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Environmental impact of surgery can be greatly reduced by using multi-use staplers

The environmental impact of surgery can be greatly reduced by using multi-use staplers (MUS) with pre-attached buttressing rather than single-use staplers (SUS) with separate buttressing, according to researchers from Germany. They reported that MUS or reusable staplers produce less waste, require less resource input, and have a reduced impact on greenhouse gas emissions caused by their lithium content compared to single-use staplers in laparoscopic sleeve gastrectomy and laparoscopic gastric bypass procedures.The findings were reported in the paper, ‘Evaluating the Environmental Impact of Single-Use and Multi-Use Surgical Staplers with Staple Line Buttressing in Laparoscopic Bariatric Surgery’, published in Dovepress.

Signia stapler (Medtronic)

The investigators noted that SUS are widely used surgical instruments that contribute to resource consumption and waste generation, whereas multi-use staplers (MUS) can greatly reduce the environmental impact of surgery. The staple lines are often reinforced with buttressing material to prevent leaks and bleeding. The generation of waste and greenhouse gases as well as resource consumption are central to the environmental impact of health care. In developed countries, hospitals generate an average 1% of a nation’s solid waste and 2.1% of its greenhouse gas emissions annually. In the USA, hospitals generate an average 5500 tons of waste daily, with operation rooms (ORs) producing approximately 20% of a hospital’s total waste (30% proportion of plastics). The need for sterility in the OR encourages the use of disposable devices and materials sealed in plastic packaging. Waste disposal costs for an OR were estimated to be US$45,000 per year.

This study examined current clinical practice and environmental concerns regarding stapling and buttressing, as well as the environmental impact of staple line buttressing in sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). In addition, it assessed the impact of packaging material and the lithium in power supplies.

The study compared two frequently used stapling systems and their respective buttressing material: the single-use Echelon Flex stapler (SUS) with the Echelon Endopath Staple Line Reinforcement (Ethicon) and the multi-use Signia stapler (MUS) with Tri-Staple reinforced reloads that already have buttressing incorporated (Medtronic).

The researchers carried out a survey of bariatric surgeons to estimate surgical stapler use and staple line reinforcement in clinical practice including surgeons’ awareness of environmental issues. In total, 37 surgeons consented to being surveyed and 18 participants from Australia, Canada, France, Italy, New Zealand, the USA and the UK completed the survey. The study focused on the 60 mm cartridges, which were commonly used in bariatric surgery. For both stapler systems, cartridge options are available for different tissue thicknesses. As their core components remained unchanged, it was considered sufficient to undertake the full analysis only on the 60 mm stapler cartridges.


The majority of survey respondents, 12 (67%) surgeons, stated that they are concerned about the environmental impact of surgery, although only 4 (22%) participants reported that their hospital promoted environmentally friendly purchasing. Half (50%) of the survey participants reported that they never made changes to their work practice based on environmental concerns, with 11 (61%) survey participants prioritising ease of use and price over environmental impact in purchasing decisions.

On average, respondents performed 24.9 (range: 4–100) SGs and 9.6 (range: 2–23) RYGBs per month. The majority (88%) of surgeons preferred powered staplers over manual staplers. Staple line reinforcement was frequently applied, with 12 (67%) surgeons using staple line reinforcement, and 7 (39%) of the 12 surgeons applying reinforcement in every procedure. For each SG, an average 0.6 45mm cartridges and 5.0 60mm cartridges were used. No use of 30mm cartridges was reported. Per RYGB, an average 0.2 30mm cartridges, 1.0 45mm cartridges, and 5.0 60mm cartridges were used. Staple-line buttressing was most frequently used with 60mm cartridges.

The total weight of each stapling system component is provided in Table 3. Overall, the MUS is heavier than the SUS by 1,356.08g, of which 388.34g are packaging material. The addition of buttressing material slightly increases the total weight of the MUS by 14.22g; the total weight of the SUS is increased more substantially by 88.67g.

They found that MUS considerably reduce the amount of product and packaging waste per surgery compared to SUSm by 813.67g and 746.47g for SG and RYGB, respectively. This translates to a total waste prevention potential of 50% for SG and 48% for RYGB. The product waste is reduced by 40% in both types of surgery, and the packaging waste is reduced by 60% per SG and by 57% per RYGB.

The Total Material Requirement (TMR) per surgery of MUS stapler cartridges (with and without preloaded buttressing) was substantially greater than that of the SUS stapler cartridges. Despite the higher TMR, the MUS shows an overall reduction compared to the SUS due to the reusability of the most resource-intensive components. The TMR associated with one SG is reduced from 330kg (SUS) to 30.9kg (MUS). For RYGB, the TMR drops from 329kg to 29.2kg, respectively. In both procedures, the TMR is reduced by more than 90%, indicating that over 90% of raw material consumption can be saved by switching from SUS to MUS. The resource efficiency is increased by factor 11.

The impact on greenhouse gas emissions per surgical procedure was based on the lithium content of the stapler’s power supplies. The MUS contains less lithium than the SUS, both in terms of relative content of the battery cells (MUS: 4.96%, SUS: 6.72%) and absolute mass (MUS: 0.348g, SUS: 0.376g). Due to this lower lithium content and the higher circulation rate of the MUS, its impact on greenhouse gas emissions per surgery at 0.018g CO2eq is 324 times smaller than that of the SUS at 5.904g CO2eq.

Both surgery types use five 60mm staple cartridges per surgery on average, the only difference is the number of cartridges that apply buttressing. In the sensitivity analysis, buttressing is either applied to none or all staple firings. The sensitivity analysis shows that MUS generate less waste and have lower TMR than SUS regardless of the rate of buttressing applied. If buttressing is applied to all staple lines, the waste reduction offered by the MUS increases to 1,022.13g (54.7%) from 649.88g (45.6%) if no staple line reinforcement is used, as the waste created by the separate buttressing material and its packaging is avoided.

The TMR results of the MUS showed a larger increase than those of the SUS if staple line reinforcement was applied at all stapler firings. The study authors said this suggests that the resource consumption to create the preloaded buttressing may be higher than that needed to create the separate buttressing. As buttressing is only responsible for a very small part of the total TMR, however, this change does not noticeably affect the overall advantage provided by the MUS.

“The results of our study show that preloaded buttressing reduces the amount of waste created by reinforcement per staple firing compared to separate buttressing. The preloaded buttressing is used with a MUS, whose reuse further reduces the environmental impact, whereas the separate buttressing is paired with the SUS,” the authors wrote.

It is important to note that the costs of the stapling systems were not included in the analysis, even though survey respondents rated the price of the device as more likely to influence their purchasing decision than its environmental impact. Although MUS are likely to reduce the costs of waste disposal, their upfront purchase cost is expected to be higher than those of SUS. The investigators said that to fully explore the financial impact, a more in-depth life-cycle cost analysis is needed.

“This study presents evidence that reusable staplers produce less waste, require less resource input, and have a reduced impact on greenhouse gas emissions caused by their lithium content than single-use staplers in laparoscopic sleeve gastrectomy and laparoscopic gastric bypass procedures,” the authors concluded. “In addition to product waste, packaging waste is substantially reduced by reusable staplers. Furthermore, buttressing that is pre-attached to the stapler reload was found to reduce the amount of waste per stapler firing that is added by staple line reinforcement in comparison to separate buttressing material.”

To access this paper, please click here

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