Stapled and handsewn anastomoses are equally effective. However, stapled suture lines are not efficient and should therefore be reserved for patient-specific indications.
It has been shown that stapled and handsewn anastomoses can be fashioned with the same degree of reliability. There was no significant difference between their early / late morbidity and mortality. Except for total colectomy and ileoanal pouch creation, in all studied operations, the surgical procedures studied cost more when the anastomoses were stapled. This is primarily driven by the material cost which accounts for a rather significant part of the total cost. The time saved in some cases by staple suturing and the corresponding decrease in labor cost generally do not favor stapled sutures.
Surgical staplers are produced in large numbers and supposedly offer an alternative to hand suturing. When handled correctly, one definite benefit of surgical staplers is their time saving standardized use with decreased contamination of the surrounding tissue.
Pros and cons of surgical staplers
Pros
- Standardized surgical technique
- Time saving and less contamination of surrounding tissue
- Less tissue trauma when used correctly
- Marked expansion of minimally invasive surgical options
Cons
- Given device sizes not necessarily matching the luminal bowel diameter
- Unreliable anastomosis when the walls are too thick
- Higher material cost
- Potential intraluminal anastomotic bleeding
- Everted approximation with linear staplers
The use of circular staplers is considered standard technique when fashioning deep rectal anastomoses
Especially with circular staplers, the rows of staples remain in the tissue and may induce a foreign body reaction with connective tissue proliferation, thus facilitating the development of stenosis.
Seromuscular double-layering (oversewing the staple line)
It is postulated that the enzymatic activity of the serosa has a high regenerative potential and therefore appears to be especially important in anastomotic healing. In addition, the serosa is involved in fibrin exudation and fashions an airproof and leakproof seal over the suture line. However, the application of linear staplers leaves everted suture lines with mucosa-mucosa contact. Therefore, oversewing the staple line with a seromuscular suture is recommended. This also prevents the staples from coming into direct contact with neighboring structures.
To date, no studies have been conducted which conclusively demonstrate the benefits of seromuscular double-layering.
After stapling, the stapler is withdrawn from the lumen and both donuts must then be checked for structural integrity along the circular circumference. If these donuts are incomplete, the anastomosis should be oversewn or fashioned anew. Although there is a lack of evidence, the anastomosis is often tested by transanally instilling air or methylene blue.
In case of bleeding, do not use cautery as this may result in electrical conduction along the metal staples with thermal tissue injury.
For esophagogastrostomy after esophageal resection, there are no evidence-based recommendations regarding handsewn or stapled anastomosis. While both the handsewn and stapled techniques are safe, stapling causes more stenoses.
Compared with handsewn anastomosis stapled cervical esophagogastrostomy yielded the best results, presumably because of the constant close contact of the esophagus with the gastric wall and the uniform distribution of tension across the anastomosis.
With leakage rates of 1%, stapled esophagogastrostomy >is described as the gold standard.
The more expensive stapled EEA anastomosis yields similar results as the handsewn anastomosis but is easier and faster to perform.
When inserting a circular stapler, make sure it does not overly dilate the tissue, thereby causing it to tear. In a narrow lumen, i.v. administration of spasmolytics (glucagon, butylscopolamine, etc.) followed by digital or instrumental dilation can be helpful.
There are no definite indications for staplers in small bowel surgery, apart from the pouch formation and postgastrectomy reconstruction techniques noted above.
Stapler techniques generally do not offer any benefits in colon surgery.
Circular staplers are considered the gold standard only when fashioning deep rectal anastomoses. Some authors prefer the so-called double stapling, where the rectum is transected with a linear cutter before the anastomosis is fashioned with a circular stapler.
In rectal cancer the rate of rectal excision has steadily decreased in recent decades because by now the rectum may be safely resected and anastomosed in the supraanal space of the lesser pelvis.