a brief overview of the principles and use of staplers in surgery and how it compares to the traditional sutured anastomosis

1. Staplers in Surgery
DR KESHAV MISHRA
Moderators DR PAWANINDRA LAL
DR ANUBHAV VINDAL

2. • No tissue tension
• Good hemostasis
• Obliteration of dead space
• Gentle handling of tissue
• Strict aseptic technique
• Sharp anatomic dissection of tissue
Halsted’s Principles of Anastomosis

3. 1. Suture/ Hand-sewn
 Why Suture?
 Standard surgical material for more than 150 years (Proven)
 Low Cost
 Ease of use
 Strength
2. Stapling Device/ Stapled approximation
 Goals of stapler
 Close abdominal wounds
 Join internal organs to restore to normal function
 Maintain hemostasis
 Reduce tissue trauma
 Reduce contamination
 Prevent postoperative morbidity and infections
Technical Options for
Surgical Procedures

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. HISTORY OF SURGICAL STAPLERS
 1921
Aladar von Petz, another Hungarian surgeon, developed a light and easy-to-use version
of stapler was more readily adopted.
 1934
Dr. H. Friedrich of Germany introduced the first stapling instrument to feature a
replaceable, preloaded staple cartridge
 1950s
Establishment of the Scientific Institute for Experimental Surgical Apparatus and
Instruments in Moscow, USSR
 1967
After observing Russian devices, an American surgeon, Dr. Mark Ravitch
introduces several key functional innovations including different length staple lines, a
reusable stapler, sterile, preloaded cartridges, and the first circular stapler with a double
row of staples.

6. HISTORY OF SURGICAL STAPLERS
 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

7. Advantages of stapling
 Stapling anastomosis is faster than traditional suturing techniques, hence reduced
operating time.
 Reduces tissue trauma by minimizing tissue handling.
 Prevents contamination
 The availability of staplers has fostered the development of procedures that were
difficult with traditional techniques because of limited access.
 Stapled tissue and anastomoses heal as reliably and rapidly as sutured anastomoses
 Not user dependent

8. STAPLE CONFIGURATION

10. STAPLING BIOMECHANICS
 Different staple cartridges designed for different tissue thickness
 Allow adequate hemostasis
 Avoid significant ischemia
 Avoid tissue destruction
 Human tissue considered biphasic – consist of solid and liquid component
 Biochemical properties- protein content and metabolic profile
 Extrinsic blood supply
 The intracellular and extracellular fluid components influence the tissue resulting in
following important phenomenon on tissue compression-
 Tissue creep
 Stress relaxation
 Sheer stress
 The phenomena of tissue creep, stress relaxation, and shear stress are dependent upon
one common factor – time.

11. STAPLING BIOMECHANICS
Optimal
stapling
Optimal compression
No excessive sheer stress
Optimal creep

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

13. STAPLING BIOMECHANICS
 The text by G.V. Astafiev, titled “Investigation of Processes Relating to Tissue
Compression in Suturing and Stapling Apparatus” back in 1967 is the pivotal paper
defining today’s industry standard.
 Optimal pressure – causes good apposition and negligent structural modifications with
no long-term tissue disruption
Gastric tissue – 8 g/m2
Oesophagus and bowel – 6 g/m2
 The maximum deformation occurred in the first 60 seconds of compression
 Tissue reached the final balance in 5 minutes.
 There was only a 5% difference in compression achieved from 2 to 5 minutes of applied
pressure

14. STAPLING BIOMECHANICS
 Under-sizing staple cartridge
 lead to excessive tissue compression, which exceeds the tissue’s tensile strength
 increases the risk for inadequate staple formation
 Over sizing staple cartridges
 Poor haemostasis
 Inadequate opposition of tissue edges
 Poor staple line formation predisposed to anastomotic leakage

15. Types of Cartridges

16. Types of Cartridges

17. The Optimal Staple
Bad Good
Staple Formation Continuum

18. Use of surgical staplers
 Linear staplers
 Close internal organs prior to transection
 Close the common opening or enterotomy after the creation of an anastomosis
 Make side to side or functional end to end anastomosis
 Biopsy or wedge resection of the lung and closing of the bronchus and to close pulmonary
vessels prior to their division
 Resection of solid organs such as liver or pancreas.

19. Use of surgical staplers
 Circular staplers (intraluminal staplers)
 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

20. Use of surgical staplers
 Curvilinear cutting staplers (contour stapler)
 transabdominal proctectomy
 very-low- anterior resection of the rectum (as it is able to fit into the narrow confines of
the pelvis)

21. Use of surgical staplers
 Procedure for prolapse and
hemorrhoid [PPH] staplers
 Used to excise prolapsed rectal
mucosa at the top of the anal canal
as a treatment for prolapsing
hemorrhoids.

22. Side to side anastomosis (Functional end
to end anastomosis)
CRITICAL CONCEPTS
• Non-tension
• GIA stapler
• Align anti-mesenteric
sides of bowel
together
• Staggered staple lines

23. Functional End-to-end anastomosis
Another way to perform a stapled end to end anastoamosis
PGY 2

24. Anastomotic leaks in stapled anastomosis
 Anastomotic leaks reported may or may not involve the staple-lines, dependent upon
the method of surgery used
 Anastomotic leaks
 Major/ manifested leaks
 Minor leaks
 Etiology of staple line 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

25. Other factors affecting stapled anastomosis
 Full-thickness over-sewing past a fixed staple-line may increase the risk of tearing at
the point of suture penetration into the distended tissue
 Staple-line buttressing significantly increased staple-line strength (but no level I
evidence)

26. Other factors affecting stapled anastomosis
 Bunching of tissue at the crotch of the stapler must be avoided as it results in
inadequate staple formation and opposition in the crumpled up tissue
 Migratory crotch staple- failure to note and remove this staple may result in a staple
misfire. If left in place, the “crotch staple” can cause the stapler to lock when firing is
attempted

27. Hand sewn Vs Stapled anastomosis
 Beart and kelly- 80 patients randomized to sutured vs stapled coloproctostomies. No
difference in post operative complications.
 Docherty- 732 patients randomized to manually constructed vs stapled anastomosis
 Significant increase in radiological leak rates in sutured group (14% vs 5%)
 No difference in clinical anastomotic leak rates, morbidity and mortality
 Correcting for tumour stage, univariate analysis showed higher rate of tumor recurrence and
cancer-specific mortality in the sutured patients (7.5% vs 6.5%,) and in patients with
anastomotic leaks.

28. Hand sewn Vs Stapled anastomosis
 Metaanalysis of 13 studies on manual vs stapled colon and rectal anastomosis
 No difference in leak rates, morbidity, mortality and cancer recurrence
 Higher rate of intraoperative technical problems and a higher rate of anastomotic strictures
after stapled anastomoses (even though blood flow rate through stapled anastomoses is
significantly higher than the standard two-layer anastomosis).
 Stapled anastomoses tend to heal by secondary intention as compared with hand-sewn
anastomoses which heal by primary intention
 Leakage can occur weeks after surgery rather than in the first week as seen with hand
sewn anastomosis

29. 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.

30. Thank you