Optimizing the Staple Line
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.
KeywordsBariatric surgery Staple line Reinforcement Bleeding
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.
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