Recent advances -Staplers in surgery Dr.B.Vinod. Dept.of General surgery Gandhi Medical college and Hospital Hyderabad, Telangana

1. STAPLERS IN SURGERY
By:Dr.B.Vinod
Dept. of General surgery,
Gandhi medical college and hospital,
Hyderabad, Telangana.

2. ● The principles for gently treating living tissue were
established more than 100 years ago by Dr. William
Halsted.
● Those principles haven’t changed. However, with the
evolution of surgery, techniques of interacting with tissue
have become more complex.

3. Halsted’s Principles of Anastomosis
• No tissue tension
• Good hemostasis
• Obliteration of dead space
• Gentle handling of tissue
• Adequate blood supply
• Adequate lumen

4. HISTORY OF SURGICAL STAPLERS
1880s
Reports of first stapler by Dr Henroz- everted bowel anastomosis in dogs.
1908
Professor Humer Hultl with Victor Fischer created a stapler with emphasis
of following principles-
Tissue compression
B-shaped configuration of closed staples
Placement of staples in double staggered rows
Use of fine wire as the staple material.
But it was heavy and its assembly was difficult and time-consuming

5. 1980
The dawn of minimally invasive procedures (MIP). Surgeons request
laparoscopic adaptation of Transecting Linear Cutter (TLC) device
1989
Titanium replaces stainless steel as the key component for staples

6. Properties of Tissue
● Living tissue mainly consists of solid and fluid (biphasic nature)
● Tissue thickness changes when external force is applied,
then tissue also has properties to return to the original shape
over time (viscoelastic nature)
● Based on biphasic and viscoelastic nature, we have to consider…
when using staplers
○ Thickness
○ Compressibility
○ Property variability

7. Materials for staplers
Stainless steel Pure Titanium Titanium Alloy*

8. Tissue Dynamics in Action: Stapling Tissue
Living tissue
compressed to
adequate thickness
for stapling.
Living tissue
before compression.
Energy is stored in
the staple as
compression is
maintained

9. Two types of compression
Closing Lever
Forward
Backward
25%
Stronger
Focal Compression (V-shape) Cam Tube Compression (Parallel)

10. Pre-Compression
Pre-compression
is necessary for
good staple
formation

11. firing
Compression Over Time
Holding compression before firing:
 Prepares the tissue to be fired upon
 Reduces stress on the tissue prior to
firing
 Minimizes tissue flow
 Optimizes staple formation
No Pre-Compression
Pre-Compression

12. Compression Dynamics

13. 0
0.29
0.41
0.49 0.50
0
0.1
0.2
0.3
0.4
0.5
0.6
0 5 10 15 20 25
Tissue thickness reduction (mm) over time (s) after jaw closure
Tissuethicknessinmm
Time in seconds
15 to 20 seconds gives an optimal thickness

14. Tissue thickness varies widely
throughout the body from organ
to organ.
Even within each organ, tissue
thickness ranges greatly.1
Diagram of the stomach indicating the locations of
measurements* (n=50) measurements at each location
*Mean measurement (maximum measurement)
Tissue Dynamics

15. Tissue thickness in a given
organ varies location by
location

16. STAPLE CONFIGURATION

17. EES Linear Cutter Cartridge
with 3D Staples
3D
Staple
The Staple & Cartridge Configuration
Appropriate staple formation is a combination of the
instrument and cartridge interaction with living tissue.
Staple Retainer
Staples
Staple Drivers
Cartridge body
3D
Staple
Linear Cutter Cartridge
with 3D Staples
3D
Staple
B-Form
Staple

18. The Staple Formation Continuum

19. Tissue Flow

20. Types of Cartridges

22. Modern Stapler Types
● Linear staplers
● Linear cutting
● Circular staplers
● Curved cutter
● Skin

23. LINEAR STAPLERS
● Close internal organs prior to transection
● Close the common opening or enterotomy after the creation of an
anastomosis
● Biopsy or wedge resection of the lung and closing of the bronchus and to
close pulmonary vessels prior to their division

24. LINEAR CUTTER STAPLERS
● Open linear cutter
Without selectable height
With selectable heights.
● Endoscopic linear cutter
Endoscopic Articulating linear
Powered Articulating Endoscopic linear cutter

26. Features Benefits
6 Row 3D Staple Technology
• Optimizes tissue compression & provides superior
hemostasis
Selectable Staple Height
• Allows surgeon to choose close staple height without
changing reload
Proximal Preload Support
• Consistent staple formation without fork deflection
Two-sided Firing •Ambidextrous use of instrument
Intermediate Locking Position • Allows repositioning of tissue
Safety Lockout Mechanism
• Prevents firing if there is no cartridge or fired cartridge
Non-slip grip surface • Tighter & stronger grip

27. Without selectable height With selectable height
4 rows of B formation 6 rows of 3D technology
No selectable height Selectable height
One sided firing Two sided firing
No gripping surface Gripping surface
Preloaded and total 8 firings No preloaded,total 12 firings

28. DEVICE CUT LINE STAPLE LINE RELOAD COLOR CLOSED STAPLE HEIGHT ROWS OF STAPLES
NTLC55 58 61 Black
1.5 mm 6
1.8 mm 6
2 mm 6
NTLC75 78 81 Black
1.5 mm 6
1.8 mm 6
2 mm 6

29. Endoscopic linear cutter

30. Endoscopic Articulating linear cutter

31. Powered Articulating linear cutter

32. Top features
● Enhanced system wise compression
Pre compression: Management of tissue before firing
3 point gap control:Ensures alignment and calibration throughout the
staple line for consistent staple formation and haemostasis.
Precision machined anvil:Removes exudative fluid and prepare for
proper staple formation

33. ● Stroke firing system:Distributes for evenly
● Articulating joint:For lateral access
● Manual Override:In surgeons control in event of power loss
● Anvil jaw release
● Knife reverse switch:Discontinue firing and reverse the knife
● Battery pack:Should be preinstalled before use

34. Circular Staplers

35. ●

36. ● Curved and Straight intraluminal staplers are anastomotic staplers
available in four sizes to permit proper matching of instrument to
diameter of the lumen.
 21 mm
 25 mm
 29 mm
 33 mm

37. Number of Reloads/Firings
Single –fire instrument and single-patient use

38. Uses
● End to end anastomosis e.g. colorectal anastomosis
in LAR
● End to side anastomosis e.g. illeocolostomy after
right hemicolectomy
● Side to side anastomosis e.g. side to side
gastrojejunostomy after billroth II gastrectomy
● Rapid creation of pyloroplasty

39. Curved Cutter Staplers
● Curvilinear cutting staplers (contour stapler)
transabdominal proctectomy
very-low- anterior resection of the rectum

40. Features & Benefits
● Simultaneous stapling and cutting
 Innovative device delivers four curvilinear rows of staples with
a single cut between- eliminating two procedure steps: the
need for a bowel clamp and scalpel
● Unique curved head design
 Delivers lower pelvic access with enhanced visibility; it also
allows placement of a 40 mm staple line in the width of 30
mm space

41. Ease of placement
Confirms to the natural anatomy of the pelvis
Lower pelvic access
For the narrow pelvis , the CONTOUR exceeds the access
of 30 mm linear stapler
Reloadable cartridges
A single device for up to six firings in a single procedure

42. Skin Staplers

43. PPH

48. Anastomotic leaks
● Mechanical/ tissue causes –Seen in first two days following surgery.
More commonly seen.
● Ischemic causes – ischemic leaks happens 5 to 7 days post
operatively

49. Advantages of stapling devices
● Less tissue handling and less tissue tension
● Less trauma
● Time saving
● Better haemostasis
● Available for MIS.

50. Contraindications
● If circular head greater diameter than lumen diameter
● Tissue in tension
● Different lumen diameter

51. Types of staplers based on usage.
● Reusable staplers with disposable catridges.
● Disposable catridges.

52. ● The use of stapling does not guarantee the successful outcome of a surgical
procedure.
● Effective and safe use of mechanical stapling devices depends upon good
basic surgical technique, including clean, atraumatic dissection, careful
hemostasis, attention to tissue condition and blood supply, and creation of
tension-free anastomoses.
"If you wouldn't sew it, don't staple it,”
A maxim that is worth remembering.
Respect for living tissue lives at the heart of what we do.

53. THANK YOU