Surgical Stapling in Abdominal Surgery

Surgical stapling equipment allows the small-animal surgeon to perform a variety of challenging abdominal surgical procedures more quickly and consistently than with conventional, hand-suturing techniques. This article will summarize the use of these devices.

Dr. Michael M. Pavletic

Surgical staplers

I use the following surgical stapling devices routinely for abdominal surgery: skin staplers, Surgiclips, the Ligate-Divide Stapler, the Thoracoabdominal Stapler, the Gastrointestinal Anastomosis Stapler, and the End-to-End Anastomosis Stapler (Tyco Healthcare/Kendall Animal Health). Each device has specific advantages. For small patients, small laparoscopic staplers can also be used during a standard laparotomy approach.

Skin staplers are quite useful to quickly close long, abdominal incisions. In thin skin, application of a standard surgical glue to the incision line after staple application helps to stabilize skin staples and minimize occasional postoperative staple movement or rotation. Vascular clips can be used to secure multiple vascular pedicles quickly in a variety of surgical procedures, including bowel resection and anastomosis, splenectomy, partial liver resection, and tumor removal. Surgiclips apply single, flat clips to small vessels, whereas the Ligate-Divide Stapler applies two curved vascular clips simultaneously while the blade within the cartridge divides the vessel between the clips. The long, narrow silhouette of Surgiclip staplers is effective in ligating vessels in recessed areas where hand ligatures are difficult or impossible to apply, such as in the removal of adrenal tumors (Figure 1). The larger Ligate-Divide Stapler is useful for ligating multiple, exposed vascular pedicles rapidly, such as in splenectomies (Figure 2).

Figure 1: Surgiclip device. Compressing the scissors mechanism will apply a single, flat staple to a small vessel. Upon release, a staple is automatically reloaded for the next application.

The Thoracoabdominal Stapler and Gastrointestinal Anastomosis Stapler apply linear rows of staples. The Thoracoabdominal Stapler, the most commonly used linear stapler, applies two rows of staggered staples (Figures 3a & 3b). The Thoracoabdominal Stapler is particularly useful for gastrotomy incision closure, partial splenectomies, and liver lobectomies. The Gastrointestinal Anastomosis Stapler applies four rows of staggered staples; the most commonly used cartridge contains a blade that divides the tissue between the second and third staple rows. The Gastrointestinal Anastomosis Stapler can staple two edges of divided tissue in a single application (Figures 4a & 4b). The Gastrointestinal Anastomosis Stapler is especially effective for partial gastrectomy in cases of necrosis secondary to gastric torsion. In conjunction with the Thoracoab-dominal Stapler, the Gastrointestinal Anastomosis Stapler can be used to perform rapid, functional end-to-end anastomosis after small bowel resection.

In contrast, the End-to-End Anastomosis Stapler applies two rows of surgical staples in a circular configuration—ideal for the end-to-end anastomosis of the larger diameter colon and esophagus in small animals. The Autosuture Pursestring 65 device (Tyco Healthcare/Kendall Animal Health) is used in conjunction with the End-to-End Anastomosis Stapler. The Autosuture Pursestring devise applies a pursestring suture to the cut end of each opposing bowel segment. Each pursestring suture is then tied to the central shaft of the End-to-End Anastomosis Stapler. Closure of the End-to-End Anastomosis Stapler aligns, apposes, and staples the segments together; the circular cutting blade located within the disposable End-to-End Anastomosis Stapler cartridge removes the pursestring and redundant tissue borders.

Figure 2: Ligate-Divide Stapler unit. Each cartridge contains 15 pairs of curved vascular clips. Compression of the handle will apply two clips to a vessel as a blade cuts between them. This device is especially useful for complete splenectomies.

All three devices come in various lengths and diameters; staple sizes also vary. Today, most internal staples are made of titanium. Thoracoabdominal Staplers are available in three basic cartridge lengths: 30 mm, 55 mm, and 90 mm, depending on the length of staples required. They use two basic staple sizes: 3.5 mm and 4.8 mm. The larger 4.8-mm staples are usually used for the thicker gastric tissues, whereas smaller 3.5-mm staples are most commonly used for the small and large intestines. The Thoracoabdominal Stapler 30 can use a vascular cartridge (V3 cartridge) that applies three rows of fine staples to larger vascular pedicles in a staggered configuration.

Figure 3a : Thoracoabdominal Stapler 55 with the green (4.8 mm) and blue (3.5 mm) staple cartridges. Two rows of staples are applied in a staggered configuration.

Applications

Surgical staplers can be used alone or in conjunction with other stapling devices.

Table 1

lists the stapling devices commonly used for small-animal abdominal procedures. Of the various procedures listed in

Table 1

, surgical staplers are especially useful for the following surgical procedures:

• Partial gastrectomy for gastric torsion-necrosis (Gastrointestinal Anastomosis Stapler or Thoracoabdominal Stapler 90)

• Billroth I and II (Gastrointestinal Anastomosis Stapler, Thoracoabdominal Stapler, Ligate-Divide Stapler, End-to-End Anastomosis Stapler)

• Gastroesophageal anastomosis (End-to-End Anastomosis Stapler, Thoracoabdominal Stapler)

• Typhlectomy (Thoracoabdominal Stapler)

• Splenectomy (Ligate-Divide Stapler)

• Liver lobectomy (Thoracoabdominal Stapler)

• Adrenalectomy and ligation of recessed vessels (Surgiclips)

• Incisional closure (skin staplers)

• Colonic anastomosis (End-to-End Anastomosis Stapler)

At Angell Animal Medical Center, staplers are the preferred tools for these specific surgeries. With other surgical procedures, the surgeon's preference varies and may depend on the patient's size and the surgeon's experience.

Figure 3b : Thoracoabdominal Stapler 30 with the white vascular cartridge. Three rows of staples are applied in a staggered configuration. This device is ideal for securing larger vascular pedicles, such as the renal vessels during nephrectomy.

Surgical considerations

Veterinary practices with an active surgical caseload will benefit the most from the use of surgical stapling equipment. However, clinicians can easily master the use of skin staplers, Surgiclips, and the Ligate-Divide Stapler with little formal training. These affordable instruments can save considerable time, reduce anesthesia time (particularly important in emergency or critical care cases), and improve the doctor's clinical productivity.

Veterinarians inexperienced in stapling are naturally reluctant to purchase the Thoracoabdominal Stapler, Gastrointestinal Anastomosis Stapler, Ligate-Divide Stapler, and End-to-End Anastomosis Stapler. But mastering these devices isn't difficult. The manufacturers of these devices provide training courses throughout the United States to accelerate the learning process. The Thoracoabdominal Stapler and Ligate-Divide Stapler are mastered easily, whereas surgeons find training or assistance invaluable in refining their use of the Gastrointestinal Anastomosis Stapler and End-to-End Anastomosis Stapler. The End-to-End Anastomosis Stapler is used the least, but it is indispensable for the more challenging procedures listed in Table 1.

Figure 4a : The Gastrointestinal Anastomosis Stapler closed with cartridge. This stapler applies four rows of staples in a staggered configuration. A cartridge blade cuts between rows two and three.

Linear (Thoracoabdominal, Gastrointestinal Anastomosis) and circular (End-to-End Anastomosis) staplers must be used correctly or dehiscence can result. Each stapler must engage the full thickness of the two organ walls (e.g., stomach and intestine) stapled together. As with conventional suturing techniques, staplers will fail if improperly applied or used to close tissues severely compromised by trauma or disease. Details on correct application can be found in the recommended sources.

Figure 4b : The Gastrointestinal Anastomosis Stapler uncoupled with the cartridge.

Conclusion

Surgical stapling devices have greatly facilitated abdominal surgery in small-animal practice. Speed, efficiency, and ease of application are the primary reasons for their widespread acceptance by veterinary surgeons. Vascular clips (Surgiclips, Ligate-Divide Staplers) and skin staplers are mastered easily with minimal training. Veterinarians will benefit from a basic training course to master the use of linear and circular staplers.

Table 1: Common Stapling Procedures in Abdominal Surgery

Suggested reading

Pavletic, M.M. (ed.): Surgical Stapling.

Vet. Clin. North Am. 24(2), 1994.

Rousch, J.K.: Biomaterials and Surgical Implants. Textbook of Small Animal Surgery, 3rd Ed. (D. Slatter, ed.). W.B. Saunders, Philadelphia, Pa., 2002; pp 141-148.

Dr. Michael M. Pavletic is the director of surgical services at the Angell Animal Medical Center in Boston. He received his DVM degree in 1974 from the University of Illinois. Dr. Pavletic is a 1981 diplomate of the American College of Veterinary Surgeons. He is the author of W.B. Saunders' Atlas of Small Animal Reconstructive Surgery and has written numerous articles on wound management, reconstructive surgery, and surgical stapling.