Use of disposable skin staplers for bowel anastomosis to reduce laparotomy time in war

Laparotomy for penetrating wounds to the abdomen is demanding in terms of time, skill and resources. Any modification of existing techniques that will lessen these demands will be of benefit at surgery in forward areas in war. A previous paper (1) compared a method of small bowel anastomosis using disposable skin staplers with a two-layer handsewn anastomosis using fresh pig ileum. The stapled method was both significantly faster to perform and mechanically superior. In two further studies on a total of 12 pigs the stapled method has been compared with a single-layer and a double-layer handsewn small bowel anastomosis. All 12 pigs recovered from laparotomy without complication. Construction times were recorded. The quality of healing of the anastomoses was assessed by clinical observation, post-mortem and histological examination, and tensiometry. The skill required to perform the stapled anastomoses was estimated subjectively. The stapled technique was consistently faster than the handsewn methods. A Kolmogorov two-sample test showed an improvement in times when comparing the stapled method with the single layer, with a significance of P = 0.05. An improvement was also seen when the stapled method was compared with the double layer, with a significance of P = 0.01. There was no statistically significant difference between the construction times for the two handsewn methods. There was no evidence of anastomotic failure or haematoma at post-mortem and no adverse reaction to the metal staples. No features were identified on histology to indicate impaired healing with the stapled method. Tensiometry of the anastomoses showed that the stapled anastomosis is as mechanically reliable as the handsewn anastomosis. The level of skill required to perform the stapled anastomosisis judged to be within the capabilities of relatively junior surgeons once the technique has been mastered in an anastomosis workshop.