Original article
Profiling surgical staplers: effect of staple height, buttress, and overlap on staple line failure

Presented at the 24th Annual Meeting of the American Society for Bariatric Surgery, June 11–16, 2007, San Diego, California
https://doi.org/10.1016/j.soard.2007.11.008Get rights and content

Abstract

Background

Few studies have been designed to assess the performance of surgical staplers. In this study, we analyzed the effect of staple height, buttressing, and overlapping of staple lines on staple line failure.

Methods

Staple lines created on fresh porcine small bowel segments ex vivo were tested for leak pressure by insufflating air into the bowel under water and recording pressure at failure. Three separate experiments were done and included staple height (white, 2.5 mm, n = 16; blue, 3.5 mm, n = 16; green, 4.1 mm, n = 16; one half of them buttressed); the absence (n = 12) or presence (n = 12) of an overlap in 3.5-mm staple lines; and the absence (n = 14) or presence (n = 11) of buttresses in 3.5-mm overlapping staple lines. Data are reported in median values and ranges; nonparametric tests were used for data analysis.

Results

In the porcine small bowel, leak pressure was related to staple height; green loads had the worst profile (35 mm Hg, range 19–105) compared with the blue (79 mm Hg, range 9–177), and white (108 mm Hg, range 28–280) loads (P = .006). Buttressing uniformly improved leak pressure for all staple loads (P <.0001). No significant difference was found between lines with overlapping (59 mm Hg, range 32–121) and those without (42 mm Hg, range 22–75; P = .162). Buttressing also improved the leak pressure of overlapping staple lines from 65 mm Hg (range 47–121) to 93 mm Hg (range 75–187; P = .0014).

Conclusion

Great variability was found in the leak pressures among the different applications of the same stapler. Staple height is an important determinant of leak pressure. The presence of an overlap did not affect leak pressure; in fact, a trend toward improvement was seen with overlapping staple lines. Buttressing improved all types of staple lines.

Section snippets

Methods

The study included three separate experiments aimed at assessing the effect of different variables on the leak pressure of a staple line: (1) staple height and buttressing of the staple line, (2) the presence of overlapping staples in the staple line, and (3) buttressing of overlapping staple lines.

Experiment 1: staple height and buttressing of staple line

The effect of the staple height and buttressing was assessed by creating 48 staple lines (leak pressure, median 69.1 mm Hg, range 1.9–280). Bursting of the bowel before the staple line leak occurred in 6 cases (2 blue loads with buttressing, 1 white load without buttressing, and 3 white loads with buttressing).

The leak pressure was significantly related to the type of staple load (Table 1). Overall, green staple loads had the lowest leak pressure (median 35.5 mm Hg, range 1.9–104.6) compared

Discussion

Surgical stapling instruments are being increasingly used for gastrointestinal anastomoses. Although it is recognized that stapled anastomoses are faster to create and lead to outcomes similar to those with hand-sewn anastomoses [12], [13], [14], the best technique and stapler profile to use remains unclear. It is also difficult to generalize the finding of these studies to other clinical scenarios. For example, it might be difficult to apply the results from a study of intestinal anastomoses

Conclusion

The variability in leak pressures among the different applications of the same stapler is great. Staple height is an important determinant of leak pressure. In our study, the presence of an overlap did not affect leak pressure. In fact, a trend toward improvement was seen with overlapping staple lines. Buttressing improves the leak pressure for all types of staple lines. Future studies are warranted to better define the ideal stapler to use for different clinical scenarios.

Disclosures

The authors have no commercial associations that might be a conflict of interest in relation to this article.

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