Laparotomy is used as a surgical procedure to treat a wide variety of acute intra-abdominal conditions, such as intestinal obstruction, perforation, ischemia/strangulation, trauma, and peritonitis.[1] Although improvements have been made in the care of the patient in the peri-operative period, emergency abdominal surgery is still associated with significant morbidity and mortality rates.[2] The patients with emergency abdominal surgery often present with sepsis, physiological instability, contamination, bowel oedema, malnutrition, and other factors that can adversely affect tissue healing.[3]

Restoration of intestinal continuity is an important decision during laparotomy in cases of emergency bowel resection.[4] Conventional hand-sewn anastomosis or mechanical stapling can be used.[5] Hand-sewn anastomosis is widely used, easy, and inexpensive and does not require any special stapling device, while stapled anastomosis can shorten the time required to make the anastomosis or enable rapid bowel reconstruction.[6] In cases of emergency surgery, however, the technique selected is of even more critical importance, as the local and systemic situations may vary significantly from those found in elective surgery.[7] Anastomotic leakage is one of the most clinically significant complications, as it can lead to intra-abdominal sepsis, formation of an abscess, re-operations, longer hospital stays, and death, which affects the overall postoperative recovery of the patient.[8]

There is limited evidence that supports the comparison of these two techniques, especially in the emergency context. However, a systematic review and meta-analysis of seven studies, with 1,120 patients and 1,205 emergency intestinal anastomoses, identified no significant difference between stapled and hand-sewn techniques in terms of anastomotic failure, anastomotic leakage, abscess, fistula, or postoperative mortality, but the authors noted that the evidence was limited and highly likely contained important biases.[9] A recent systematic review and meta-analysis of trauma patients also reported no difference between stapled and hand-sewn repair for anastomotic leakage, but the studies included in the analysis were moderate-to-high risk of bias and had limited adjustments for confounding factors.[10] On the other hand, a Cochrane review of randomized trials of ileocolic anastomoses found fewer anastomotic leaks using staples, and outcomes can vary by the site of the surgery, the patient population, and the surgical conditions.[11]

The uncertainty is especially important in the case of emergency laparotomy, and there may be a risk of anastomotic healing being compromised by contamination, poor perfusion, bowel oedema, systemic inflammatory response, and haemodynamic instability.[12] Furthermore, anastomosis leakage is just one of the postoperative recovery parameters; operative time, return of bowel function, postoperative complications, hospital stay, and requirement for reintervention are other clinically relevant parameters.[13] A previous study has often included patients undergoing elective, trauma, and emergency surgery, or included mainly colorectal surgery, which may limit its relevance to patients undergoing emergency laparotomy.[14] Thus, a comparison of stapled vs hand-sewn bowel anastomosis specifically in the emergency laparotomy setting may yield clinically relevant data on the safety of the anastomosis and postoperative recovery.

The ongoing debate about the best technique for bowel anastomosis after laparotomy in the emergency setting, and the limited and diverse evidence from emergency surgery, make a focused comparative assessment of the techniques highly relevant. The comparison of stapled versus hand-sewn anastomosis for differences in anastomotic leakage and postoperative recovery may contribute to better postoperative management in patients undergoing emergency bowel surgery and may help the surgeon make evidence-based intraoperative decisions. Thus, the purpose of this study is to compare the two techniques of stapled and hand-sewn bowel anastomosis after emergency laparotomy in terms of the presence of anastomotic leakage and recovery after laparotomy.

A comparative observational study was conducted in the Department of General Surgery, Jinnah Postgraduate Medical Center, Karachi for one year from 1st June, 2025 to 30th May, 2026. The sample size was determined using OpenEpi version 3.0, and anastomotic leakage was defined as the primary outcome. The failure rates of the anastomoses were 15.0% in the stapled group and 6.1% in the hand-sewn group in previous emergency general surgery data.[15] With a two-sided 95% confidence level, 80% statistical power, and an expected difference in the leakage proportions of 15.0% versus 6.1%, the calculated sample size was approximately 206 patients (103 in each group). Patients were selected using consecutive sampling. All patients who were admitted for emergency laparotomy and bowel resection and primary intestinal anastomosis during the study period were assessed to see if they were eligible. Recruitment was continued until the needed number of recruits was obtained. The patients were classified based on different types of intestinal anastomosis: stapling device vs conventional hand-sewn suturing. Anastomosis techniques were performed as per intra-operative clinical conditions, bowel condition, anatomical location, and availability of resources and were not standardized solely for the study. Emergency laparotomy was performed in patients aged 18 years or more undergoing surgery for acute intra-abdominal conditions that involved bowel resection and primary intestinal anastomosis. Patients who had undergone small bowel to small bowel anastomosis, small bowel to colon, or colon to colon were eligible, with primary anastomosis being performed during the index surgery. All patients who underwent stapled or hand-sewn anastomosis and all patients who gave informed consent were included. Patients excluded included those who did not have bowel continuity restored during the index procedure, including those with end ileostomy, colostomy, mucous fistula, or bowel exteriorized. Patients with planned second-look laparotomy or delayed anastomosis were also not included in the study as they were excluded from elective laparotomy. Patients who had had previous anastomosis leakage or who underwent second abdominal surgery on the same admission before they were evaluated on the index surgery were excluded, as were those for whom there was inadequate clinical data to assess the index anastomosis. Patients who died during or in the immediate postoperative period before the anastomosis could be clinically evaluated were also considered not to have anastomosis leakage and not included in the analysis of anastomosis leakage. After obtaining ethical approval from the institutional research and ethical review committee, eligible patients presenting to the Department of General Surgery with an indication for emergency laparotomy were screened consecutively according to the predefined inclusion and exclusion criteria. Patients meeting the inclusion criteria who had undergone bowel resection with primary anastomosis were included in the study. Written informed consent was obtained from the patient before inclusion in the study. When patients were unable to give consent due to an emergency, altered consciousness, or clinical instability, consent was secured from a legally authorized representative following institutional ethical requirements. Demographic and clinical details were captured using a proforma of a standardized structure as baseline information. The parameters that were recorded are age, gender, BMI, diagnosis at presentation, duration of symptoms before admission, relevant clinical comorbidities, and pre-admission hemodynamic status. Routine clinical evaluation and appropriate laboratory tests were conducted to evaluate the patient, and the results were documented prior to surgery. Subsequently, patients were grouped based on the technique used for bowel continuity (stapled and hand-sewn). Intraoperative data were directly extracted from surgical and operative notes. The following operative variables were documented: indication for emergency laparotomy, type of bowel removed, site of anastomosis, configuration of anastomosis, stapled vs hand-sewn technique of anastomosis, total operative time, level of peritoneal contamination, and need for perioperative blood transfusion. Prospective follow-up was undertaken from the day of surgery until discharge or death. Special emphasis was placed on the development of anastomotic leakage, which was confirmed by clinical, radiological, operative, or drain/wound criteria, such as radiological diagnosis of an anastomotic defect or collection, operative evidence of leakage, or passage of enteric contents through a drain or wound. The other postoperative outcomes recorded were time to return of bowel sounds, time to first oral feeding, surgical-site infection, intra-abdominal collection, postoperative ileus, need for reoperation, length of hospital stay, and in-hospital death. All patients were followed up during the early post-operative period in the hospital to detect any complications, and the relevant clinical findings, investigations, interventions, and outcomes were recorded systematically and systematically on the study proforma. The data collected were entered and analyzed on IBM SPSS Statistics 26. Continuous variables were tested for normality with the Shapiro-Wilk test; normally distributed variables were shown as mean ± SD, while non-normally distributed variables were shown as median with interquartile range. Categorical variables were presented as frequencies and percentages. Demographic, Preoperative, intraoperative, and Postoperative Parameters of the stapled versus hand-sewn groups were compared. Normally distributed continuous variables were compared using the independent-samples t-test, while the Mann-Whitney U test was used for non-normally distributed continuous variables. Categorical variables were compared using the chi-square test and Fisher's exact test. Anastomotic leakage and other binary postoperative outcomes were compared between the two groups using appropriate measures of association with 95% confidence intervals. The potential confounding factors such as age, sex, comorbidities, nutritional status, degree of contamination, site of anastomosis, and severity of presenting condition were taken into consideration in multivariable logistic regression analysis. Stratification was used for important variables, including anastomotic site, degree of peritoneal contamination, and comorbid factors, to determine if the relationship between anastomotic technique and postoperative outcomes was similar in each stratum. A p-value less than 0.05 was regarded as statistically significant.

The demographic and baseline characteristics of the participants were comparable between the stapled and hand-sewn groups. Demographic data, anthropometric parameters, comorbidities, duration of the symptoms, and preoperative laboratory and clinical data were not significantly different. This suggested that there were no significant differences in baseline characteristics between the two groups before surgery, decreasing the risk of a large baseline imbalance effect impacting postoperative comparisons between the groups. (Table 1)

Table 1. Demographic and baseline characteristics of the study participants

The operative characteristics demonstrated that the distribution of anastomosis sites and intra-abdominal contamination were recorded for both groups. The groups were also similar with respect to the need for perioperative transfusion. A statistically significant difference was observed in operative duration, with the analysis indicating a difference between the two anastomotic techniques. (Table 2)

Table 2. Operative characteristics of the study participants

Postoperative comparisons indicated variations in several measures of postoperative recovery between the groups. The outcomes analyzed were anastomotic leakage, surgical-site infection, intra-abdominal collection, postoperative ileus, reoperation, and postoperative mortality. Furthermore, gastrointestinal recovery and overall hospitalization were evaluated, and statistically significant differences were found in time to bowel function, oral feeding, and overall hospitalization. (Table 3)

Table 3. Primary and secondary postoperative outcomes

Analysis of the site of the anastomosis revealed that leakage occurred in both groups at small-bowel anastomosis, ileocolic anastomosis, and colocolic anastomosis. The proportion of leakage observed in the different techniques was different across the anatomical subgroups numerically, but there was no statistically significant association. (Table 4)

Table 4. Anastomotic leakage according to anatomical site

Anastomotic leakage was seen in both localized and generalized or peritoneal contamination groups when analysis was performed based on the degree of intra-abdominal contamination. The leakage rates of the two anastomosis techniques were different in each of the contamination strata, but not significantly different. (Table 5)

Table 5. Anastomotic leakage according to degree of contamination

Stratified analysis for age, diabetes mellitus, serum albumin, preoperative sepsis, and hemodynamic stability was conducted to examine the consistency of the association between anastomotic technique and leakage. There was no difference in leakage between stapled and hand-sewn anastomoses in all the clinical strata analyzed, indicating that the observed relationship was not significantly influenced by these individual clinical factors. (Table 6)

Table 6. Stratification according to important clinical factors

Clinically relevant confounding factors were included in a multivariable logistic regression model to assess the independent relationship of the anastomotic technique used with postoperative leakage. Demographic, nutritional, systemic, contamination-related, and anatomical variables were all included in the analysis. All of the variables entered into the model showed no statistically significant independent association with the development of anastomotic leakage at the present level of significance, though some did display a trend for increased leakage. (Table 7)

Table 7. Multivariable logistic regression analysis for factors associated with anastomotic leakage

The current study compared the use of stapled and hand-sewn bowel anastomosis in 206 patients who underwent emergency laparotomy and looked at anastomotic leakage as the primary outcome, along with recovery and complications. Numerically, the stapled group experienced less leakage from the anastomosis than the hand-sewn group, but this was not statistically significant. Likewise, there were no significant differences in surgical-site infection, intra-abdominal collection, postoperative ileus, reoperation, or postoperative mortality. On the contrary, stapled anastomosis was found to be significantly associated with shorter operative duration, earlier recovery of bowel function, earlier introduction of oral feeding, and shorter hospital stay. The results of the present study indicate that leakage was not significantly reduced with stapling, but mechanical anastomosis was associated with improved indices of operative efficiency and postoperative recovery. The results on anastomotic leakage are comparable to the 2021 Cochrane systematic review by Neutzling et al. that analyzed nine RCTs with 1233 patients who underwent colorectal anastomosis. There were no significant clinical or radiological differences between the stapled and hand-sewn techniques regarding anastomotic dehiscence, mortality, reoperation, or wound infection. But it took less time to create the anastomosis with stapling. The present study also revealed no differences with respect to leakage or other significant postoperative complications, but it did show that stapled anastomosis had a statistically significantly shorter operative time. The Cochrane review focused on elective colorectal surgery, while the current study was limited to emergency laparotomy, so the agreement is more relevant, as there are other physiological factors and factors related to contamination that can affect healing in emergency patients.[16] In a 2022 Pakistani study by Ghafoor et al., stapled and hand-sewn anastomoses were compared for 60 patients who were undergoing elective gastrointestinal surgery. The investigators found that there was a significant difference in the integrity of the anastomosis, the length of the procedure, and postoperative hospital stay, with the stapled group performing better on both of these measures, but no significant difference in return of bowel activity was found. In the present study, the operative time and hospital stay were also found to be shorter with stapling, but the present group comprised only emergency laparotomy patients with a wider spectrum of bowel anastomotic sites. The difference in clinical setting is significant because emergency cases may have peritonitis, bowel oedema, sepsis, nutritional compromise, and haemodynamic instability, which may mask the separate effect of the anastomosis technique.[17] In 2023, Brillantino et al. reviewed 137 hemodynamically stable patients with intestinal obstruction (IO) and secondary mesenteric ischemia (SI) following emergency small bowel resection (SBR). They did end to end anastomosis done with hands and compared them to stapled end-to-side, end-to-end, and side-to-side anastomoses. There was no significant difference in anastomotic failure or hospital stay between the groups, but the operative time was significantly longer in the hand-sewn group. These findings are similar to the current results, as both studies compared the safety of the anastomosis and operative time of stapling versus hand suturing in emergency bowel surgery, with the same conclusion. The present study further showed that stapling also proved to be more efficient than traditional suturing in restoring bowel function and transitioning to oral feeding and a shorter duration of hospitalization, which may not just be due to the technicality of the anastomosis.[18] The result of the present study is also comparable to the 2024 systematic review and meta-analysis by Le et al., which was performed specifically on gastrointestinal anastomosis in trauma patients, comparing stapled vs hand-sewn. A total of eight studies with 931 patients were analysed and showed no difference in anastomotic leakage between the stapled and hand-sewn methods. Similarly, no significant difference was observed between the composite outcome of leakage, deep intra-abdominal abscess, and enterocutaneous fistula. The authors found there was not enough evidence to conclude that one technique was superior to the other, especially in the studies included were moderate-to-high risk of bias and limited adjustment for confounding factors. The present study also did not show any statistically significant difference between leakage and emphasizes the need to take the emergency clinical context and patient related factors into account, rather than assuming that one type of reconstruction technique is always leakage-proof.[19] A study by Lahes et al. (2024) performed a retrospective analysis of 339 patients with Crohn's disease who had undergone bowel resection and compared the stapled and hand-sewn anastomoses. They did not find a significant difference in any of the surgical outcomes, including anastomotic leak, mortality, reoperation, or length of hospital stay after surgery. No differences were seen in the rate of anastomotic leakage between the groups. In general, these observations are similar to the present study as far as leakage, reoperation, and mortality rates are concerned, which were not found to be statistically significant. The Crohn's disease population differs greatly, however, from the current emergency laparotomy cohort due to the potential impact of chronic inflammatory disease, immunosuppressive therapy, nutritional deficiency as a result of the disease and the risk of recurrence on outcome. However, this study suggests that the technique of anastomosis may not be the primary factor in determining postoperative complications.[20] A study by Kshirsagar and Himashree (2024) performed a prospective non-randomized study of 60 patients undergoing different gastrointestinal surgeries, including elective and emergency surgeries. The outcome of the stapling procedure was good, with short recovery time and operative time, and the influence of anastomosis technique on leakage was dependent on the clinical scenario. They also identified a significant correlation between low albumin level and development of anastomosis leakage. The present study also included serum albumin as a covariate in the stratified and multivariable analyses. Hypoalbuminemia was linked to increased odds of leakage in this analysis, but this relationship was not statistically significant. The agreement among these studies, however, underscores nutrition as a significant possible factor in anastomotic healing and indicates that this factor should be taken into account when assessing the impact of different operative techniques.[21] In 2024, the study from a large population in Finland compared 2,164 patients undergoing gastrectomy who had stapled versus hand-sewn anastomoses. The differences in anastomotic leakage were initially significant in the unadjusted analysis, but were not present in the adjusted analysis after controlling for appropriate predictive variables and did not exist after stratification by the type of gastrectomy. This is relevant in the present multivariable analysis, where the odds of leakage were lower for stapled anastomosis; however, the association was not statistically significant. These results together highlight the need to consider patient and operative factors before attributing the difference in leakage to the anastomosis technique. Direct comparison should be made with caution as the Finnish study was performed on patients who had gastric cancer surgery rather than emergency intestinal resection.[22] Benshabat et al. (2025) compared stapled and hand-sewn Kono-S ileocolonic anastomoses in 25 patients with Crohn's disease. This stapled technique was associated with significantly reduced operative time compared to the other techniques, with no significant difference in complications or reoperation rates. This result is consistent with the current study, especially regarding the benefit of staples in terms of the time of surgery, and the absence of statistically significant differences in surgical complications. Direct generalization to the situation of emergency laparotomy is not possible in the smaller sample size and in a very specific Kono-S configuration; however, the consistency of the operative-efficiency finding in the different surgical populations suggests that mechanical stapling is advantageous where it is technically appropriate.[23] A randomized controlled trial was performed in 2025 in Punjab, Pakistan, that involved 114 patients who were undergoing elective colorectal surgery, comparing stapled with hand-sewn anastomoses. The investigators found that the stapled group had a significantly shorter operating time and hospital stay, and the same rate of anastomotic leakage and surgical-site infection. These results are similar to the current results, especially the significantly reduced duration of operation and hospital stay for stapling and the absence of a significant difference in major complications in the postoperative period. Although the study used an observational design, it is the randomized design of the first study that affords stronger evidence about comparative technique, not the observational design of the present study; however, the elective colorectal population of the first study is different from the multi-site bowel-anastomosis population evaluated in the present study.[24] The latest evidence comes from Ijaz Ul Haq and colleagues' (2026) systematic review and meta-analysis of observational cohorts that compared stapled and hand-sewn colorectal anastomosis. The anastomosis technique showed no significant difference in the incidence of anastomotic leakage, surgical-site infection, length of stay, and mortality rate in the included studies; in some cases, the stapled technique used a shorter operating time. The authors also highlighted the added value of heterogeneity due to the varied surgical contexts, e.g., elective, emergency, or Crohn's disease surgery. This trend is very similar to the current results: No significant difference in leakage, SSI, or mortality, and an operative-efficiency advantage for stapling. This trend is very similar to the current results: No significant difference in leakage, SSI, or mortality, and an operative-efficiency advantage for stapling. The present study builds on this literature by specifically targeting emergency laparotomy and investigating postoperative gastrointestinal recovery, as well as common surgical complications.[25] The present study has a number of strengths. It specifically examined patients undergoing emergency laparotomy and not combined emergency and elective cases, multiple anatomical sites of bowel anastomosis, both primary and secondary postoperative outcomes, and included clinically important factors like nutritional status, contamination, sepsis, and hemodynamic instability. Stratified analysis and multivariable logistic regression were also used to evaluate whether the association between the technique of the anastomosis and leakage was consistent across clinically relevant subgroups. These types of features offer a more clinically oriented evaluation of bowel anastomosis in the emergency. LIMITATIONS There were a few limitations to this study. First, the observational design of this study made it difficult to assess the selection bias and the residual confounding that could occur when deciding between stapled and hand-sewn anastomosis, as the choice was at the discretion of the surgeon performing the procedure. Second, the study took place at one center, and the results of this study may not be generalizable to other centers due to differences in patient populations, surgical experience, and resources available. Third, the relatively small number of anastomotic leakage events may have reduced the statistical power to detect clinically meaningful differences and resulted in relatively wide confidence intervals in the multivariable analysis. Finally, unmeasured factors like the viability of the bowel, extent of bowel edema, surgeon experience, and exact intraoperative tissue character could not be completely controlled.

There were no statistically significant differences in postoperative safety outcomes between stapled and hand-sewn bowel anastomoses in patients undergoing emergency laparotomy in terms of anastomotic leakage, surgical-site infection, intra-abdominal collection, postoperative ileus, reoperation, or mortality. However, stapled anastomosis had an earlier return of bowel function, earlier commencement of oral feeding, shorter hospital stay, and shorter operative time. These findings may reflect a recovery advantage with stapling, but such an advantage cannot be conclusively attributed to the technique of anastomosis alone because of the observational nature of the design. Larger multicenter prospective studies and RCTs are needed to further assess the comparative effectiveness of stapled versus hand-sewn bowel anastomosis in emergency surgery.