The end-to-side approximation is physiologic, simple, and safe to perform. The small intestine, still held in its clamp, is brought up adjacent to the anterior taenia of the colon (Figure 7). The small intestine should retain a good color and give evidence of adequate blood supply before the anastomosis is attempted. If its color indicates an inadequate blood supply, the surgeon should not hesitate to resect a sufficient length until its viability is unquestionable. Next, the omentum, if not previously excised, is retracted upward, and the anterior taenia of the transverse colon is grasped with Babcock forceps at the site chosen for anastomosis (Figure 7). Following this, the edge of the mesentery of the small intestine should be approximated to the edge of that of the large intestine, so that herniation of the small intestine cannot occur beneath the anastomosis into the right gutter (Figure 14). This opening is closed before the anastomosis is started, since on rare occasions the blood supply may be injured by the procedure and the viability of the anastomosis jeopardized. A small, straight crushing clamp is applied to the anterior taenia, including a small bite of the bowel wall (Figure 8). Following this, the clamps on the terminal ileum, as well as on the anterior taenia of the transverse colon, are so arranged that a serosal layer of interrupted 000 mattress or nonabsorbable synthetic sutures can be placed, anchoring the terminal ileum to the transverse colon (Figure 9). The two angle sutures are not cut and serve as traction sutures (Figure 9). An opening is made into the large intestine by excising the protruding contents of the crushing clamp that has been applied to the anterior taenia (Figure 10). An enterostomy clamp is then applied behind each of the crushing clamps. The crushing clamps are removed, and the terminal ileum is opened; likewise, the crushed contents of the transverse colon are separated. Sometimes it is necessary to enlarge the opening in the mucosa of the colon, since the previous excision of the contents of the crushing clamp did not provide a sufficiently large stoma for satisfactory anastomosis. The mucosa is then approximated with a continuous locked nonabsorbable suture on atraumatic needles, which is started in the midline posteriorly. The sutures, A and B, are continued as a Connell inverting suture around the angles and anteriorly to ensure inversion of the mucosa (Figures 11 and 12). Interrupted fine 000 silk sutures are preferred by some for closing the mucosal layer. An anterior row of mattress sutures completes the anastomosis. Several additional mattress sutures may be placed to reinforce the angles (Figure 13). The patency of the stoma is tested. It should permit introduction of the index finger. If the tension is not too great, the raw surface over the iliopsoas muscle may be covered by approximating the peritoneum of the lateral abdominal wall to the mesentery.