An end to end anastomosis is the most common type of anastomosis between the colon and rectum. This typically is described as a double-stapled technique as the rectum is divided with a linear stapler and the end to end anastomosis is created across this staple line using a circular stapler. To prepare the proximal colon, a purse string is placed to secure the stapling anvil. A purse string can be placed with either a disposable device, a reusable device using a 2-0 monolament suture on a Keith needle, or as a handsewn purse string. The key concept is to ensure the edges of the colotomy are everted and that the purse string is complete and secure. For a hand­sewn purse string, a running Connell stitch is best to ensure these principles are met (Fig.18.1a, b). It allows for full-thickness bites circumferentially around the lumen of the proximal colon. When using a disposable device, be aware that the staples securing the purse string only grab the serosa with or without the underlying muscu­laris, so it is very important to ensure the mucosal edges are everted to adequately secure the entire bowel edge around the post of the anvil when cinching the purse string down. It is up to the surgeon to “clean” tissue from the colon at the level of the anvil. The goal of this would be to minimize fat within the staple line, to identify diverticula that could be caught in the circular staple line, and to ensure a complete purse string. If a diverticulum is identied that may fall within the staple line, it is drawn up into the anvil with a stitch. A full-thickness stitch is placed just proximal to the diverticulum, and the suture is then tied around the post of the anvil. This maneu­ver allows the diverticula to be drawn up and out of the staple line. This is important as these colonic diverticula are false diverticula, so they only contain mucosa and serosa. After the anvil has been securely placed, the anastomosis can be performed.