There are a variety of staplers that are used in the OR, but gastrointestinal staplers, or GI staplers, are a common source of confusion for nurses. Surgical techs can also struggle with this topic; however they typically receive an in-depth lesson on staplers. I’m going to explain the purpose of each stapler and the mechanism of action to help give you a better understanding of each stapler. Having a deeper knowledge of staplers will help you anticipate more appropriately and help ensure the best possible care is given. Hope you find this helpful!

First Up.. GIA Stapler

If you are getting ready for a bowel resection of any sort, ensure you have the GIA staplers ready to go. This is the most common stapler used. You will typically use more than 1 ‘load’ as well. GIA stands for gastrointestinal anastomosis. Anastomosis means to ‘surgically connect’. This stapler is also called a “Linear Cutter” through a different company, but most likely the surgeon will still call it a GIA no matter the brand. The GIA transects the tissue completely leaving two separate stapled tissues. This stapler comes in 3 sizes: each size with 2-3 different types of loads.

Sizes (refers to the length of the staple line)

· 60mm

· 80mm

· 100mm

Loads (refers to the staple height)

· White (2.5mm)- this is a vascular load

· Blue (3.8 mm)- medium load

· Green (4.8mm)- thick load

The GIA60 has all three loads available. The GIA80 and GIA100 only have blue (medium) and green (thick) loads available.

100 mm GIA stapler with reload

80 mm GIA stapler with reload

Tips for using a GIA Stapler

· Can be reloaded up to 8 times (remember, if integrity is questioned always get a new stapler).

· Use a wet sponge to wipe bioburden and loose staples between each use. If there are loose staples left when firing the next load, the staple line could be compromised.

· Remember to use bowel technique and keep the stapler, loads, etc. away from your clean table. I like to keep the wet sponge and used loads in a kidney basin.

· When reattaching the two sizes, always start by placing the ‘pin’ together at the base of the handle.

· A GIA stapler can be applied from the outside of the bowel, but can also be used inside the bowel.

INTRAOPERATIVE TIP

For most open belly procedure, such as an exploratory laparotomy or an incarcerated/strangulated hernia repair, always have a handful of GIA staplers and reloads ready to open!

INTRAOPERATIVE TIP

EEA Stapler

The EEA stapler is needed if there is going to be an ‘end to end’ anastomosis performed. EEA= end to end anastomosis. This stapler will be used through the patient’s rectum. This will require a separate set-up which will be your ‘dirty’ set-up. When opening the package to the sterile field there will be TWO items to remove from the package, the stapler itself and the anvil. You cannot use the stapler without the anvil, so ensure that it is not forgotten or dropped. This stapler fires from inside the bowels. The handpiece will be passed down to the dirty field (avoiding contamination) and the anvil will stay on the clean field. Typically, the surgeon will want a Kelly or Peon to hold the anvil. The EEA comes in 5 different sizes and there are no reloads.

Sizes (refers to the lumen size of the tissue needing anastomosed)

· 21mm

· 25mm

· 28mm

· 31mm

· 33mm

25 mm EEA Stapler

Tips for using an EEA Stapler

· Do NOT lose/forget the anvil in the packaging.

· Always open to the clean field and then pass handpiece to dirty set-up.

· The surgeon will typically measure the diameter with an EEA sizer from the abdomen. Once used it should be passed to the dirty set-up immediately. He may use them again rectally.

· You will need lube, 1-2 laps, EEA sizers (after used abdominally), and a proctoscope on the dirty set-up.

· After the anastomosis is complete, the surgeon will remove the anvil to check for the ‘donut’. The ‘donut’ is the ring of tissue that remains between the anvil and the stapler- a complete donut is an indicator of a good staple line.

· The surgeon will use the proctoscope while the abdomen is filled with sterile water or saline to complete a ‘bubble test’. This will check for an incomplete anastomosis- you do not want to see bubbles!

· Open extra gowns and gloves for everyone, but minimum 2 for the surgeon as they may have to move between ‘clean’ and ‘dirty’.

· You should be using ‘bowel technique’ when entering the colon which requires an additional set up for closure. This set up should not be touched until closure begins.

· You will likely need an auto purstring device available. A surgeon may use this device to secure the anvil to the bowel instead of trying to place a stitch by hand. Typically instead of cutting the suture, they will tag it with a Kelly clamp until the anastomosis is complete.

Auto Purstring Device

Contour Stapler

The Contour stapler is designed to be used deep in the pelvis. On most patient’s performing a tissue resection in the pelvis is challenging, unless you are using the robot or doing the case laparoscopically. The name of the Contour stapler comes from it’s staple line being curved (or contoured). This Contour comes in one size, 40 mm. There are two different reloads available- a 1.5 mm and a 2.0 mm. Most places will only stock one of the two, in my experience it’s been the 2.0 mm as it is primarily used on the colon, which is a thicker tissue. This stapler can be fired a total of 6 times (5 reloads).

Contour Stapler and reload

Tips for using a Contour Stapler

· The middle handle performs the closure (tissue compression) and the outer trigger performs the stapling.

· The sliding mechanism is a retaining pin- this helps to align the stapler sides but also helps to keep tissue within the staple line.

· When loading/unloading ensure that the cutting slider is retracted (away from the handle).

· When unloading, place the pressure on the curved portion slide out with the curve.

· Place used loads with your ‘dirty’ instruments/supplies.

TA Stapler

The TA stapler is a single line stapler with a double or triple staggered row of staples. This device does not cut the tissue, but does have a cutting guide for transection with another instrument. TA stands for Thoraco-Abdominal as it can be used in a variety of settings- bleb resections, lobectomy, gastric resections, etc. The TA has a max of 8 firings (7 reloads) per device. The TA stapler comes in a few sizes and has a handful of loads.

Sizes (refers to the length of the staple line)

· 30mm

· 45mm

· 60mm

· 90mm

Loads (refers to the staple height)

· White (2.5mm)- this is a vascular load

· Blue (3.5 mm)- medium load

· Green (4.8mm)- thick load

The TA30 has all loads available. The TA45, TA60, TA90 have the blue (medium) and green (thick) loads available.

TA60 Stapler with reload

Tips for using a TA Stapler

· 1st semi-squeeze is a ‘pre-clamp’ to ensure proper tissue placement- after surgeon is happy, they will complete the first squeeze to compress tissue.

· The 2nd complete squeeze is what fires the staples.

· Grasp the finger pads to remove and insert the loads- there will be an audible click.

· Like the Contour stapler, the sliding mechanism is a retaining pin- this helps to align the stapler sides but also helps to keep tissue within the staple line.

· Like always, wipe the stapler with a wet sponge between firings to remove any loose staples or bioburden.

General Tips & Info for GI Staplers

Always have multiple reloads available! Typically, a surgery department will have cart loaded with each stapler as well as the reloads for each stapler. This is very handy to pull over to your room just in case you need more than was pulled for your procedure. Some facilities may not pull the staplers/reloads from central supply, instead use the cart as their stock. As long as there is a method in place, it usually works! Typically there is someone assigned to stock this cart, but if you use it, just replace it! When opening staplers to the field, I find it easiest to lay the bottom of the package against my forearm and open from my palm towards me (which is also proper sterile technique). After opening, hold onto that package for dear life! Sometimes the staplers seem to be glued in there! Most reloads are much easier to open than the actual device. My biggest tip for staplers is to just practice loading and unloading them- that’s how you’re going to get comfortable. When you’re not pressed for time with the surgeon (not so) patiently waiting on you to hand it over. Feel free to leave a comment if you have any questions or want something else covered! Thanks for reading!

A Guide to Gastrointestinal (GI) Staplers in Surgery