Mechanical considerations

Staplers are available in different sizes and heights.

The surgeon must be familiar with stapling devices, and their use in tissue of different thickness and compressibility in order to optimise the stapler-tissue interaction.

A surgeon’s experience with the use of stapler devices in different clinical settings may be crucial to achieve a meaningful reduction in anastomotic leak.

Factors to consider when choosing a stapler include:

• Inherent tissue properties such as the tissue thickness, ratio of liquid and solid, protein content and metabolic profile
• The extrinsic blood supply to the bowel
• Patient’s co-morbidities that are relevant to healing of the anastomosis
• Concurrent treatments, for example steroids or neo-adjuvant therapies

Mechanical studies of gastrointestinal anastomoses have demonstrated that compression improves staple line integrity, and a smaller staple height is associated with a lower incidence of haemorrhage, stenosis and leak. Excessive compression can result in ischaemia and tissue disruption.

However the use of larger staple heights in the presence of increased tissue thickness should be avoided due to a higher risk of staple misfiring, and staple line dehiscence as tissue oedema, inflammation or distension reduces postoperatively.

The video below shows a discussion between surgeons about choice of stapler size, and choice of anastomotic technique in the presence of increased tissue thickness: