For nearly two centuries, surgeons have been using mechanical devices to approximate tissues and facilitate their healing process. Currently, surgical staplers are widely used and have become essential tools in surgery. Staples facilitate rapid wound closure, hence shortening the duration of the surgical procedure. In comparison to intradermal sutures, stapling is associated with better cosmetic outcomes.1 However, stapling results in more complications and prolongs hospital stay.2 3
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Staplers are classified into five categories: circular, linear, linear cutting, ligating, and skin staplers. Furthermore, contemporary variations have emerged to accommodate minimally invasive surgery.4 Every category includes a variety of commercial models, each characterized by distinct features. With distinct names, color-coded features, and variations in length and tissue thickness, each stapler serves a specific purpose in the surgical setting. The distinct characteristics of various tissue types in the human body significantly influence the selection of staples. To achieve the best stapling results for any type of tissue, it is important to have a sufficient amount of time for the tissue to be compressed to allow elongation of the tissue being compressed, while preventing the possible risk of tearing.5
This video aims to provide a comprehensive overview of stapling instruments and their associated use. The skin staplers, presented first, are typically crafted from a titanium alloy with minimal reactivity with tissues. The sizing of skin staples, such as 35R for regular or 35W for wide, is crucial, and their deployment aims to approximate rather than strangulate the tissue. The intraoperative staplers are presented next. Inside the human body, clips are often used on structures such as the cystic duct and the homonymous artery during gallbladder surgery. Laparoscopically, clip appliers with digital readouts are employed. For gastrointestinal side-to-side anastomoses or partial lung and liver resections, surgeons may use stapling devices such as the gastrointestinal anastomosis (GIA) stapler, which lays down two rows of staples and cuts in between.
Linear staplers are reusable. There are linear staplers with and without cutting functions. The latter may have different surgical uses than those that have cutting properties (e.g. digestive tract reconstruction or incisions during liver resection). Linear staplers contain a handle at the opposite end of the jaw. The surgeon manipulates the jaw using its handle to apply staples to the incision. Every time the surgeon fires a staple, a row of staples is ejected and applied to the tissue. The reloads for linear staplers are color-coded based on their intended use: white for vascular, blue for regular tissue, and green for thicker tissues.
The end-to-end anastomosis (EEA) circular stapler serves specific purposes such as end-to-end anastomoses. Unlike reusable staplers, the EEA stapler is a one-time-use item and is discarded after use. The stapler joins two hollow organs, creating a stapled anastomosis. For endoscopic procedures, Endo GIA staplers provide versatility. They are available in various lengths, and their disposable units are color-coded as well. The staplers allow surgeons to manipulate and fire the device through trocars, being incredibly useful in the context of minimally invasive surgery (MIS).
Surgical staplers are a wide range of instruments that have distinct uses in surgical practice. From skin closure to gastrointestinal anastomosis, each stapler is designed to meet the unique demands of a given surgical intervention. The operative staff should understand the features and uses of staplers to effectively handle the complexity of these devices.
Check out the rest of the series below:
Clinical Exercise: Scalp Laceration (stapling)
Scenario:
Following a bus collision several dozen injured patients are transported to shock trauma and the emergency department. Many of the injuries consist of lacerations from sharp edges of metal and glass during the collision including several with deep scalp lacerations bleeding profusely.
Diagnosis/Considerations:
You recognize that for most minor wounds suturing provides for the two primary goals, hemostasis and achievement of a functional scar that is cosmetically acceptable.
Staples are an acceptable alternative for linear lacerations through the dermis that have straight, sharp edges and are particularly well suited for scalp lacerations. The closure of scalp wounds with staples is faster than sutures with similar outcomes when compared to sutures (indistinguishable infection, healing time, and cosmetic outcomes compared to sutures). However, since meticulous skin positioning is not readily achievable with staples, injuries involving the face should be closed with sutures. Additionally, due to patient discomfort injuries to hands and feet are also typically not closed with staples.
Because staples may be placed more rapidly than sutures and eliminate the risk of needle stick injury which is elevated in the busy environment of a multiple casualty event, you decide that the patient's scalp wound is best addressed using a skin stapler.
Mechanism:
The goal is to bring the edges of the cut tissues close together to promote healing and provide sufficient security across the opening to achieve hemostasis.
Modern surgical staplers consist of disposable plastic dispensers that can deliver single staples either with a low profile head (usually for skin) or a long endoscopic head that can be articulated (to allow reaching deep structures through a small opening). For a scalp laceration a low profile head provides suitable access.
The use of a skin stapler involves light compression of the skin on each side of the laceration with forceps in order to bring the edges into continuity. Pressure slightly elevates the skin edges of the laceration for the staple to penetrate.
Treatment (perform these steps on the donor in a mock-procedure):
PREPARATION: Send a member of your team to the instrument supply tables to fetch one 35-staple skin-type disposable dispenser and one staple remover, which looks like a small white handle scissor-like instrument (please take only the supply numbers indicated to ensure sufficient supplies are available for all tables).
In a living patient, the skin on each side of the laceration would be anesthetized using topical (e.g. lidocaine-epinephrine-tetracaine [LET] gel) or an infiltrate analgesic (e.g. isotonic buffered lidocaine). In our donor we will skip this step.
1) Open the sterile stapler packet, observing the staple delivery and trigger ends of the device.
CAUTION: exercise care when handling staplers to prevent stapling parts of your hand or body.
Note, it is difficult for one person to staple an incision. Typically, one person will use forceps to control the edges of the laceration to bring them into contact (i.e. reapproximate the edges) while the second person utilizes the stapler.
In a living patient, the skin is controlled using mouse-tooth forceps (i.e. the 'toothed' end forceps style), but with the higher density of tissue in an embalmed donor you may need to use a hemostat (hemostats may damage living tissue).
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2) The first person should use forceps, or a hemostat if needed, to position the edges of your prior scalp incision into continuity (i.e. pressing the edges together) applying light pressure so that the skin bulges slightly on each side of the incision.
3) The second person should then position the stapler across the incision site close to the forceps tips, such that the cut edges of the tissue are positioned against the 'gap' in the dispenser from which the staple will be delivered.
4) Squeeze smoothly and firmly on the dispenser trigger and then release.
A staple should have been expelled with one arm of the staple penetrating the tissue on each side of the incision and holding the edges together.
5) Repeat the process approximately 3-5mm along the incision.
Each person should use only 3-4 staples evenly spaced. Each stapler holds only 35 staples and everyone in the team should have the opportunity to use the instrument and be the skin control person. If the stapler runs out, there are several additional at the supply table
Scenario (addendum):
As you place the staples you realize that one of them has been incorrectly positioned and is gripping only one side of the incision. Leaving the incorrectly placed staple in place would interfere with another staple in that location and could cause a weak point that may continue to bleed. Thus, you need to remove the incorrectly placed staple and re-staple securely in that location.
Treatment (continued):
7) Identify the two sides of the staple remover teeth.
One side will be a flat ring-like structure, with the other side a vertical arm that will pass between/inside the ring. The device operates by bending the center bar of the staple which pulls the ends smoothly out of the skin.
8) Insert the flat ring-like side of the instrument deep to the staple.
9) Close the scissor arms of the instrument which will reform the staple such that it can be lifted out.
Note, the reforming bends the staple into an 'M' so the penetrating arms of the staple are now straightened and slide easily out.
NOTE: when finished suturing ensure that any removed staples are collected into one of your trays and transported to the sharps containers for safe disposal.
Return the staple remover and stapler (if any remain inside it) to the supply table.
Outcome:
The staples are neatly performed and the bleeding is controlled in this patient. You apply light antibiotic ointments to the laceration area and left open to the air (scalp stapling is typically left open, while staples to torso/limbs are covered with sterile dressing). After 7-10 days for skin healing, the patient returns to their regular physician to have the staples removed.
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