■ AUTOMATED STAPLERS
Compendium March 2000
show that true approximation of the histologic layers of
ends of cut intestine is infrequently achieved, even un-
der experimental surgical conditions. Eversion, inver-
sion, and overlapping of the intestinal ends most fre-
quently occur with approximating techniques, as
reported by DeHoff, Ellison, and Bone and their col-
leagues, and may explain why discussions of approxi-
mating intestinal anastomosis are lacking in the human
surgical literature.
Recently, Weisman and colleagues reported that a
modified simple continuous pattern for closure of in-
testinal incisions is an acceptable alternative to the sim-
ple interrupted pattern in dogs and cats.61 Reported ad-
vantages of a simple continuous enteric closure include
surgical speed, decreased tissue handling, improved ap-
position of intestinal layers, and a low rate of clinical
complications. 61 Simple continuous approximating
anastomosis has been shown experimentally to achieve
better continuity of the histologic intestinal layers than
do simple interrupted approximating techniques.58
STAPLED INTESTINAL ANASTOMOSIS
The current automated stapling instruments for in-
testinal anastomosis originated in the former Soviet
Union after World War II.62 These stapling devices
were first tested in the United States in the 1960s and
became widely accepted for use in human surgical pa-
tients in the 1970s.62–64 Automated intestinal stapling
devices allow rapid, secure, inverting anastomosis of the
intestine and are typically used to create antiperistaltic
side-to-side (functional end-to-end) or true end-to-end
anastomoses.65 Reported complication rates for stapled
anastomoses are similar to those for conventional hand-
sewn methods.66
Hess and coworkers published the first veterinary
study that compared mechanically stapled with hand-
sewn small intestinal anastomoses.67 Although the out-
comes of the two techniques were similar, the mechani-
cal staples were applied more consistently and required
less surgical time than did the sutures.67 Stoloff and col-
leagues compared stapled and hand-sewn colonic anas-
tomoses in dogs.68 They reported less tissue reaction,
improved healing, and fewer adhesions with the invert-
ed stapled anastomosis.68
In 1991, Ullman and colleagues reported good clini-
cal results in 24 dogs and cats that had open intestinal
anastomosis performed with automated surgical sta-
plers.69 The primary postsurgical complications were
anastomotic leakage (2 of 24 cases) and localized ab-
scess formation (1 of 24 cases). 69 No long-term compli-
cations were observed in the 23 surviving patients. Fa-
vorable results have also been published for colonic
anastomosis with automated staplers in cats.70,71
Compendium March 2000

Surgical stapling devices have numerous potential ap-

plications in small animal GI surgery. The primary lim-
Your Animal
itations to widespread use of these devices are the cost
of the instruments and lack of familiarity with auto-
mated intestinal stapling techniques.
Health Collection
A biofragmentable ring for intestinal anastomosis has
been experimentally tested in dogs72,73 and cats74 and
has been used clinically in humans.75 The ring is similar
Isn’t Complete
to the Murphy button except that it is composed of
polyglycolic acid and thus breaks down approximately
12 days after implantation.74 The remains of the device
Without
eventually pass with the feces. Experimental data show CE CREDIT FROM MICHIGAN STATE UNIVERSITY Volume 21 Number 9 September 2000

that colonic anastomoses achieved with a biofrag-

mentable ring have higher initial bursting strength and
similar healing patterns compared with sutured and sta-
Veterinary Breathing Easy
(page 509)

pled anastomoses.73 Clinical application of the biofrag-

mentable anastomosis ring has not been reported in the
Technician
The Complete Journal for the Veterinary Hospital Staff
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veterinary literature. 504

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lustrations), eversion of the mucosa from the cut ends 518
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and retraction of the outer seromuscular layers occur. on HIRING

Although direct, end-to-end apposition of the intestinal 526

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layers is a reasonable goal and primary healing of the A Roundtable on
SENIOR CARE

intestinal wall can occur, 44,58 such healing is rarely Check out TechMart.
See page 541.

achieved even under ideal surgical settings. Indeed, a Dana Farbman, CVT
National Animal Poison
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critical review of the literature shows that true histolog-

ic approximation of the layers of intestine is infrequent,
mucosal eversion is common, and secondary healing of
approximating end-to-end anastomoses is the most
The Most Widely Read
common scenario. Veterinary surgeons are aware of the
difficulty in achieving true approximation of the cut in-
Journal in Its Field
testine and have tried to minimize mucosal eversion by
either trimming the exposed mucosa or taking modi- ■ The technician’s right hand—the source
fied bites that exclude the mucosa altogether or invert they reach for first
the mucosal layer. The end result of these modifications
is often inversion of the histologic intestinal layers ■ Articles of interest to animal health
rather than apposition. professionals of all kinds: breeders,
Automated surgical stapling devices and biofrag- caretakers, trainers…
mentable anastomotic rings can also be used to rapidly
create efficient enteroanstomoses in small animals. ■ Medical and management articles of
These devices typically create inverting anastomoses interest to the dedicated pet owner
and have complication rates similar to those of hand-
sewn methods. Widespread use of intestinal stapling
equipment by veterinarians has been limited by cost
and lack of familiarity with stapling techniques.
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Lembert’s principle of serosal inversion, single-layer in-
verting techniques remain the most widely used meth- Veterinary Technician is published by
ods for hand-sewn end-to-end anastomosis of the intes- Veterinary Learning Systems
tine in human surgery.12,47–48 In veterinary surgery, the 275 Phillips Blvd.
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Small Animal/Exotics
single-layer, approximating technique for intestinal
anastomosis has become widely accepted.49–51
There are several reasons veterinarians have accepted
the approximating technique for intestinal anastomosis.
First, the technique is simple to perform and has yield-
ed consistent results. Second, the lumen of canine and
feline intestine is narrower than that of the human in-
testine; thus postanastomotic stricture after the invert-
ing technique is more of a concern in veterinary pa-
tients. Third, postsurgical abdominal adhesions, which
occur more frequently with noninverting intestinal
anastomoses, are less of a clinical concern in small ani-
mals than in humans. Finally, veterinary surgeons are
less strongly tied to Lembert and 175 years of surgical
doctrine than are human surgeons.
Nearly 200 years after the start of the “modern era of
intestinal surgery,”1 veterinary surgeons have arrived at
an approximating technique for hand-sewn end-to-end
intestinal anastomosis that is almost identical to the
method described by Travers in 1812.2 Just as Lembert
has been called the founder of modern intestinal sur-
gery, perhaps Travers should be regarded as the founder
of modern veterinary intestinal surgery.
REFERENCES
1. Senn N: Enterorrhaphy: Its history, technique, and present
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trating wounds and strangulated hernia. London, UK, Long-
man, Hurst, Rees, Orne, and Brown, 1812.
3. Lembert A: Nouveau procede d’enterorraphie. Repertoire
General d’Anatome et de Physiologie Pathologique 2:3–101,
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4. Ravitch MM: Observations on the healing of wounds of the
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8. Connell ME: An experimental contribution looking to an
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Compendium March 2000
12. Nelson RL: Surgical techniques and care of obstruction of
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4. Baltimore, Williams & Wilkins,1941, pp 180–213.
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North American Veterinarian, 1949, pp 318–320.
16. Frank ER: Veterinary Surgery Notes, ed 5. Minneapolis,
Burgess, 1950, pp 21–23.
17. Frank ER: Veterinary Surgery, ed 6. Minneapolis, Burgess,
1959, pp 20–22.
18. Lacroix JV, Hoskins HP: Canine Surgery, ed 3. Evanston, IL,
North American Veterinarian, 1952, pp 396–401.
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Evanston, IL, North American Veterinarian, 1957, pp 441–
448.
20. Larson LH: Stomach and small intestine, in Archibold J (ed):
Canine Surgery, ed 5. Santa Barbara, American Veterinary
Publications, 1965, pp 494–534.
21. Leonard EP: Fundamentals of Small Animal Surgery. Phila-
delphia, WB Saunders Co, 1968, pp 194–202.
22. Gambee LP: Single layer open intestinal anastomosis appli-
cable to small as well as large intestine. West J Surg 59:1–5,
1951.
23. Gambee LP: Ten years’ experience with a single layer anasto-
mosis in colon surgery. Am J Surg 92:222–227, 1956.
24. Hertzler JH, Tuttle WM: Experimental method for everting
end-to-end anastomosis in the gastrointestinal tract. Arch
Surg 65:398, 1952.
25. Galluzi W, Possenti B: The everting suture applied to per-
form an end-to-end anastomosis on the small bowel. Minerva
Chir 9:1008, 1954.
26. Ravitch MM: Some considerations on the healing of intesti-
nal anastomoses. Surg Clin North Am 49:627–635, 1969.
27. Knowles RP: Eversion technique for intestinal anastomosis.
Proc AVMA Ann Meet:192–193, 1964.
28. Mellish RWP: Inverting or everting sutures for bowel anas-
tomoses. J Pediatr Surg 1:260–265, 1966.
29. Getzen LC, Roe RD, Holloway CK: Comparative study of
intestinal anastomotic healing in inverted and everted clo-
sures. Surg Gynecol Obstet 123:1219–1227, 1966.
30. Ravitch MM, Canalis F, Weinshelbaum A, McCormick J:
Studies on intestinal healing: III. Observations on everting
intestinal anastomoses. Ann Surg 166:670–680, 1967.
31. Loeb MJ: Comparative strength of inverted, everted, and
end-on intestinal anastomoses. Surg Gynecol Obstet 125:301–
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About the Authors
When this article was submitted for publication, Dr. Cool-
man was the chief surgical resident at the College of Vet-
erinary Medicine, University of Illinois, Urbana, Illinois. He
is currently affiliated with Veterinary Surgical Services,
Fort Wayne, Indiana. Drs. Ehrhart and Manfra Marretta
are affiliated with the Department of Veterinary Clinical
Sciences, School of Veterinary Medicine, University of Illi-
nois, Urbana, Illinois. Dr. Ehrhart is a Diplomate of the
American College of Veterinary Surgeons, and Dr. Man-
fra Marretta is a Diplomate of the American College of
Veterinary Surgeons and the American Veterinary Dental
College.