This document summarizes the history and development of stapling devices in surgery from 1908 to present day. It begins with early stapling instruments developed in Hungary in the early 1900s and progresses through key innovations such as disposable, sterile cartridges; linear, circular, and hemorrhoidal staplers; adoption of titanium staples; and development of laparoscopic staplers. The document also discusses tissue properties, biomechanics of stapling, factors that influence optimal staple formation such as precompression time, and evidence that stapling results in fewer leaks and strictures compared to hand-sewn anastomoses.

1. STAPLING DEVICES IN SURGERY
Dr. Ankita Singh
MBBS-LHMC, MS-MAMC
SR- AIIMS Delhi

2. HISTORY
• 1908
– Professor Humer Hultl Professor and Chief
Surgeon in Budapest at the St Rokus and St
Stephen’s Hospitals, produced the first
sophisticated stapling instrument.
– Emphasis on
• Tissue compression
• B-shaped configuration of closed staples
• placement of staples in double staggered rows
• use of fine wire as the staple material.
HULTL H. (1909) Zweite Kongress der Ungarischen Gesellschaft fur Chirurgie, Budapest, May 1908, Pester Med. -
Chir. Presse 45, 108- 10, 12 1-2.

3. •Assembly took 2 hours to complete
•Weighted 3.5kg
•Had 4 lines of staples

4. • 1924
– Alader Petz, another Hungarian simplified the
instrument, making it a giant Payr’s clamp
– 2 rows of staples
PETZ A. (1924) Zur technik der Magenrektion: Ein neuer Magen-Darm-Nahapparat. Z. Chir. 51, 179.

5. • 1934
– Friedrich changed the configuration of the
instrument to allow multiple use at one operation
• 1936
– Sandor, a pupil of Hultl’s, modified the Petz
technique to a drive that placed the staples
simultaneously rather than sequentially
SANDOR S. (1936) Magen-Darmnaht mit Metallklammern nach Hiiltl und ein neues Nahinstrument. Zentralbl.
Chir. 63, 1334

6. • 1940s
– Scientific Research Institute for Experimental
Apparatus and Instruments in USSR
– Emphasis on
• Biological result superior to manual suturing
• Quicker than manual suturing
• independent of the skill of the surgeon
• cause less trauma than a manual technique

7. • 1967
– Mark Ravitch, University of
Pittsburgh after attending
conference in USSR and
experimenting with Russian
devices, modified the device and
introduces several key functional
innovations
• different length staple lines
• reusable stapler
• sterile, preloaded cartridges
• circular stapler with a double row of
staples.
RAVITCH M., LANE R., CORNELL W. P., RIVAROLA A. & MCENANY T.(1966) Closure of duodenal, gastric and
intestinal stumps with wire staples: Clinical and experimental studies. Ann. Surg. 163, 573-9.

8. • 1976
– Ethicon, Inc. introduces the first completely
disposable, single patient use mechanical stapler
• 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

9. Basic Principles
• Device Used
– Basic Unit
• Staple
– Desired outcome
• Create an anastomotic staple line
– Types of device
• Stapler
• Properties of tissues
• Biomechanical Interactions

10. Basic Principles

14. Tissue Properties
• Biphasic nature-
– liquid and solid properties
– different ratios of liquid and solid components as
well as air components
• Protein content
• Metabolic profile
• Vascular innervation

15. Tissue Properties
• Changes with
– age
– sex
– organ/system/anatomical structure
– location within an organ
– preoperative therapies
– intraoperative medications
– disease state

16. Biomechanics
Living tissue before compression.
Living tissue compressed to adequate
thickness for stapling.
Living tissue after stapling. The material
composition of the staple should avoid
spring back to keep the tissue compressed.

17. • Viscoelastic phenomenon
– Tissue creep: Tissue elongation with crushing
force
– Stress relaxation: Reduction in amount of force to
maintain the applied displacement
– Shear stress: Increasing compression producing
excess tissue shear or tensile stress resulting in
tearing of tissues
• Depends on common factor: TIME
Baker RS, Foote J, Kemmeter P, et al. The science of stapling and leaks. Obesity surgery.
2004;14(10):1290–1298

18. • Optimal stapling would consist of allowing
adequate time for tissue compression and
creep while not producing excessive tensile
stress
• A precompression time of 1 min was
associated with significantly better outcome
as compared with no precompression time
and no significant difference with
precompression time of 3 min
Serosal Laceration During Firing of Powered Linear Stapler Is a Predictor of Staple Malformation, Fumihiko Matsuzawa, MD

19. Choosing correct staple

20. • Over sized staple height
– Inadequate apposition of tissues
• leakage,
• bleeding
• dehiscence.
• Under sized staple height
– ischemia,
– serosal shearing
– cheese wiring
– leakage
– frank necrosis.

21. TYPES OF STAPLING DEVICES
• TA Stapler – Pure stapler

22. Linear Cutter
Both stapling and cutting

23. New Technology Linear Cutter (NTLC)

24. Laparoscopic Linear Cutter

25. Curved Cutter

26. Circular Stapler

28. Hemorrhoidal Stapler

29. Fifteen studies were used, comprising 3203 patients (n = 2027 LS and 1176
HS). Primary outcome analysis revealed a significant decrease in anastomotic
leakage (RR = 0.51, 95%CI: 0.41-0.65; P < 0.00001associated with LS
anastomosis. A significantly reduced rate of anastomotic stricture associated
with LS was also found (RR = 0.56, 95%CI: 0.49-0.64; P
< 0.00001).Linear stapled technique contributes to a reduced rate of leakage
and stricture compared with the hand sewn method.

30. Fourteen studies including 5084 patients were identified.
Meta-analysis showed that stapled closure was associated with a lower rate
of SBO overall (OR = 0.56, P < 0.00001) and early (within 30 days of closure)
SBO (OR = 0.51, P < 0.00001).
This difference persisted for direct ileostomy closure (OR = 0.62,
P = 0.02) or closure with bowel resection and hand sewn anastomosis (OR =
0.44, P < 0.00001).

31. Is stapler better than handsewn
anastomosis?
This systematic review found seven randomised controlled trials with a
total of 1125 participants (441 stapled, 684 handsewn) comparing
these two methods. The leak rate from the bowel join for stapled
anastomosis was 2.5%, significantly lower than handsewn (6%).
(S=11/441, HS=42/684, OR 0.48 [0.24, 0.95] p=0.03)

32. The review with nine randomised controlled trials (1233 patients, 622 with
stapling and 611 with the handsewing technique)compared the safety and
effectiveness of stapled versus handsewn colorectal anastomosis surgery.
The evidence found did not indicate superiority of stapled over handsewn
technique in colorectal anastomosis, regardless of the anastomotic level.
Stricture was more frequent with stapling(P < 0.05)

33. Role of precompression and firing time
Porcine stomachs were divided using an endoscopic powered linear stapler with gold
reloads. We divided the specimens into 9 groups according to the precompression
time (0/60/180 seconds) and firing time (0/60/180 seconds)
The occurrence and length of laceration and the shape of the staples were evaluated.
Precompression significantly decreased the occurrence and length of serosal
laceration
Precompression time (0 seconds), firing time (0 seconds), and presence of serosal
laceration were significantly associated with a low optimal formation rate

34. A 45-mm linear stapler with a blue cartridge (staple leg length, 3.5 mm) was
used on three portions each of six porcine stomachs (cardia, center, and
pylorus).
Staple shape and height were examined according to the precompression
time (0, 1, or 5 min) before firing
The optimal staple rate in the 5-min group (52.7%) was significantly higher
than in the 1-min group (28.7%; p<0.001) or the 0-min group (17.1%; p =
0.002).

35. In precompression group, we secured more than 30-s intervals before each
firing of the linear stapler, and more than 2-min interval before firing of the
circular stapler, while we did not secure such enough precompression time in
the non precompression group.
Anastomotic leak was 28.6 % in the non-precompression group vs. 8.7 % in the
precompression group P = 0.008

36. Direction of staple firing
Burst pressure was significantly greater when the staplers were driven from the small
intestine into the esophagus.
Stapler should be driven from the thin to the thick intestine.

37. Forty-eight patients underwent Lap-DP
The pancreas was compressed directly with Echelon. After the first
compression, the pancreas was kept compressed for another 3 min, and then
the stapler was fired. After firing, the pancreas was kept compressed for a
further 2 min
the peritoneal drainage period in the PFC group (5 days) was significantly
(p<0.05) shorter than that in the no-PFC group (11.5 days)
Median postoperative hospital stay was also shorter in the PFC group (13 days)
than in the no-PFC group (17 days, p<0.05)

39. Nine trials were included comprising 9374 patients (2946 linear vs. 6428 circular)
Statistically significant increase in the rate of GJ stricture associated with circular-
stapled anastomosis.
Significantly reduced rate of wound infection, bleeding, and operative time
associated with linear stapler

40. Stapled anastomosis had lessser reduction in blood flow as compared with
hand sewn anastomosis
1987

41. The healing of 3-cm longitudinal colotomies closed with either Czerny-
Lembert suture lines (CLSL) or TA-30 staple lines (SSL) were studied in 28
mongrel dogs using bursting strength (BS) measurements.
Mean BS for the SSL in all 14 dogs was 165 mmHg ± 64 and for CLSL 80
mmHg ± 49 (DF = 13; t = 5.5672; p < 0.00005 for matched pairs).
Microscopic examination revealed a greater inflammatory response to the
CSLS than the SSL.
SSL healed more rapidly than the CLSL as measured by BS. The SSL healed
with a negligible Lag Period of wound healing entering directly into the
Period of Fibroplasia.

42. Complications due to strictures were found to be lower for the buttressing
group (0% buttressing versus 2.3% nonbuttressing, P= 0.0851). Specific rates
of bleeding-related complications were significantly lower for the group in
which buttressing was used (0% buttressing versus 3.1% nonbuttressing, P =
0.0463).

43. Peri-Strips Dry® with Veritas® (PSD-V) is used in staple-line reinforcement. This was a
single-investigator, multicenter, randomized study of 100 patients undergoing
standard sleeve gastrectomy with a 34 or 36 French bougie
Fewer staple-line bleeds were observed in the PSD-V group than the control group
(23/51 [45.1 %] vs 39/49 [79.6 %] patients; p=0.0005), and the bleeding was of a
lower severity (p=0.0002). No staple-line leaks were observed. Surgical time was
shorter in patients who received PSD-V (58.8 vs 72.8 min; p=0.0153), and fewer
patients required hemostatic clips and/or sutures (10/51

44. Staples in Bariatric Surgery
• Tissue thickness varies
• Careful consideration of specific location of
the planned staple line
• Complications includes
– Leak
– Bleeding
– Stenosis

45. Anastomotic Leak
• Major Leak
• Minor Leak
• Etiology
– Mechanical/Tissue Related
– Ischemia

46. • Vast majority of leaks occurred in the first 2
days following surgery.
• On reoperation, no evidence of ischemia but
instead evidence of staple-line failure in well-
perfused tissue.

47. • Undersizing of staple cartridge
– Ripped tissue
– Incomplete staple leg at crotch

48. • Full-thickness over-sewing past a fixed staple-
line increase the risk of tearing at the point of
suture penetration into the distended tissue

49. • Staple-line buttressing
• Bunching of tissue at the crotch
• Migratory crotch staple

50. Bleeding

51. Stenosis

52. Sleeve Gastrectomy

53. Gastric Bypass

54. Thoracic Surgery
• The inherent air content of the lungs make them
more variable in thickness than many other
tissues
• Lung tissue has a natural elasticity due to its
higher proportion of elastin
• Periphery of the lung
– more air than solid or liquid components- shorter
prefiring compression time.
• Centre of lung
– more fluid and solid components- longer compression
times and taller staples

55. • Disease process
– Lung fibrosis, asbestosis, carcinoma
– Emphysema and

56. A total of 233 lung resections were reviewed. Mechanical stapling reduced the rate
of bronchopleural fistulas to 2.0% compared with 7.1 % after manual suturing

57. Four hundred fifty cases of pneumonectomy for carcinoma of the
bronchus were reviewed. The incidence of fistula was 11.1% in the
interrupted suture group and 2.6% with the auto-suture group

58. Thank you