Stapling

Principles of stapling

• Choose the appropriate staple size for tissue. If too big - excessive staple-line bleeding, or rarely leakage through the intact staple line. If too small - staples won't reach full thickness and won't form correctly, leading to failure and leak.
  • It's probably better to use a staple size that is too big rather than too small.
  • Sometimes the tissue (for example some re-operative stomachs) are too thick for any stapler, and hand-sewn is the best option
• Staplers from different manufacturers can have subtle differences, despite similar appearances
• 'Rest' the tissue for 15 seconds after fixing the stapler to allow oedema to reduce
• Be careful firing staplers across an existing staple line - the knife can catch on existing staples, pulling them out of place and disrupting. To avoid this, always fire at an angle of at least 45 degree.
• No good data to support or refute oversewing staple lines
• Where possible, test staple lines intra-operatively
• Intra-luminal staple line bleeders can be controlled with sutures or careful cautery

Types of staplers

Linear staplers (TA - transverse anastomosis)

• • The length refers to the length of the eventual staple line
  • Each applies a double staggered row of staples
  • Each is available with 3.8 or 4.8mm staples
  • Staples generally made from titanium
  • Requires a smaller cuff of tissue than GIA
  • Examples
    • White - vascular
    • Blue - medium
    • Green - thick
  • Technique
    • Pull trigger once to fix tissue in place (can be released at this point)
    • Pull trigger again, all the way tightened
    • Need to use a blade to detach the tissue, on whichever side is needed
    • Press button on back to detach stapler
  • Contour stapler - Echelon - comes in green or blue
    • Drop retaining pin with grey top slider
    • Fire inside trigger to compress
    • Fire outside trigger to deploy staples

Linear cutting stapler (aka GIA - gastrointestinal anastomosis)

• • Applies two double rows of staples, while the knife divides the tissue between the two double rows
  • Used for side-to-side anastomoses and functional end-to-end anastomoses
  • Examples:
    • Endo-GIA (manual laparoscopic linear cutting) - 30, 45, 60mm
      • Gray - vascular
      • Tan - vascular medium
      • White - vascular medium, small diameter
      • Purple - medium/thick
      • Black - extra-thick
    • GIA (manual open linear cutting) - 60, 80, 100mm - little boy blue, jolly green giant.
      • White - vascular - 2.5mm - Only available in 60mm size
      • Blue - medium - 3.8mm leg length, also 4mm wide across base. Legs close to 1.5mm.
      • Purple - medium/thick
      • Green - thick - 4.8mm leg length, 4mm wide across base. Legs close to 2mm.
      • Black - very thick
    • Echelon (powered linear cutting) - available 45mm or 60mm lengths
      • White - thin tissue - duodenum
      • Blue - regular - can do any small bowel, gastrojejunostomy, oesophagus
      • Gold - regular/thick
      • Green - thick - stomach
      • Black - very thick
    • Signia motorised linear cutting stapler, any angle, more manoeuvrable than Echelon, more expensive too

Circular staplers (EEA - end to end anastomosis)

• • Utilises a circular anvil, a circular staple cartridge, and a circular knife to produce a double staggered row of staples that approximate two tubular structures in inversion while the knife cuts the tissue just inside the staple line
  • Creates an end-to-end anastomosis with a lumen ranging from 12 to 24mm
  • Compresses tissues to approximately 2mm, although this can be customised on many staplers
  • Ethicon EEA staplers
    • 21mm (yellow)
    • 25mm (white)
    • 29mm (blue)
    • 33mm (green)
  • Ethicon EEA Powered stapler
    • 23mm
    • 25mm
    • 29mm
    • 31mm (commonly use for colon)
  • Medtronic (aka Covidien) - comes in purple (thick) or black (extra thick)
    • 25mm
    • 28mm (purple, common for colorectal anastomosis in women)
    • 31mm (purple, common for colorectal anastomosis in men)
    • 33mm
  • OrVil stapler for upper GI
  • Technique
    • Open proximal staple line by cutting across it with Mayo scissors, then insert anvil (largest size that fits easily), secure with whip stitch purse-string (3/0 Prolene, start outside to inside, repeat, then end outside; throw first knot then insert anvil and tighter)
    • Insert rectal stapler. Guide to right location. Spike advanced through rectum, usually just posterior to the stapled stump (turn knob anti-clockwise).
    • Apply spike to anvil
    • Recheck - be certain no gaps, and that the purse-string is secure. Don't allow bulky puckering of excess tissue.
    • Tighten stapler to correct thickness for the height of its staples, as shown on colour-bar indicator on the stapler handle, by turning the knob clockwise. If a lot of force is required, there might be too much tissue captured, or the stapler might be too small.
    • Wait 15 seconds then trigger released, handles squeezed to fire and create anastomosis
    • Detach stapler by returning safety to lock position, then turn knob 720 degrees anti-clockwise. Rotate 90 degrees both directions then slowly remove while rotating.
    • Inspect doughnuts - if gaps, reinforce with sutures
  1. Step by Step Guide to Use Ethicon Circular Stapler | Ethicon

Causes of failure following stapled anastomosis

• Poor tissue quality - bowel that is not fit for suturing, is not fit for stapling
• Thick tissues which have been over-compressed
• Tension
• Instrument failure
• Inclusion of mesentery/other tissues in the staple line
• Bleeding following stapling