Purpose <p>Hollow viscus and mesenteric injuries after blunt or penetrating trauma are challenging due to their rarity, diagnostic uncertainty, and consequences if left untreated. The aim of this study was to report the characteristics, management and outcomes of patients with traumatic bowel lesions at a major European trauma center and assess the safety of primary repair or anastomosis at index operation.</p> Methods <p>We conducted a retrospective cohort study including all patients with traumatic bowel injuries from January 1, 2018, to June 30, 2023. Patients were grouped according to surgical strategy: (1) primary repair or anastomosis at index laparotomy, or (2) diversion and/or staged operation. Primary outcomes were surgical strategy, anastomosis formation, and postoperative abdominal complications. Secondary outcomes included non-surgical complications, ICU admission, length of stay, mortality, and results from multivariable logistic regression adjusting for demographic and clinical covariates.</p> Results <p>Seventy-six patients were included, of whom 51 (67%) received primary repair or anastomosis and 25 (33%) underwent diversion or a staged procedure. Postoperative abdominal complications during the index admission occurred in 20% of patients in the primary repair/anastomosis group versus 60% in the diversion/staged group. Anastomotic leakage occurred in two patients (6%) following index anastomosis. On multivariable logistic regression, diversion or staged strategy was associated with higher odds of abdominal complications (OR 3.76, 95% CI 1.06–6.00).</p> Conclusion <p>Patients undergoing primary repair or anastomosis had markedly fewer abdominal complications than those undergoing diversion or staged surgery. Whenever possible, primary repair or anastomosis should be considered during the index operation.</p>