Surgical staplers can be one of the most confusing aspects of what we do, they all have weird names, they're color-coded, they are by length and by thickness of tissue, and they each have their own purpose.
One of the first things we're normally pretty familiar with are skin staples. Skin staples are made of a titanium alloy that is pretty inert, meaning that the metal inside the tissue has very little reaction.
We use skin staples in most places for closure. Skin closures are usually accomplished by holding an Adson forceps in each hand, we evert the skin edges and then we apply the stapler right at the area where the skin meets.
On the table are three different versions of a skin stapler. You'll notice on the side, skin staples usually have a size, 35R, which is regular, or 35 wide, which is a 35W.
If we pick up one of the staplers, we can see that at the end of the stapler is a black arrow. The black arrow is where we want the skin edges to meet. We can squeeze the stapler and deploy the beginnings of the stapler and then apply them and hold up while our surgeon or assistant grabs the two skin edges with Adsons and moves down to one more length. When we let go, we'll see the staple fall out. Now, skin staples, unlike paper staples, are wide. We want to approximate the tissue, not strangulate.
Some staplers will come in this sideways pistol grip, and they too at the very end of the stapler have a line that shows us where to put the skin edges so that we get both edges together. And once again, unlike paper staples, skin staples are going to approximate, not strangulate.
This is another skin stapler, and once again, we have the mark in the middle, and this one has a pistol grip to it, like Richard-Allan staplers.
Inside the body, we use clips. We put clips on cystic duct and cystic artery for gallbladders all the time. Laparoscopically, this is a 5 mm clip applier made by Covidien. Once we get the clip applier out, we pull the tag, and if you can zoom in on this, it actually shows at a digital readout, the number of clips that are left in and it will give us a countdown as we use it.
The endoscopic clip applier puts a flat clip, and I'll put one in my hand. Now the flat clip can be used to clip off a blood vessel or a duct, and we do - we usually put two above and two below, and cut in between. These clips will be retained within the body, and the body will encapsulate them with tissue.
If we need to resect bowel, stomach, or lung, we often go to a bigger kind of staple. This stapling device has multiple names. We can call it a GIA stapler - it's for gastrointestinal anastomosis, or we can call it a linear cutter. The reason why we call it that is because it will lay down two rows of staples, and cut in between, and evenly divide the tissue.
We separate it right here, and this is actually the insert. This gun can be used multiple times, and each time we use it, all we have to do is lift up on the base and pull off the reload. When it comes time to use the same staple device, we'll take the tag off, start at the tip of the stapler, and lock it in. We can hold the stapler back together, close it, and then hand it to our surgeon in such a way that he just puts his hand around it and he opens it up.
There is a color code to the reloads. They're sized by their length, like 55, 75, or 85 - they are sized by the length of staple. The reloads that are white are vascular. The reloads that are blue are for regular thickness tissue. If we get into something a little thicker, we can go up to the green reloads for thick tissue.
The two rows of staples on either side. There is a razor blade in the center of the stapler so that when we connect these two and close it, when we move this trigger forward, it activates both rows of staples and runs a razor blade and cuts it in between. This is a one-use item - once we fire this off, we could open it up and just change out the inner reload to a different one, and we can keep using this for usually up to close to 20 times.
This stapler is called a linear stapler. It doesn't cut on its own, it simply lays down two rows of staples.
The gun itself is reusable, what we have to do is change out the staple reload. We'll slide the reload out, have the circulator give us another, and slide it right back in. When we hand this to our surgeon, we want to hold it by the end and put the stapler right in his hand.
When this stapler is applied, it will lay down just the two rows of staples. In addition to this instrument, our surgeon will either need a knife or a scissor to divide the tissue.
This stapler is called the Black Stallion made by Ethicon. It has two names, either an EEA stapler,which means it's an end-to-end anastomosis stapler, meaning that we're going to join two pieces of a hollow structure with a lumen back together. It could also be called an intraluminal stapler.
We often use these down deep in the pelvis close to the rectum when we have to do a bowel resection, we introduce this from below, we separate the bell from the rest of the stapler, sew the bell end to the proximal end of the bowel, and then plug it back in. When we tighten down the bell, what's going to happen is when we fire this stapler, it is going to staple a ring, which is actually two rows of bowel staples, and then when we fire it, a round razor blade comes up and cuts out the center. When we slide this out, there's been a staple anastomosis of two hollow structures. This is a one-time use item, there is no reload for it. Once we use it, it's disposed of.
Once the EEA stapler is introduced to the field, the surgical tech can deploy the bell by twisting the valve at the end of the stapler. Once the bell is completely deployed, the bell end of the stapler can be removed. We have stapled off the proximal end of the bowel, and a purse-string stitch is sewn in the end. The purse-string stitch is cinched up around the bell in the proximal side, and now after we lower the spike and introduce this instrument usually through the anus into the lower rectum, we'll introduce the stapler. Once we're inside all the way to the staple line on the distal side, we will deploy the spike once again.
When the spike comes out, the bell from the proximal side will be attached. And we will compress the two pieces of tissue together. As we bring them together, we'll be able to approximate the tissues and be ready to fire our stapler. Once the stapler is fired, when we squeeze the handle, two things will happen. Two rows of bowel staplers in a circular pattern will seal the bowel, but - I'll back this up a little bit. When we squeeze the handle, you'll see a round razor blade come up and it will center punch out the bowel from the center and that gives us a workable lumen. Once that happens, the stapler gets taken out, and we go back and we look at the doughnut that is left inside the staple unit. We want to see a perfectly round circle, if we see a "C", then that means that the backside of the staple line wasn't completely stapled.
Previously, we looked at a GIA stapler. The GIA is gastrointestinal anastomosis stapler, we can also call it a linear cutter. It's going to lay down two rows of staples and it's gonna divide with a razor blade straight down the center cutting our tissue as we staple it. This is for an open procedure.
We have the same stapler for endoscopic surgery that we call an Endo GIA. The gun is usually opened separately, this one is made by Covidien. Because there are so many different lengths and tissue sizes - is it vascular? Is it regular? Is it thick? We open the gun separately, and then by the length and the thickness of the tissue - and we color code them. Our surgeon may ask for a blue, a green, a gray, whichever color code they're using.
When we connect these, it's usually pretty simple. If we look on the side of the stapler, there's an arrow that says load. And on the side of the disposable unit, there is another arrow that says load. We put them together and twist until the load and the white line meet up.
Now, I close the stapler, hold it at the edge, and pass it to my surgeon. Once he takes it, introduces it through the trocar, he can now open it up, he can roticulate it, he can move the stapler from side-to-side, he can twist its length, he can move it around and then when he's ready, he'll fire it.
To remove it - on the underside, it simply says unload. To remove this staple device off and change out heads, what I need to do is pull down and twist, and off it comes.
This ligation unit is called a "SULU" - a single-use ligation unit. I fire it one time and then dispose of it. If I need another, I ask my circulator to open another one, and then it loads the same way.