Stapled and hand-sewn anastomoses are equally effective. However, stapled sutures are not efficient and should therefore be reserved for individual indications.
It has been shown that stapled and hand-sewn anastomoses can be created with equal safety. Both early and late morbidity and mortality did not differ significantly. In all examined operations, with the exception of total colectomy and ileoanal pouch formation, the operation was more cost-intensive when the reconstruction was performed using stapled technique. This is particularly due to the very high proportion of material costs in the total costs. Even the partial time savings through mechanical suturing and the associated reduction in personnel costs did not overall favor the stapled suture.
Stapling devices are offered in large numbers and are intended to represent an alternative to hand suturing. An advantage of these stapling devices is certainly their standardized application with time savings and lower contamination of the environment when handled correctly.
Advantages and Disadvantages of Stapling Instruments
Advantages
- standardized surgical procedure
- time savings and lower contamination of the environment
- lower traumatization with correct application
- significant expansion of minimally invasive surgical options
Disadvantages
- limiting use regarding lumen width with given device size
- uncertain closure with too thick wall conditions
- higher material costs
- potential anastomotic bleeding after intraluminal
- everted adaptation with linear staplers
The use of circular staplers is considered the standard method in the creation of deep rectal anastomoses
The staple line remains in the tissue and can induce connective tissue proliferation through a foreign body reaction and thus, especially with circular stapler application, lead to stenosis development.
Serosalization (seromuscular oversewing of the staple line).
It is postulated that the serosa has a high regenerative potential due to its enzymatic activity and therefore appears particularly important for anastomotic healing. Furthermore, the serosa provides fibrin exudation and forms a gas- and liquid-tight closure of suture connections. However, the use of linear staplers results in an everted suture connection with mucosa-mucosa contact. Therefore, the so-called “serosalization”, i.e., the seromuscular oversewing of the staple line, is recommended. This also prevents direct contact of the staples with adjacent structures.
There are no studies to date that unequivocally prove the advantages of serosalization.
After stapling, the removal of the stapler from the lumen follows and the checking of the two tissue rings (doughnuts), which must be circularly intact. If these tissue rings are not complete, oversewing or new anastomosis creation is recommended. Despite lacking evidence, a tightness check is often performed using air or blue application
In case of bleeding, cauterization should be avoided, as current conduction at the metal staples can lead to thermal damage.
Regarding esophagogastrostomy after esophageal resection
there are no evidence-based recommendations for manual or mechanical anastomosis creation. Both the manual and mechanical methods are considered safe, with stapling causing more stenoses
Mechanical cervical esophagogastrostomy achieved the best results compared to hand-sewn anastomoses, presumably due to a constant, tight apposition of the esophagus to the stomach wall as well as a uniform tension distribution over the anastomosis
The stapled esophagogastrostomy is described with leak rates of 1% as the gold standard.
The more expensive circular stapled anastomosis achieves similar results to hand suturing, but is simpler and faster to perform.
When inserting circular staplers, care must be taken not to cause excessive dilatation with tissue tearing. In narrow lumens, i.v. application of spasmolytics (glucagon, butylscopolamine, etc.) with subsequent digital or instrumental dilatation can be helpful.
Apart from the already mentioned pouch formations and reconstruction techniques after gastrectomy, there are no actual indications for the use of stapling devices in small bowel surgery.
Stapler techniques generally show no advantages in the colon area.
The use of circular staplers is considered the standard method only in the creation of deep rectal anastomoses. Some authors favor the so-called double-stapling method, in which the rectum is transected with a linear stapler before the anastomosis is subsequently created with the circular stapler.
Due to the possibility of safely resecting and anastomosing the rectum in the supra-anal space of the small pelvis, the extirpation rate for rectal carcinoma has steadily declined in recent decades