Journal of Surgical Simulation 2022; 9: 67 - 73

Published: 04 August 2022


Original article

Bowel anastomosis training simulator: design and pilot testing

Britney Niemann, Conley Stout, Justin Chambers, Sijin Wen and Nova Szoka
Corresponding author: Britney Niemann, West Virginia University, 1 Medical Center Drive, Morgantown, WV 26505, USA. Email:


Background: Simulation in surgical training continues to evolve. As surgical trainees have limited opportunities to regularly practice hand-sewn bowel anastomoses, the aim of this pilot study was to design a low-cost simulation system, the bowel anastomosis training simulator (b-ATS), for teaching hand-sewn small bowel anastomoses and providing learners with real-time feedback via leak testing.

Methods: The study consisted of three phases. Phase 1 was the initial design of the b-ATS. The b-ATS consists of a base, stand, fluid bags, tubing, and a novel silicone bowel (bowel A). Phase 2 consisted of data collection. Two PGY-1 residents and one bariatric surgeon created multiple anastomoses using bowel A, several commercially available synthetic bowels, and porcine small bowel. Leak pressures were compared to determine which synthetic bowel most closely resembled biologic tissue. Phase 3 implemented the findings from phase 2 to refine the b-ATS and select the optimal bowel for use in the simulator.

Results: The synthetic bowel had the following average leak pressures with polydioxanone (PDS)/Vicryl (cmH2O): bowel A, 39.2/37.1; bowel B, 11.4/17; bowel C; 30/36.2; bowel D, 68/65.1; bowel E, 38.2/38.1; and bowel F, 55.2/39.2. The average leak pressures for porcine bowel were 62.3/61.6 cmH2O with PDS/Vicryl. The most common location of leaks was between the suture and suture holes, followed by the site of attachment to the circular stand. Porcine bowel had the lowest cost at US$0.10 per inch compared with the synthetic bowel tissues which ranged from US$1.66 to US$6.00 per inch. Based on these results, phase 3 consisted of refinements to the simulator structure to prevent the latter leaks and selection of bowel D for use in the final simulator model.

Conclusion: The b-ATS is a functional simulator for teaching hand-sewn small bowel anastomosis. Bowel A had significantly lower leak pressures compared with porcine bowel. Bowel D had the closest leak pressure to porcine bowel, at low cost and with adequate durability. Further research is needed to validate the efficacy of this tool.


laparoscopic training tool; surgical training; small bowel anastomosis; surgical education; surgical resident; design and bench testing