Standardized Use And Types of Surgical Staplers

In gastrointestinal surgery, stapling devices are widely used. From linear cutting staplers to circular staplers, they facilitate surgical procedures by simplifying operative techniques, shortening operative time, reducing tissue trauma and bleeding, lowering the risk of surgical site infection, and promoting faster recovery of organ function, thereby shortening the length of hospital stay.

1.Types and Classification

① Circular staplers: Available in various outer diameters ranging from 21–33 mm, and can be divided into:

Straight circular staplers (for end-to-end or end-to-side anastomosis)

Curved circular staplers (for anastomosis in areas with difficult exposure, such as the rectum or esophagus)

② Linear cutting staplers, which can be divided into:

Linear cutting staplers (used in open surgery)

Endoscopic linear cutting staplers (used in open or minimally invasive/laparoscopic surgery)

③ Linear staplers, mainly used for side-to-side anastomosis of the digestive tract.

The cartridge is a detachable structure at the distal end of the stapler head and contains metal staples.

Different cartridge heights can be selected according to the application scenario. For example, in the author’s institution, cartridges of 2.0 mm, 1.8 mm, 1.5 mm, and 1.0 mm are available, typically distinguished by different colors.

The formed staple height is generally recommended to be approximately 75% of the tissue thickness. The appropriate cartridge height should be selected based on actual conditions.

2.Clinical Applications

Staplers can be used in various gastrointestinal reconstructions.

① Gastric surgery:

Proximal gastrectomy: esophagogastric anastomosis

Total gastrectomy: esophagojejunostomy

Subtotal gastrectomy: gastroduodenostomy or gastrojejunostomy

② Colorectal surgery:

Right hemicolectomy: ileocolic end-to-side anastomosis

Transverse colectomy: colocolic end-to-end anastomosis

Sigmoid colectomy: colorectal end-to-end anastomosis

③ Rectal surgery:

End-to-side anastomosis

End-to-end anastomosis (via abdominal or transanal stapler insertion, including construction of a colonic reservoir/pouch, etc.)

3.Principles of Stapler Use

① Adequate pre-compression: Close the jaws and wait for 15 seconds before firing to expel tissue fluid, reduce tissue thickness, and protect the mucosa and submucosa at the anastomotic site.

② Select cartridges appropriate to tissue thickness.

③ Fire steadily, ensuring device stability during firing and avoiding traction.

④ Use energy devices cautiously in case of bleeding or oozing at the anastomosis to prevent collateral injury.

⑤ Reinforcement when necessary: After firing, inspect the staple line—especially overlapping staple areas—and reinforce with full-thickness or seromuscular sutures if needed.

4.Related Complications

I. Anastomotic Leakage

① Causes:

Poor blood supply to the bowel ends

Excessive tension at the anastomosis

Improper use of the stapler

Inadequate clearance of surrounding tissue, leading to inadvertent inclusion in the anastomosis

Excessively long inverted purse-string stump

Oversized stapler causing partial tearing of the bowel wall

Missing staples

Excessive traction after anastomosis, among other factors

② Prevention:

Pay special attention to preserving blood supply of both proximal and distal bowel segments

Preserve the marginal artery in the proximal colon and observe pulsation of marginal vessels

Limit mobilization of the bowel wall at the purse-string site to ≤2.0 cm

Routinely check staple integrity before anastomosis

Inspect the completeness of the purse-string suture after anastomosis

Ensure no surrounding tissue is entrapped in the anastomotic site

II. Anastomotic Stenosis

① Causes:

Inappropriate stapler size selection

Excessive tension at the anastomosis

Infection or leakage at the anastomotic site

② Prevention:

Select a stapler size appropriate to the intestinal lumen diameter

III. Anastomotic Bleeding

① Causes:

Often caused by inclusion of epiploic appendages or mesenteric vessels in the anastomosis

② Prevention:

Clean the bowel segment before introducing it into the stapler

Remove fat appendages that may cause bleeding

Use and fire the stapler correctly

Ensure complete purse-string suturing

Carefully inspect the integrity of both proximal and distal doughnuts after anastomosis