Optimizing the Staple Line

  • Edgardo Serra
  • Carlos Eduardo Jacob†


To optimize means to make something as good as possible. This is the aim of a surgeon when performing any surgical procedure, including all bariatric techniques. Gastrointestinal surgeries are performed either openly or through minimally invasive techniques using regular sutures or mechanical staplers. Mechanical staplers are a mainstay of laparoscopic gastrointestinal surgery, in particular bariatric surgery.

Staple-line failure is the most common cause of postoperative gastrointestinal hemorrhage, after sleeve gastrectomy and Roux-en-Y gastric bypass, and occurs in 1–3% and 1.9–4.4%, respectively. Possible factors that affect the risk of bleeding can be related to the device (staple height, type of device), the tissue, and also to surgeons’ experience.

Although several papers discuss postoperative leaks and bleeding, few discuss intraoperative events. It seems that intraoperative bleeding and staple failure are not frequent. Staple-line reinforcement with sutures, tissue sealants, glues, or buttressing materials can address this problem. In this chapter, we will discuss the role of staple-line reinforcement.


Bariatric surgery Staple line Reinforcement Bleeding 

Supplementary material

Video 33.1

Oversewing running suture. A laparoscopic sleeve gastrectomy was performed with a five-port technique following all the standard steps: dissection of greater omentum with vascular sealer or harmonic scalpel, calibration with 36 Fr bougie, and section under calibration with a laparoscopic linear stapler starting in the greater curvature 4 cm from the pylorus to 1 cm next to the angle of His. In our standard technique, as in the video we show, reinforcement with oversewing non-imbricating running suture of the entire staple line of the gastric tube was made. The oversew was performed with absorbable polyglactin 910 2-0 and SH needle. The time for this specific reinforcement is between 8 and 15 min. The final steps in the technique are methylene blue test, extraction of the specimen, and placement of abdominal drain routinely.


  1. 1.
    Abou Rached A, Basile M, El Masri H. Gastric leaks post sleeve gastrectomy: review of its prevention and management. World J Gastroenterol. 2014;20:13904–10.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Aggarwal S, Sharma AP, Ramaswamy N. Outcome of laparoscopic sleeve gastrectomy with and without staple line oversewing in morbidly obese patients: a randomized study. J Laparoendosc Adv Surg Tech A. 2013;23:895–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Al Hajj GN, Haddad J. Preventing staple-line leak in sleeve gastrectomy: reinforcement with bovine pericardium vs oversewing. Obes Surg. 2013;23:1915–21.CrossRefPubMedGoogle Scholar
  4. 4.
    Alasfar F, Chand B. Intraoperative endoscopy for laparoscopic Roux-en-Y gastric bypass: leak test and beyond. Surg Laparosc Endosc Percutan Tech. 2010;20:424–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Albanopoulos K, Alevizos L, Flessas J, Menenakos E, Stamou KM, Papailiou J, Natoudi M, Zografos G, Leandros E. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing two different techniques. Preliminary results. Obes Surg. 2012;22:42–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc. 2012;26:1509–15.CrossRefPubMedGoogle Scholar
  7. 7.
    Aydin MT, Aras O, Karip B, Memisoglu K. Staple line reinforcement methods in laparoscopic sleeve gastrectomy: comparison of burst pressures and leaks. JSLS. 2015;19.Google Scholar
  8. 8.
    Bulbuller N, Aslaner A, Oner OZ, et al. Comparison of four different methods in staple line reinforcement during laparoscopic sleeve gastrectomy. Int J Clin Exp Med. 2013;6:985–90.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Casella G, Soricelli E, Genco A, Ferrazza G, Basso N, Redler A. Use of platelet-rich plasma to reinforce the staple line during laparoscopic sleeve gastrectomy: feasibility study and preliminary outcome. J Laparoendosc Adv Surg Tech. 2015;3.Google Scholar
  10. 10.
    Cha J, Shademan A, Le HND, Decker R, Kim PCW, Kang JU, Krieger A. Multispectral tissue characterization for intestinal anastomosis optimization. J Biomed Opt. 2015;20(10):106001.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Gagner M, Buchwald JN. Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review. Surg Obes Relat Dis. 2014;10:713–23.CrossRefPubMedGoogle Scholar
  12. 12.
    Gagner M, Deitel M, Erickson AL, et al. Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus summit on sleeve gastrectomy. Obes Surg. 2013;23:2013–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Shikora SA, Mahoney CB. Clinical benefit of gastric staple line reinforcement (SLR) in gastrointestinal surgery: a meta-analysis. Obes Surg. 2015;25:1133–41.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Jamil KM, Rahman AS, Bardhan PK, Khan AI, Chowdhury F, Sarker SA, Khan AM, Ahmed T. Micronutrients and anaemia. J Health Popul Nutr. 2008;26(3):340–55. ReviewPubMedPubMedCentralGoogle Scholar
  15. 15.
    Madan AK, Martinez JM, Lo Menzo E, Khan KA, Tichansky DS. Omental reinforcement for intraoperative leak repairs during laparoscopic Roux-en-Y gastric bypass. Am Surg. 2009;75(9):839–42.PubMedGoogle Scholar
  16. 16.
    Alasfar F, Chand B. Intraoperative endoscopy for laparoscopic Roux-en-Y gastric bypass: leak test and beyond. Surg Laparosc Endosc Percutan Tech. 2010;20(6):424–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Greenstein AS. New targets and opportunities at the level of the endothelium. Hypertension. 2012;60(4):896–7. Epub 2012 Aug 20CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Edgardo Serra
    • 1
  • Carlos Eduardo Jacob†
    • 2
  1. 1.Bariatric Surgery, Centro CIENCorrientesArgentina
  2. 2.Division of Gastrointestinal Surgery and Coloproctology – Hospital das ClínicasUniversity of Sao Paulo School of MedicineSao PauloBrazil

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