Ann Surg Treat Res.  2020 Aug;99(2):72-81. 10.4174/astr.2020.99.2.72.

Compression injury of the circular stapler for gastrointestinal end-to-end anastomosis: preliminary in-vitro study

  • 1Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea
  • 2Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
  • 3Department of Food and Nutrition, College of Medical and Life Science, Silla University, Busan, Korea
  • 4Department of Biomedical Engineering, Pusan National University School of Medicine, Yangsan, Korea
  • 5Biomedical Materials Science, School of Dentistry, University of Birmingham, Birmingham, United Kingdom


This preliminary in-vitro study was designed to evaluate the risk factors of compression injury from use of a circular stapler for end-to-end anastomosis.
Transparent collagen plates were prepared in dry and wet conditions. Physical properties of collagen plates and porcine colon tissue were examined using a rheometer. Adjustable and fixed-type circular staplers were applied on the collagen plates and the gap distance and compressive pressure were measured during anvil approximation. Tissue injury was evaluated using a compression injury scale. Compression properties were accessed to optimal or overcompression based on gap distance.
Unacceptable injuries were rarely observed on the dry collagens, regardless of compression device. In the adjustable compression, the compressibility ratio was similar between dry and wet collagen. Overcompression and unacceptable injury increased on the wet collagens. In the fixed compression, the compressibility ratio increased significantly and unacceptable injuries were observed in more than 50% of wet collagens. Peak pressure was significantly higher in the fixed-compression types than those of adjustable type. On bivariate correlation analysis, fixed-compression type and wet collagens were respectively associated with overcompression. On multivariate analysis, edematous collagen condition was the most important risk factor and proximal anvil side, fixed compression type, and overcompression were also independent risk factors for unacceptable compression injury.
In the edematous tissue condition, unintentional overcompression could be increased and result in tissue injury on the compression line of the circular stapler.


Anastomotic leak; Colorectal surgery; Soft tissue injuries; Surgical anastomosis; Surgical staplers


  • Fig. 1 Structure of 2 commercial circular stapler devices. (A) Anvil connecting unit of adjustable-compression type stapler showed round anvil edge and small staple driver on the staple cartridge when firing trigger was fully closed. (B) Fixed-compression type stapler had sharp lip on anvil edge and pusher bar protruding from the staple cartridge. (C) The cross-sectional view of collagen plates on the circular stapler with compressive pressure sensor placed between proximal and distal collagen plates. (D) Controlled tissue compression (CTC) scale and (E) indicator window with green bar on the stapler shafts using indicators for proper compression. (F) Optimal and overcompression depending on the gap distance between anvil and staple cartridge.

  • Fig. 2 Compression injury scale. Acceptable injury was defined as cases in which the depth of tissue injury extended to less than half of collagen thickness (score 1–3); unacceptable injury was defined as cases where the depth of damage exceeded the half of collagen thickness (score 4–5).

  • Fig. 3 The gap distance and unacceptable injury of the adjustable type stapler according to compression propriety on the wet collagen plates. (A) Comparing with optimal compression, the overcompression cases had significantly lower gap distance. (B) The incidence of unacceptable injuries was higher in the overcompression cases than optimal compression cases. *P < 0.05.

  • Fig. 4 Real-time compressive pressure measurements. Compressive pressure curves according to compression type of AC (A), MC (B), and FC (C) on the both dry and wet collagen plates. Peak compressive pressure levels showed significant increment in FC on the dry (D) and wet (E) collagen plates. (F) The upward curve patterns of compressive pressure were different on the collagen conditions. In contrary to steep pressure rising on the dry collagen plates, gradual plateau was showed even after optimal compression point on the wet collagen. AC, adjustable compression; MC, maximal compression; FC, fixed compression; CTC scale, controlled tissue compression scale. *P < 0.05, *P < 0.001.

  • Fig. 5 The bivariate correlation analysis of the risk factors relating unacceptable injury.


1. Nakayama S, Hasegawa S, Hida K, Kawada K, Sakai Y. Obtaining secure stapling of a double stapling anastomosis. J Surg Res. 2015; 193:652–657. PMID: 25277356.
2. Ikeda T, Kumashiro R, Taketani K, Ando K, Kimura Y, Saeki H, et al. Endoscopic evaluation of clinical colorectal anastomotic leakage. J Surg Res. 2015; 193:126–134. PMID: 25103641.
3. Offodile AC 2nd, Feingold DL, Nasar A, Whelan RL, Arnell TD. High incidence of technical errors involving the EEA circular stapler: a single institution experience. J Am Coll Surg. 2010; 210:331–335. PMID: 20193897.
4. Slieker JC, Daams F, Mulder IM, Jeekel J, Lange JF. Systematic review of the technique of colorectal anastomosis. JAMA Surg. 2013; 148:190–201. PMID: 23426599.
5. Mery CM, Shafi BM, Binyamin G, Morton JM, Gertner M. Profiling surgical staplers: effect of staple height, buttress, and overlap on staple line failure. Surg Obes Relat Dis. 2008; 4:416–422. PMID: 18226977.
6. Rho SY, Bae SU, Baek SJ, Hur H, Min BS, Baik SH, et al. Feasibility and safety of laparoscopic resection following stent insertion for obstructing left-sided colon cancer. J Korean Surg Soc. 2013; 85:290–295. PMID: 24368987.
7. Maisel W. Safe use of surgical staplers and staples - letter to health care providers [Internet]. Silver Spring: US Food and Drug Administration;2019. cited 2020 Jul 3. Available from:
8. Chekan E, Whelan RL. Surgical stapling device-tissue interactions: what surgeons need to know to improve patient outcomes. Med Devices (Auckl). 2014; 7:305–318. PMID: 25246812.
9. Nakayama S, Hasegawa S, Nagayama S, Kato S, Hida K, Tanaka E, et al. The importance of precompression time for secure stapling with a linear stapler. Surg Endosc. 2011; 25:2382–2386. PMID: 21184102.
10. Sureshkumar S, Jubel K, Ali MS, Vijayakumar C, Amaranathan A, Sundaramoorthy S, et al. Comparing surgical site infection and scar cosmesis between conventional linear skin closure versus purse-string skin closure in stoma reversal - a randomized controlled trial. Cureus. 2018; 10:e2181. PMID: 29657907.
11. Matsuzawa F, Homma S, Yoshida T, Konishi Y, Shibasaki S, Ishikawa T, et al. Serosal laceration during firing of powered linear stapler is a predictor of staple malformation. Surg Innov. 2017; 24:590–597. PMID: 28962536.
12. Ikeda T, Kumashiro R, Oki E, Taketani K, Ando K, Aishima S, et al. Evaluation of techniques to prevent colorectal anastomotic leakage. J Surg Res. 2015; 194:450–457. PMID: 25544478.
13. Baker RS, Foote J, Kemmeter P, Brady R, Vroegop T, Serveld M. The science of stapling and leaks. Obes Surg. 2004; 14:1290–1298. PMID: 15603641.
14. Yang J, Soltz M, Russell H, Beres J, Zhao J, Liao D, et al. Surface deformation analysis of end-to-end stapled intestinal anastomosis. Surg Innov. 2012; 19:281–287. PMID: 22075437.
15. Kimura M, Takahashi H, Tanaka T, Sagawa H, Takeyama H. Profiling surgical staplers: does staple direction affect the strength of the anastomosis. Dig Surg. 2015; 32:454–458. PMID: 26488286.
16. Egorov VI, Schastlivtsev IV, Prut EV, Baranov AO, Turusov RA. Mechanical properties of the human gastrointestinal tract. J Biomech. 2002; 35:1417–1425. PMID: 12231288.
17. Myers SR, Rothermel WS Jr, Shaffer L. The effect of tissue compression on circular stapler line failure. Surg Endosc. 2011; 25:3043–3049. PMID: 21487874.
18. McGuire J, Wright IC, Leverment JN. An in vitro assessment of tissue compression damage during circular stapler approximation tests, measuring expulsion of intracellular fluid and force. Proc Inst Mech Eng H. 2001; 215:589–597. PMID: 11848391.
19. Watters DA, Smith AN, Eastwood MA, Anderson KC, Elton RA, Mugerwa JW. Mechanical properties of the colon: comparison of the features of the African and European colon in vitro. Gut. 1985; 26:384–392. PMID: 3920126.
20. Chung RS. Blood flow in colonic anastomoses: effect of stapling and suturing. Ann Surg. 1987; 206:335–339. PMID: 3307654.
21. X Zhang. LP Covidien. Circular stapler with visual indicator mechanism. United States patent. US 16/073,354. 2019. 2. 07.
Full Text Links
  • ASTR
export Copy
  • Twitter
  • Facebook
Similar articles
Copyright © 2023 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: