Choosing the correct stapler
Objective 1: Choosing the correct stapler and why this is important
In order to select the most appropriate stapler for an ileocolic anastomosis, it is important to understand how the stapler mechanism works, their strengths, and limitations.
Firstly, lets review the stapler mechanism
The tissues of the bowel are biphasic in that they contain both solid and fluid elements. Staplers are designed to affect the properties of bowel in both phases.
Compression with the stapler arms decreases tissue oedema and elongates (stretches) the tissue being compressed. This ensures that the staples satisfactorily secure the tissues together and that the staple line is not disrupted.
Tissue compression needs time in order to be fully effective.
Manufacturers recommend a 15 second pause after securing the stapler arms across the two bowel limbs before firing the staples, or using the cutting function where this is available.
A 15 second pause balances staple line integrity and risk of tissue ischaemia from prolonged compression. Ensure that you time this using a clock in theatre, with the support of the operating theatre team if necessary.
To learn more about tissue compression within a stapler device please click below:
The normal tissue thickness of the jejunum and ileum is 1-2 mm, for the colon and rectum it is up to 3 mm.
Tissue thickness can be increased in the presence of:
- radiation
- inflammatory bowel disease
- infection or contamination
- chronic obstruction
- lymphoma
- systemic inflammatory diseases (e.g. systemic lupus erythematosus)
Key message:
Increased tissue thickness may mean that staplers should not be used for bowel anastomosis. If the tissue thickness is outside the range of the manufacturers recommended limits, the staple line may not form correctly, and staples may loosen if tissue thickness subsequently decreases
(for example, after resection of an obstructing tumour)
To learn more about mechanical considerations when selecting a stapler type please click below:
This video shows a discussion between surgeons about their choice of stapler type and size:
It is important to have an appreciation of the different staple heights provided by different staplers.
The ESCP Safe-anastomosis programme recommends that if you are thinking about moving to a larger stapler type in the presence of thickened tissues (gold, or green), to discuss whether a stapled anastomosis is definitely the most appropriate choice.
Stapler sizes and staple height
Tissue. Open staple height.
White Vascular. 2.5 mm.
Blue Standard. 3.5 mm.
Gold Standard/thick. 3.8 mm.
Green Thick. 4.1 mm.
Optimal user of stapler
It is essential to choose the right stapler for the tissue type and thickness you wish to anastomose.
- Appropriate force of tissue compression: To achieve good haemostasis and avoid destruction of tissue.
- Smooth firing: High shearing forces when using a cutting stapler can cause damage to tissue or misalignment.
- Consistent staple line: Thick or bunched tissue leads to poor compression, and risk of anastomotic dehiscence.
- Correct staple height: Too high, risks anastomotic bleeding or dehiscence. Too low, risks tissue shearing or ischaemia.
Related paper: Surgical stapling device–tissue interactions: what surgeons need to know to improve patient outcomes
This video shows a discussion between surgeons about choice of anastomotic technique in diseased bowel: