While the stomach is generally thicker than the small bowel and therefore requires a greater staple height, not all parts of a hollow viscus are the same thickness. The difficulty for the surgeon lies in selecting the correct staple height for each tissue in each patient. Most surgeons aim to achieve an anastomotic or staple line leak rate under four percent for primary procedures. Reported leakage and hemorrhage rates following bariatric procedures employing stapling devices vary between 0 and 20 percent and 0.6 to 4.4 percent, respectively. If the staple height is too high, the staples fail to ensure adequate apposition, leading to bleeding from the staple line or leakage. If the staple height is too low, the staples can cut through the tissue or lead to tissue ischemia, resulting in leakage. These differing staple heights are designed to ensure that, when closed, the staples provide secure apposition of the edges of the bowel.
Manufacturers provide a combination of different cartridge lengths, each with staples that close to a different height. Side-to-side joining of the jejuno-jejunostomy is almost universally achieved with a linear cutting stapling device. Circular devices may also be used to join bowel and have the advantage of no enterotomy to be closed at the site of the anastomosis, making this method quicker than side-to-side stapled anastomoses.
Once the stapling device is withdrawn, the remaining hole in the anterior wall of the anastomosis can be closed with a further firing of the device or a suture. The size of the anastomosis depends upon the length of the cartridge and the degree to which it is inserted, the longer the cartridge and/or the more that is inserted, the larger the lumen. When fired, the device joins the stomach to the small bowel and divides the tissue between them making an anastomosis. The stapling device is inserted into small holes made in the small bowel and gastric pouch (enterotomies and gastrotomies, respectively). Linear cutting staplers can also be used to join pieces of bowel, such as in the formation of the gastrojejunal anastomosis in RYGB. The gastric pouch in laparoscopic Roux-en-Y gastric bypass (RYGB) is formed using such a device. When the device is fired, the action leads to the sealing and division of the tissue. In the linear cutting staplers, two or more rows of staples (most commonly three) are laid down either side of a central channel, through which a blade passes. In bariatric surgery, the tissues most commonly divided are stomach and small bowel, although stapling devices can also be applied across mesentery, lung, heart, and blood vessels. Laparoscopic stapling devices are designed to facilitate the division of a piece of tissue or tissues, while at the same time ensuring that the divided ends are sealed. Leaks may occur as a result of failure of the stapling device to work correctly, because they are employed under circumstances or in tissues for which they were not designed or because of “surgeon factors.” This paper examines the available evidence surrounding staple line and anastomotic leaks from laboratory-based and clinical studies and suggests strategies for minimizing leaks. Stapling devices are used for dividing and joining bowel and it is now possible to complete a bariatric procedure, such as Roux-en-Y gastric bypass, without sutures, although many surgeons continue to use sutures for at least part of this procedure.
Leaks from staple lines or anastomoses represent a significant cause of morbidity and mortality in patients undergoing bariatric procedures. This paper examines factors that are important in leading to these complications and suggests ways to avoid them. In spite of these benefits, their use is associated with a variety of problems, including leakage from staple lines or anastomoses, bleeding, and fistula formation, which can, on occasion, prove fatal. They are simple to use, provide a rapid means of dividing and joining bowel, and require less skill and experience on the part of the operator than that required for laparoscopic hand suturing. The invention of stapling devices, which can be used in laparoscopic surgical procedures, provides a number of benefits to surgeons.
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