Surgical staple

Staples used in surgery in place of sutures

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34 surgical staples closing scalp following craniotomy Projectional radiograph of surgical staples

Surgical staples are specialized staples used in surgery in place of sutures to close skin wounds or connect or remove parts of the bowels or lungs. The use of staples over sutures reduces the local inflammatory response, width of the wound, and time it takes to close.[1]

A more recent development, from the s, uses clips instead of staples for some applications; this does not require the staple to penetrate.[2]

History

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The technique was pioneered by "father of surgical stapling", Hungarian surgeon Hümér Hültl.[3][4] Hultl's prototype stapler of weighed 8 pounds (3.6 kg), and required two hours to assemble and load.

The technology was refined in the s in the Soviet Union, allowing for the first commercially produced re-usable stapling devices for creation of bowel and anastomeses.[4] Mark M. Ravitch brought a sample of stapling device after attending a surgical conference in USSR, and introduced it to entrepreneur Leon C. Hirsch, who founded the United States Surgical Corporation in to manufacture surgical staplers under its Auto Suture brand.[5] Until the late s USSC had the market essentially to itself, but in Johnson & Johnson's Ethicon brand entered the market and today both are widely used, along with competitors from the Far East. USSC was bought by Tyco Healthcare in , which became Covidien on June 29, .

Safety and patency of mechanical (stapled) bowel anastomoses has been widely studied. It is generally the case in such studies that sutured anastomoses are either comparable or less prone to leakage.[6] It is possible that this is the result of recent advances in suture technology, along with increasingly risk-conscious surgical practice. Certainly modern synthetic sutures are more predictable and less prone to infection than catgut, silk and linen, which were the main suture materials used up to the s.

One key feature of intestinal staplers is that the edges of the stapler act as a haemostat, compressing the edges of the wound and closing blood vessels during the stapling process. Recent studies have shown that with current suturing techniques there is no significant difference in outcome between hand sutured and mechanical anastomoses (including clips), but mechanical anastomoses are significantly quicker to perform.[7][2]

In patients that are subjected to pulmonary resections where lung tissue is sealed with staplers, there is often postoperative air leakage.[8] Alternative techniques to seal lung tissue are currently investigated.[9]

Types and applications

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Close-up demonstration of a surgical skin stapler.

The first commercial staplers were made of stainless steel with titanium staples loaded into reloadable staple cartridges.

Modern surgical staplers are either disposable and made of plastic, or reusable and made of stainless steel. Both types are generally loaded using disposable cartridges.

The staple line may be straight, curved or circular. Circular staplers are used for end-to-end anastomosis[broken anchor] after bowel resection or, somewhat more controversially, in esophagogastric surgery.[10] The instruments may be used in either open or laparoscopic surgery, different instruments are used for each application. Laparoscopic staplers are longer, thinner, and may be articulated to allow for access from a restricted number of trocar ports.

Some staplers incorporate a knife, to complete excision and anastomosis in a single operation. Staplers are used to close both internal and skin wounds. Skin staples are usually applied using a disposable stapler, and removed with a specialized staple remover. Staplers are also used in vertical banded gastroplasty surgery (popularly known as "stomach stapling").

Vascular stapler for reducing warm ischemia in organ transplantation. With this model each stapler end can be mounted on donor and recipient by independent surgical teams without care for reciprocal orientation, being the maximal possible vascular axis torsion &#;30°. Activating guide-wire is connected just immediately before firing (video)

While devices for circular end-to-end anastomosis of digestive tract are widely used, in spite of intensive research [11][12][13][14][15] circular staplers for vascular anastomosis never had yet significant impact on standard hand (Carrel) suture technique. Apart from the different modality of coupling of vascular (everted) in respect to digestive (inverted) stumps, the main basic reason could be that, particularly for small vessels, the manuality and precision required just for positioning on vascular stumps and actioning any device cannot be significantly inferior to that required to carry out the standard hand suture, then making of little utility the use of any device. An exception to that however could be organ transplantation where these two phases, i.e.device positioning at the vascular stumps and device actioning, can be carried out in different time, by different surgical team, in safe conditions when the time required does not influence donor organ preservation, i.e. at the back table in cold ischemia condition for the donor organ and after native organ removal in the recipient. This is finalized to make as brief as possible the donor organ dangerous warm ischemia phase that can be contained in the couple of minutes or less necessary just to connect the device's ends and actioning the stapler.

Although most surgical staples are made of titanium, stainless steel is more often used in some skin staples and clips. Titanium produces less reaction with the immune system and, being non-ferrous, does not interfere significantly with MRI scanners, although some imaging artifacts may result. Synthetic absorbable (bioabsorbable) staples are also now becoming available, based on polyglycolic acid, as with many synthetic absorbable sutures.

Removal of skin staples

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Where skin staples are used to seal a skin wound it will be necessary to remove the staples after an appropriate healing period, usually between 5 and 10 days, depending on the location of the wound and other factors. The skin staple remover is a small manual device which consists of a shoe or plate that is sufficiently narrow and thin to insert under the skin staple. The active part is a small blade that, when hand-pressure is exerted, pushes the staple down through a slot in the shoe, deforming the staple into an 'M' shape to facilitate its removal. In an emergency it is possible to remove staples with a pair of artery forceps.[16] Skin staple removers are manufactured in many shapes and forms, some disposable and some reusable.

See also

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References

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History

The surgical stapler most likely has a European history. To prevent spillage of bowel contents during abdominal surgery, the Hungarian surgeon Hümer Hültl developed the first known surgical stapler together with the engineer Victor Fischer in (Fig. 1)1,2.

The stapler consisted of U-shaped steel wire staples. After stapling, the tissue had to be cut. The staples did not completely close to prevent tissue necrosis, but were left in a B shape after stapling to allow tissue perfusion. The Fischer&#;Hültl stapler took 2 h to reload with individual staples and weighed about 5 kg. The first operation using this stapler was a subtotal gastrectomy for gastric cancer. In , Aladar Petz, who was trained by Hültl, developed a lighter version that used nickel&#;silver alloy staples and weighed 1 kg (Fig. 2)3.

The Petz stapler gained in popularity and became the most used stapler for the next 40 years. An important modification was made by the German surgeon Friedrich, who developed replaceable cartridges preloaded with staples in . Here, an exchange system comparable to that of surgical blades developed by Morgan Parker, as described earlier in this series, was introduced4.

Vascular stapler

In World War II, Vasilii Kolesov worked as a military surgeon during the siege of Leningrad5. His hospital had a high caseload owing to the numerous war injuries, and was often confronted with vascular injury. To decrease procedure time, the engineer Vasilii Gudov developed a vessel stapler to anastomose blood vessels (Fig. 3)5,6.

Kolesov eventually used this device in coronary artery surgery. In addition, it was often used in animal experiments and laboratory settings. However, the vascular stapler was not practical to use and needed more vessel length in comparison to a sutured end-to-end anastomosis.

Intercontinental stapling

Staplers become more popular in the Soviet Union, and several models were developed for vascular anastomoses, parenchymal resection, and gastrointestinal anastomoses1.

It was Mark Ravitch who brought surgical stapling from the Soviet Union to the USA. Ravitch was a New York-born surgeon and son of Russian immigrants. In , a group of American surgeons, including Ravitch, visited Kiev to learn about Russian blood banking principles. Here, Ravitch met Nikolai Amosov, head of a thoracic surgery department. When shown movies of pulmonary resections, Ravitch saw stapled bronchus resections and metal staples on postoperative chest X-rays. Ravitch requested the staplers used, but was refused. Eventually he bought several models of surgical stapler in a store in Leningrad and started using them to close bronchial stumps2.

Becoming part of the armamentarium

In Leon Hirsch, a businessman who collaborated with Mark Ravitch, founded the United States Surgical Corporation. Based on the staplers from the Soviet Union, they added improvements such as linear cutting and circular stapling, and developed the thoracoabdominal (TA) stapler and gastrointestinal anastomosis (GIA) model under the brand name Auto Suture&#; (Fig. 4).

Fig. 4

Latest models of thoracoabdominal and gastrointestinal anastomosis staplers7

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These staplers gained in popularity and the company grew. Interchangeable cartridges with different sizes and heights of staple specifically for the tissue stapled were introduced. With the rise of laparoscopic surgery, stapling technology further developed, and automated firing and powered stapling was added (Fig. 5).

Fig. 5

Endostapler for use in tissue division and anastomoses in thoracolaparoscopic surgery.

The stapler is battery-powered and uses automated firing8.

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From an environmental perspective, staplers are made from disposable materials and equipped with single-use batteries. Recently, more attention has been given to the concept of reusing materials, and reusable staplers may possibly become more popular again. Several projects have been initiated to reuse individual components of staplers.

Funding

The author has no funding to declare.

Disclosure

The author declares no conflict of interest.

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The company is the world’s best Power-assisted surgical stapler supplier. We are your one-stop shop for all needs. Our staff are highly-specialized and will help you find the product you need.

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