1. A good stapler in the hand of a surgeon with minimal training makes a good anastomosis.

2. A bad stapler, even in the hand of an experienced surgeon, makes a doubtful anastomosis

3. Stapled anastomosis is faster than a hand sewn anastomosis.

4. There are a few places where hand sewn anastomosis can not be safely performed such as: deep in the pelvis (colo-anal anastomosis) or up at the diafragmatic hiatus(in GEJ cancers)

5. Advanced laparoscopic surgery can not be imagined without staplers

6. Due to economical conditions in some regions staplers are not fully available, so go for staplers but learn also hand-sewn anastomosis.

Dr Mogoanta, could you elaborate more on :

"A bad stapler, even in the hand of an experienced surgeon, makes a doubtful anastomosis"

We use staplers selectively (viz LAR, IPAA). For small bowel and rest of anastomosis we prefer hand-sewn, single layer interrupted anastomosis. The main complication of stapled anastomosis are financial i.e expensive ;-))

The range of staplers constits of five established stapler categories (Circular, linear, linear cutting, ligating and cutting, and skin staplers) They are an adjunct and not a substitute for meticulous surgical techniqe.

clinically apparent anastomotic leak ranges from 2-15% and second most common complication is increased rate of anastomotic strictures.

Ulman SL et al in animal models reported haemorrhage (13%), postoperative leakage at the anastomosis site (8%) and localized abscess formation at the stapled line (4%).

Orkin BA et al in a retrospective review tried to answer whether stapler brand is a risk factor for anastomotic leak?

In this study were included all the anastomoses of the recum and colon and were excluded ileoanals. The cohort consisted of 807 anastomoses in 797 patients.

They concluded that although the overall leak rate with Covidien staplers was significantly higher than with Ethicon staplers, detailed analysis suggested that other risk factors play a larger role than stapler brand.

Therfore, we can conclude that the complication rate of stapled anastosis is based on patient related factrs such as malnutrition, chronic steroidal use, diabetes mellitus, malignancy(chemoradiotherapy), hypotension, emergency surgery.

I think that surgery is an handcraft work. Despite a lot of reviews and EBM scientific paper an eclectic way of thinking is essential in surgery. Like " the only good knot is the right one" we can say that "the only good anastomosis is the right one". Often also a stapled anastomosis needs a tailored execution , adding , ad example , a running suture tu assure hemostasis of stapled line.

When you respect the three holy principles of good blood supply , tension free and impermeability , the technique of anastomosis is irrelevant.

I was trained in Hand sewn anastamosis ,but I had an opportunity to use staplers ever since Autosuture introduced them in UK.Staplers are easy to use,leaks are less.we use staplers for all most in all situations.In Laparoscopic era these are very essential.Powered staplers are still more safer as the compression excerted is uniform.Of course the three holy principles mentioned by Dr Bruno should be kept in mind always..

In my country, we use staplers selectively, due to economical conditions, staplers are not fully available.

if you want to have a complete non-industry-driven overview of the range of surgical staplers, please visit

www.surgicalstaplermuseum.com