Single-Layer Versus Double-Layer Hand-Sewn Intestinal Anastomosis: A Prospective Randomized Study in a Resource-Limited Setting

Background: The choice of suturing technique for intestinal anastomosis remains a critical consideration in bowel surgery. Evidence comparing single-layer and double-layer techniques in terms of operative efficiency, post-operative recovery and resource utilization is limited, particularly in emergency surgical settings. This study aimed to compare clinical outcomes and cost-effectiveness of single-layer versus double-layer anastomosis in adult patients undergoing bowel resection. Methods: A prospective, single-center randomized controlled trial was conducted from June to November 2024. Adults aged 20-59 years undergoing small or large bowel resection with primary hand-sewn anastomosis were randomized to receive either single-layer or double-layer closure (31 patients per group). The primary outcome was time to return of bowel sounds. Secondary outcomes included anastomosis time, time to first bowel movement, length of hospital stay, post-operative complications and cost-effectiveness. Data were analyzed on an intention-to-treat basis using standard statistical tests. Results: Baseline characteristics were comparable between groups. Single-layer anastomosis required significantly less operative time (16.4 ± 3.3 vs 24.1 ± 3.3 minutes; P = 0.01). Post-operative recovery was faster in the single-layer group, with earlier return of bowel sounds (2.3 ± 0.9 vs 3.4 ± 1.1 days; P = 0.01), earlier first bowel movement (4.2 ± 1.1 vs 5.5 ± 1.2 days; P = 0.01) and shorter hospital stay (5.9 ± 1.5 vs 7.3 ± 1.4 days; P = 0.01). Post-operative complications occurred in 9.7% of single-layer patients and 22.6% of double-layer patients, without a statistically significant difference. One anastomotic leak occurred in the double-layer group, with none in the single-layer group. Although procedural costs were slightly higher per patient in the single-layer group, the technique demonstrated favourable cost-effectiveness due to reduced complications and shorter hospitalization. Conclusion: Single-layer intestinal anastomosis is a safe and efficient alternative to double-layer closure, offering significant advantages in operative time and post-operative recovery without increasing complication rates. These findings support its use in high-volume and resource-constrained surgical settings.