To the Editor: 
[Re: “Surgical Stapler Safety Took Center Stage in 2019”]

I am a missionary surgeon from the United States, and I routinely bring staplers with me for open surgeries that are often on patients with very advanced diseases. My preference is Ethicon GIA 75 mm; I have blue, green and yellow loads. I use the staplers on all gastrointestinal cases and do not usually reinforce the staple line except for a stitch or two at the crotch of an anastomosis. The staplers are great for the common intraabdominal disasters that I see. I might add that due to resource conservation, I often reuse staplers after re-sterilization and often use the staplers more than the recommended number of times.

I have seen a few leaks, but they usually occur in the sickest patients—especially patients who come late and are septic, such as a patient with typhoid perforation. I cannot remember a case where I have had a stapler malfunction. I believe most leaks are related to non-stapler issues. There are some factors that I think are important to avoid leaks: 

1. After I perform the anastomosis, I examine the entire suture line carefully, and then perform a mild pressure check by compressing the bowel proximal and distal to the anastomosis. 
2. I make sure I am stapling through healthy tissues that are well vascularized.
3. I try to make sure the patient is as healthy as possible and perform an ostomy if they are not.
4. I perform a second-look operation after 48 hours for damage-control patients or patients who required an unusually difficult operation. In these cases, I do the anastomosis on the second look and may then do a third-look operation. This allows me to save staple reloads in patients who unfortunately die before the second look.
5. I am careful to avoid using a stapler after it has been used to cross another staple line that can dull the cutting blade in the stapler.

In the times that I have had leaks, it is usually the sickest patients who have a generalized disease and are septic, such as the typhoid patients. In these patients, the staple lines are usually intact. Small leakage can be seen at each staple suggesting that the tissues are not sealing and healing. I don’t know all the mechanisms that prevent healing in these patients. One of my attendings believed the lack of healing was “intestinal failure.”

I agree with Dr. Ross Goldberg that surgical judgment is critical. Blame the fool, not the tool.

Brian Camazine, MD
Missionary Surgeon
President, Earthwide Surgical Foundation

Dr. Camazine reported no relevant financial disclosures.