Misfire in laparoscopic stapled bariatric surgery. Pilot error or technical failure: who's to blame for it?

Background: Use of laparoscopic mechanical suture increased dramatically in the last 20 years. Use of staplers in laparoscopic bariatric surgery is mandatory in order to perform minimally-invasive, complex and routine procedures that include ligation, division, resection, anastomosis and fascial closure. Methods: Malfunction is defined as failure of the device to meet its performance expectations. Problems that one can encounter during stapling are related to stapler, cartridge, reload or operating room personnel. Results: The incidence of these events is very low, estimated to 0.003% but the implications on postoperative evolution vary from little or no consequences to catastrophic events. User error can be attributable to personal experience or misjudge of staple size, length, tissue thickness. Device failure to form properly and suture line separation or device specific malfunctions (staples partially firing or staples misfire and not releasing) are most common aspects. A survey of misfire events was conducted through the Romanian bariatric surgical community, with high positive response of such events (over 90%). Conclusion: Report of such events is mandatory in order to improve both user experience and device function as well.