Allv.
N . Z . J . Surg 1992.62, 740-741
LIGATURE VERSUS PURSE STRING FOR SURGICAL STAPLED ANASTOMOSES
:d
JOHNR . A L L ~ O P Department of Surgery, Royal Melbourne Hospital, arkville and St George’s Hospital, Kew. Victoria, Austr lia lntraluminal circular stapling in gastrointestinal surgery re uires a purse string suture which secures the bowel around the anvil of the head of the stapling gun before firing. An alternative method of securing the bowel around the anvil is described. Key words: circular stapling, gastrointestinal surgery, ligature, purse string.
Introduction lntraluminal circular stapling techniques now have an established role in gastrointestinal surgery. The introduction of stapling guns with a detachable head has simplified the use of these instruments and extended their rate of application. These stapling techniques necessitate a purse string suture which secures the bowel around the anvil of the detachable head of the instrument prior to firing. An alternative method of securing the bowel around the anvil of the detachable head is described.
Technique The following description relates to anterior resection but is equally applicable to oesophageal work. The relevant steps are depicted in Fig. 1. The selected site of proximal transection of the bowel is chosen. Mesenteric vessels are ligated in accordance with usual principles. The serosal aspect of the bowel is cleared of appendices epiploicae and mesenteric attachments for 2 cm distal to the proposed line of proximal transection. No clamps are applied to the bowel in the vicinity of the proposed line of division. A non-crushing clamp should be applied higher up, after milking any bowel contents upwards from the level of the pathology to minimize the risk of later contamination. A crushing or non-crushing clamp should also be applied below the proposed opening into the bowel lumen to avoid reflux of bowel contents from below.
Correspondence: Mr John R . Allsop, 566 Rivcrsdale Road. Camberwell. Vic. 3124, Australia. Acceptcd for publication 5 March 1992
The opening into the bowel lumen is made /angirudinally approximately 5 cm distal to the proposed line of proximal transection. If the operation is for neoplasia, the longitudinal opening ought to be sufficiently above the growth in order to avoid incising directly through tumour. The sides of the longitudinally opening are held apart with Babcock forceps and the detachable head of the stapler is introduced. The head is pushed first towards the exposed back wall and then upward. It may be necessary to have a third Babcock at the proximal limit of the longitudinal opening to help shoe horn the staple head into the lumen of the bowel. The process is facilitated by mounting the detachable stapler head on an introducer. The introducer is simply a straight hollow tube whose internal diameter matches the external diameter of the shaft of the stapler head. There is no concern about firmly grasping the margins of the longitudinal opening because it is destined to become part of the operative specimen. Once the head of the instrument is in the lumen, it is gently pushed proximally to the desired level. The introducer also assists this step but the whole process can be readily performed without an introducer. A single heavy ligature is now applied around the bowel so that it is tied down on to the shaft bf the detachable stapler head. The ligature is tight enough to avoid the shaft slipping proximally but not so tight as to cut through the layers of the bowel wall. As the ligature is snugged home, it is important to check that the face of the anvil is square to the bowel lumen. Intact mesenteric vessels should immediately abut the tissue which is destined to be incorporated in the staple line. The Autosuture Premium CEEA staple head has a convenient groove on its shaft which the ligature will engage. This groove eliminates potential prob-
74 I
LIGATURE VS PURSE STRING IN STAPLING
beyond the ligature is retained so that the ligature does not slip off. Any excess cuff which could conceivably interpose itself in the staple line is trimmed away with scissors. At this stage, any proximally applied non-crushing clamp can be removed. The detachable stapler head is reunited with the staple-gun after carrying out the distal part of the operation by conventional techniques. After appropriately aligning the bowel ends and closing the instrument. the staples are fired. The staple line doughnuts are inspected in the usual manner,
Discussion
Fig. 1. (a) An introducer carries the head of the staple gun into the isolated bowel segment via a longitudinal opening below the level of proposed division. Before introducing the staple-gun head. the isolated opened segment may be irrigated with bacteriocidal. or other. agents. (b) Bowel at the selected line of transection is ligated down onto the shaft of the staple-gun head. Preferably. the shaft of the staple-gun head has a groove into which the ligature will seat. (c) The bowel is divided beyond the ligature. A sufficient cuff is left so that the bowel does not slip out from under the ligature. The cuff should not be so generous that it can interpose itself in the ultimate staple line. (d) The introducer is disengaged from the
staple-gun head
and the non-crushing proximal clamp removed from the retained bowel segment. The clamp on the distal operative specimen is retained to avoid retlux of bowel contents and contamination of the operative field.
lems of the ligature slipping along the shaft. The groove also lessens the risk of the trimmed bowel slipping out from under the ligature. Staple-gun heads which have such a groove on their short length of shaft are therefore preferred over those which do not. For additional security a purse string style ligature can also be inserted alongside the initial simple ligature after it has been tied. The final step is to detach the operative specimen from retained proximal bowel by cutting down, with a scalpel, onto the shaft of the stapler head, just below the ligature. A sufficient cuff of tissue
The conventional method of performing a circular stapled anastomosis involves the placement of a purse string suture at the line of bowel transection. This purse string may be inserted by hand using a whip stitch or, alternatively, devices such as the Furness clamp or a staple-attached encircling suture employed. Proper preparation of the bowel end to be anastomosed is crucial, regardless of the method of purse string placement. With the conventional method, the head of the staple-gun is introduced at the actual site of bowel transection and after placement of the purse string suture. The introduction of the staplegun head can prove difficult and techniques such as progressive gentle dilatation, triangulation of the opening and the use of smooth muscle relaxants have been employed to coax the instrument into place. Introduction in this way may cause longitudinal splitting of the muscle layers or inadvertent rolling upward of mucosal layers, such that they are not incorporated in the staple line. Inspection of the proximal and distal doughnuts following firing of the staple-gun has always been advised because of acknowledged difficulties with instrumentation and purse stringing on either or both sides of the anastomosis. The doughnuts should contain the full circumference of both mucosal and muscular layers of the bowel. In addition to problems with incomplete doughnuts, the incorporation of too much tissue within the purse string may result in tissue prolapsing between the bowel ends which are destined to be stapled together. Such interposition of detached necrotic tissue between viable bowel ends is as potentially hazardous as having an incomplete doughnut, The ligature technique just described for dealing with the proximal bowel segment has several advantages over the conventional technique. First, it ensures easy introduction of the staple-gun head into the bowel lumen, regardless of bowel spasm. This ease of introduction will often allow the selection of a larger diameter staple-gun than would
ALLSOP
142
have been possible with the conventional method. A second advantage is that introduction through the more distal longitudinal opening eliminates upward mucosal stripping. The use of this distal longitudinal opening also means that there is no traumatic handling of the tissues which are ultimately destined to be stapled together. Because a single ligature is used, the entire circumference of both mucosal and muscular layers are incorporated, thereby guaranteeing a complete proximal doughnut. The trimming of the bowel beyond the ligature ensures that tissue from this area is not prolapsing into the staple line. A third advantage is the ability to control contamination during introduction of the staple-gun head, which is the same with this technique as it is with the conventional purse string system. In both instances, the chosen section of bowel is milked free of contents and isolated by clamps above and below. Residual contamination, not cleared by milking, can be dealt with through the longitudinal bowel opening, just as it is when the bowel is transected using the conventional method. Similarly. local measures to control tumour implantation such
as irrigation of the lumen with cetrimide, can be performed equally well through the longitudinal opening before the staple head is introduced. A final advantage of the ligature technique relates to its application in oesophageal surgery. With this new method, the staple-gun head of the instrument is introduced and tied into place before transecting the oesophagus. Problems with the proximal retained oesophagus retracting upwards durirlg attempts to place a conventional purse string and to introduce the staple-gun head are thereby avoided.
Conclusion A technique for introducing and ligating into place the detachable head of a circular stapling device is described. The technique is simpler and safer than conventional purse string techniques. The claim of improved safety is based on the logical advantages described. It seems inappropriate to formally trial this simpler method against conventional purse string techniques.
N . Z . J . Surg 1992.62, 740-741
LIGATURE VERSUS PURSE STRING FOR SURGICAL STAPLED ANASTOMOSES
:d
JOHNR . A L L ~ O P Department of Surgery, Royal Melbourne Hospital, arkville and St George’s Hospital, Kew. Victoria, Austr lia lntraluminal circular stapling in gastrointestinal surgery re uires a purse string suture which secures the bowel around the anvil of the head of the stapling gun before firing. An alternative method of securing the bowel around the anvil is described. Key words: circular stapling, gastrointestinal surgery, ligature, purse string.
Introduction lntraluminal circular stapling techniques now have an established role in gastrointestinal surgery. The introduction of stapling guns with a detachable head has simplified the use of these instruments and extended their rate of application. These stapling techniques necessitate a purse string suture which secures the bowel around the anvil of the detachable head of the instrument prior to firing. An alternative method of securing the bowel around the anvil of the detachable head is described.
Technique The following description relates to anterior resection but is equally applicable to oesophageal work. The relevant steps are depicted in Fig. 1. The selected site of proximal transection of the bowel is chosen. Mesenteric vessels are ligated in accordance with usual principles. The serosal aspect of the bowel is cleared of appendices epiploicae and mesenteric attachments for 2 cm distal to the proposed line of proximal transection. No clamps are applied to the bowel in the vicinity of the proposed line of division. A non-crushing clamp should be applied higher up, after milking any bowel contents upwards from the level of the pathology to minimize the risk of later contamination. A crushing or non-crushing clamp should also be applied below the proposed opening into the bowel lumen to avoid reflux of bowel contents from below.
Correspondence: Mr John R . Allsop, 566 Rivcrsdale Road. Camberwell. Vic. 3124, Australia. Acceptcd for publication 5 March 1992
The opening into the bowel lumen is made /angirudinally approximately 5 cm distal to the proposed line of proximal transection. If the operation is for neoplasia, the longitudinal opening ought to be sufficiently above the growth in order to avoid incising directly through tumour. The sides of the longitudinally opening are held apart with Babcock forceps and the detachable head of the stapler is introduced. The head is pushed first towards the exposed back wall and then upward. It may be necessary to have a third Babcock at the proximal limit of the longitudinal opening to help shoe horn the staple head into the lumen of the bowel. The process is facilitated by mounting the detachable stapler head on an introducer. The introducer is simply a straight hollow tube whose internal diameter matches the external diameter of the shaft of the stapler head. There is no concern about firmly grasping the margins of the longitudinal opening because it is destined to become part of the operative specimen. Once the head of the instrument is in the lumen, it is gently pushed proximally to the desired level. The introducer also assists this step but the whole process can be readily performed without an introducer. A single heavy ligature is now applied around the bowel so that it is tied down on to the shaft bf the detachable stapler head. The ligature is tight enough to avoid the shaft slipping proximally but not so tight as to cut through the layers of the bowel wall. As the ligature is snugged home, it is important to check that the face of the anvil is square to the bowel lumen. Intact mesenteric vessels should immediately abut the tissue which is destined to be incorporated in the staple line. The Autosuture Premium CEEA staple head has a convenient groove on its shaft which the ligature will engage. This groove eliminates potential prob-
74 I
LIGATURE VS PURSE STRING IN STAPLING
beyond the ligature is retained so that the ligature does not slip off. Any excess cuff which could conceivably interpose itself in the staple line is trimmed away with scissors. At this stage, any proximally applied non-crushing clamp can be removed. The detachable stapler head is reunited with the staple-gun after carrying out the distal part of the operation by conventional techniques. After appropriately aligning the bowel ends and closing the instrument. the staples are fired. The staple line doughnuts are inspected in the usual manner,
Discussion
Fig. 1. (a) An introducer carries the head of the staple gun into the isolated bowel segment via a longitudinal opening below the level of proposed division. Before introducing the staple-gun head. the isolated opened segment may be irrigated with bacteriocidal. or other. agents. (b) Bowel at the selected line of transection is ligated down onto the shaft of the staple-gun head. Preferably. the shaft of the staple-gun head has a groove into which the ligature will seat. (c) The bowel is divided beyond the ligature. A sufficient cuff is left so that the bowel does not slip out from under the ligature. The cuff should not be so generous that it can interpose itself in the ultimate staple line. (d) The introducer is disengaged from the
staple-gun head
and the non-crushing proximal clamp removed from the retained bowel segment. The clamp on the distal operative specimen is retained to avoid retlux of bowel contents and contamination of the operative field.
lems of the ligature slipping along the shaft. The groove also lessens the risk of the trimmed bowel slipping out from under the ligature. Staple-gun heads which have such a groove on their short length of shaft are therefore preferred over those which do not. For additional security a purse string style ligature can also be inserted alongside the initial simple ligature after it has been tied. The final step is to detach the operative specimen from retained proximal bowel by cutting down, with a scalpel, onto the shaft of the stapler head, just below the ligature. A sufficient cuff of tissue
The conventional method of performing a circular stapled anastomosis involves the placement of a purse string suture at the line of bowel transection. This purse string may be inserted by hand using a whip stitch or, alternatively, devices such as the Furness clamp or a staple-attached encircling suture employed. Proper preparation of the bowel end to be anastomosed is crucial, regardless of the method of purse string placement. With the conventional method, the head of the staple-gun is introduced at the actual site of bowel transection and after placement of the purse string suture. The introduction of the staplegun head can prove difficult and techniques such as progressive gentle dilatation, triangulation of the opening and the use of smooth muscle relaxants have been employed to coax the instrument into place. Introduction in this way may cause longitudinal splitting of the muscle layers or inadvertent rolling upward of mucosal layers, such that they are not incorporated in the staple line. Inspection of the proximal and distal doughnuts following firing of the staple-gun has always been advised because of acknowledged difficulties with instrumentation and purse stringing on either or both sides of the anastomosis. The doughnuts should contain the full circumference of both mucosal and muscular layers of the bowel. In addition to problems with incomplete doughnuts, the incorporation of too much tissue within the purse string may result in tissue prolapsing between the bowel ends which are destined to be stapled together. Such interposition of detached necrotic tissue between viable bowel ends is as potentially hazardous as having an incomplete doughnut, The ligature technique just described for dealing with the proximal bowel segment has several advantages over the conventional technique. First, it ensures easy introduction of the staple-gun head into the bowel lumen, regardless of bowel spasm. This ease of introduction will often allow the selection of a larger diameter staple-gun than would
ALLSOP
142
have been possible with the conventional method. A second advantage is that introduction through the more distal longitudinal opening eliminates upward mucosal stripping. The use of this distal longitudinal opening also means that there is no traumatic handling of the tissues which are ultimately destined to be stapled together. Because a single ligature is used, the entire circumference of both mucosal and muscular layers are incorporated, thereby guaranteeing a complete proximal doughnut. The trimming of the bowel beyond the ligature ensures that tissue from this area is not prolapsing into the staple line. A third advantage is the ability to control contamination during introduction of the staple-gun head, which is the same with this technique as it is with the conventional purse string system. In both instances, the chosen section of bowel is milked free of contents and isolated by clamps above and below. Residual contamination, not cleared by milking, can be dealt with through the longitudinal bowel opening, just as it is when the bowel is transected using the conventional method. Similarly. local measures to control tumour implantation such
as irrigation of the lumen with cetrimide, can be performed equally well through the longitudinal opening before the staple head is introduced. A final advantage of the ligature technique relates to its application in oesophageal surgery. With this new method, the staple-gun head of the instrument is introduced and tied into place before transecting the oesophagus. Problems with the proximal retained oesophagus retracting upwards durirlg attempts to place a conventional purse string and to introduce the staple-gun head are thereby avoided.
Conclusion A technique for introducing and ligating into place the detachable head of a circular stapling device is described. The technique is simpler and safer than conventional purse string techniques. The claim of improved safety is based on the logical advantages described. It seems inappropriate to formally trial this simpler method against conventional purse string techniques.
