Endoscopic Stapler Research Articles

Intracorporeal semi-hand-sewn Billroth I reconstruction in total laparoscopic distal gastrectomy.

Intracorporeal Billroth I (B-I) reconstruction using an endoscopic linear stapler (ELS) is widely performed in total laparoscopic distal gastrectomy. However, conventional procedures require many ELSs for anastomosis. Here, we introduce the novel intracorporeal semi-hand-sewn (SHS) B-I reconstruction. After the transection of stomach and duodenum using ELS following adequate lymph node dissection, small entry holes were made on the anterior wall in the greater curvature of the stomach and the duodenal stump. The posterior walls of both the remnant stomach and the duodenum were attached with the ELS and fired to create the posterior wall of the B-I anastomosis. All the transection line of the duodenum and one-third of the transection line of the stomach were dissected; finally the anterior wall suturing at the anastomotic site was performed by the laparoscopic hand-sewn technique. SHS procedure was performed for 17 gastric cancer patients. There were no intraoperative complications or conversions to open surgery. One intra-abdominal abscess was observed although there was no anastomotic leakage. The median reconstruction time was 48 minutes (32-63). The SHS procedure was safe, feasible, and economical, although it requires sufficient laparoscopic suturing and ligation skill.

Sleeve Resection for Rectosigmoid Endometriosis

Study Objective The purpose of this video is to demonstrate the technical bases of a new conservative surgical technique, called Sleeve Resection (SR), for the treatment of endometriosis infiltrating the rectosigmoid wall. Design The SR technique was used as an alternative to the shaving and discoid resection techniques. Setting Lesions infiltrating the muscular layer of the wall of the low, medium, high rectum or sigmoid, separated or contiguous, were excised using a endoscopic linear stapler inserted through intentional colpotomy or using the existing vaginal opening during hysterectomy or endometriosis resection infiltrating the posterior vaginal fornix. Patients or Participants From June 2013 to May 2020, 82 patients, diagnosed preoperative or during surgery, underwent resection of all lesions. Interventions Lesions located in the retosigmoid were identified. Vicryl-00 stitches, transfixed in a long way in the longitudinal direction of the intestinal loop and drawn ventrally, provided an adequate individualization of the lesion margins. The endoscopic linear stapler was inserted parallel to the axis of the rectosigmoid through vaginal route for the excision of one or more lesions. Intestinal permeability was ensured through the placement of a 2.0 cm transanal probe. Additional stapling, sequential or interspersed, were used for total excision of one or multiple lesions. Measurements and Main Results All lesions were fully resected. At postoperative, there was no evidence of leakage or stenosis and neither immediate nor late intestinal obstruction up to a maximum followup of 7 years. Conclusion The laparoscopic sleeve resection technique, using the vaginal route as an access for the endoscopic linear stapler, proved to be safe and feasible for the short and medium followup and can be an alternative to traditional shaving and discoid resection techniques. A significant number of segmental resections were avoided. Future studies are needed to assure the effectiveness of this technique.

Total Laparoscopic Rectosigmoidectomy without Bowel Exteriorization: A New Surgical Technique for Endometriosis.

Study Objective The purpose of this video is to demonstrate the technical bases of a new laparoscopic technique for segmental resection of the rectosigmoid without intestinal exteriorization. Design 19 patients with indication for segmental resection of the rectosigmoid, due to infiltrative endometriosis, underwent this less invasive technique compared to classic techniques, which involves the externalization of the bowel through minilaparotomy or vaginally for intestinal resection and anvil placement. Setting The insertion of the endoscopic linear stapler and anvil, as well as the removal of the surgical specimen, were carried out through the vaginal route using intentional colpotomy or opportunely during the hysterectomy or resection of endometriosis infiltrating the posterior vaginal fornix. Patients or Participants Between June 2019 and January 2020, 19 patients underwent total laparoscopic rectosigmoidectomy to treat deep endometriosis. Interventions A 0˚ optic was introduced in a 10mm trocar and 3 auxiliary 5mm punctures were used in the inferior abdomen. Lesions located in the rectosigmoid were identified. The segment was prepared and isolated. A linear endoscopic stapler vaginally inserted was used to section the bowel. The proximal stump had its suture line opened with scissors and a purse-string suture was used to fix the anvil vaginally inserted into the abdominal cavity. A transanal circular stapler was used together with the anvil for anastomosis. Measurements and Main Results There were no intraoperative complications. At postoperative, there was no evidence of leakage, need for transfusion nor readmissions for a period of up to 60 days. Conclusion The total laparoscopic technique prevents traction and externalization of the intestinal loop through minilaparotomy or the vagina. There was a decrease in surgical time, less traction of the mesentery, preserving of vascularization and innervation, thus improving the quality of the anastomosis and protecting the nerves of the intestinal segment.

A Phase II Study on the Safety of Minimally Invasive Surgery Using Endoscopic Stapler to Prevent Tumor Spillage in Cervical Cancer

Study Objective The Laparoscopic Approach to Cervical Cancer (LACC) trial demonstrated that patients treated with minimally invasive surgery (MIS) techniques resulted in poorer outcomes than those treated with laparotomic techniques. In order to overturn the suggestion that MIS is inferior to laparotomic techniques, we designed and are now performing a phase II study on the safety of laparoscopic or robotic radical surgery using endoscopic stapler for inhibiting tumor spillage of cervical neoplasms (SOLUTION trial). Design A 42-year-old patient with cervical cancer clinical stage IB3 underwent robotic radical hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic sentinel lymphadenectomy with additional steps to improve surgical and morbidity outcomes. Setting In a Trendelenburg position, the patient is placed under general anesthesia. Patients or Participants This study is a prospective, multi-center phase II trial recruiting patients with early-stage cervical cancer. Interventions Key points of the operation are as follows: First, we perform tubal ligation and vaginal tube insertion, and then intracorporeal colpotomy using an endoscopic stapler to prevent tumor spillage into the peritoneal cavity. Second, we resected the stapled vaginal stump to retrieve the tumor specimen, and then close the vaginal stump again with continuous suture. Finally, we perform washing cytology three times: after trocar site insertion, intracorporeal colpotomy, and vaginal stump closure to check tumor spillage. Measurements and Main Results Ten patients so far have been enrolled in this study and all have received this surgery successfully without positive washing cytology, indicating no tumor spillage during the surgery. We plan to enroll a total of 120 patients within three years. Conclusion This is a feasible study design that can be performed with MIS, which is why it is valuable to prove its efficacy and safety through a phase II trial in order to overcome the limitations of MIS suggested in LACC trial. (SOLUTION ClinicalTrials.gov number, NCT04370496)

A multi-centre analysis of a decade of endoscopic pharyngeal pouch surgery in Cheshire and Merseyside.

There are sparse data on the outcomes of endoscopic stapling of pharyngeal pouches. The Mersey ENT Trainee Collaborative compared regional practice against published benchmarks. A 10-year retrospective analysis of endoscopic pharyngeal pouch surgery was conducted and practice was assessed against eight standards. Comparisons were made between results from the tertiary centre and other sites. A total of 225 procedures were performed (range of 1.2-9.2 cases per centre per year). All centres achieved 90 per cent resumption of oral intake within 2 days. All centres achieved less than 2-day hospital stays. Primary success (84 per cent (i.e. abandonment of endoscopic stapling in 16 per cent)), symptom resolution (83 per cent) and recurrence rates (13 per cent) failed to meet the standard across the non-tertiary centres. Endoscopic pharyngeal pouch stapling is a procedure with a low mortality and brief in-patient stay. There was significant variance in outcomes across the region. This raises the question of whether this service should become centralised and the preserve of either tertiary centres or sub-specialist practitioners.

Endoscopic stapling versus laser for Zenker diverticulum: a retrospective cohort study.

Despite the evolution of the endoscopic techniques for the treatment of symptomatic Zenker diverticulum, comparative studies are lacking. Aim of this observational study was to compare safety, efficacy, and outcomes of endoscopic stapling (ES) versus Laser (EL). A prospectively collected database of patients who underwent treatment for Zenker diverticulum at a single institution was reviewed. Consecutive patients treated by ES or EL were included in the study. Demographic data, presenting symptoms, diverticulum characteristics, and intra- and postoperative data were analyzed. The Functional Outcome Swallowing Scale (FOSS) and MD Anderson Dysphagia Inventory (MDADI) questionnaires were administered to assess severity of dysphagia and quality of life before and after treatment. Between March 2017 and September 2018, 36 patients underwent ES or EL. In the TL group (n = 19), the diverticulum size was smaller compared to the EL group (n = 17) (p = 0.002). Two perforations occurred in the EL group, one treated conservatively and the other requiring drainage of a mediastinal abscess. At a median follow-up of 16months, symptoms improved in both groups but the number of patients with a postoperative FOSS score ≥ 2 significantly decreased only after EL (p < 0.001). The scores of all items of the MDADI questionnaire significantly increased in both groups, but the average delta values were greater in the EL patients (p < 0.001). Both TL and ES are effective treatment options for Zenker diverticulum. Postoperative quality of life was significantly higher in patients undergoing EL compared to ES.

Safety and Efficacy of Using Staplers and Vessel Sealing Devices for Laparoscopic Splenectomy: A Randomized Controlled Trial.

Background. Laparoscopic splenectomy (LS) is considered the operation of choice on elective basis for managing patients with certain hematological disorders. Hemostatic control of the splenic pedicle is one of the crucial steps in LS. This study compares the safety and efficacy of using endoscopic staplers and vessel sealing devices to control the splenic pedicle in patients with nonsevere splenomegaly. Methods. Fifty-one consecutive patients with different blood disorders including idiopathic thrombocytopenic purpura (ITP), hypersplenism, and lymphoma were randomized for elective LS. Traditional steps of LS, via lateral approach, were followed, and pedicle control was done with either endovascular gastrointestinal anastomosis stapler (n = 26) or vessel sealing device (Ligasure) (n = 25). Results. No difference was noted with different splenic spans when using either methods of pedicle control (P = .145). The volume of blood loss was higher in the Ligasure group compared to the staplers group (182mL vs 131mL, respectively), but was not statistically significant (P = .249). Conversion to open was notably higher in the Ligasure group (P = .034), but the intraoperative complications were comparable in both groups (P = .357). Conclusion. The use of vessel sealing devices for splenic pedicle control has comparable surgical outcomes compared with the use of endoscopic staplers for LS, but with higher rate of conversion to open surgery.

Initial experience of single-incision plus one port left-side approach totally laparoscopic distal gastrectomy with uncut Roux-en-Y reconstruction.

BACKGROUNDSingle incision plus one port left-side approach (SILS+1/L) totally laparoscopic distal gastrectomy (TLDG) is an emerging technique for the treatment of gastric cancer. Reduced port laparoscopic gastrectomy has a number of potential advantages for patients compared with conventional laparoscopic gastrectomy: relieving postoperative pain, shortening hospital stay and offering a better cosmetic outcome. Nevertheless, there are no previous reports on the use of SILS+1/L TLDG with uncut Roux-en-Y (uncut R-Y) reconstruction.AIMTo investigate the initial feasibility of SILS+1/L TLDG with uncut Roux-en-Y digestive tract reconstruction (uncut R-Y reconstruction) to treat distal gastric cancer.METHODSA total of 21 patients who underwent SILS+1/L TLDG with uncut R-Y reconstruction for gastric cancer were enrolled. All patients were treated at The Second Hospital of Shandong University. Reconstructions were performed intracorporeally with 60 mm endoscopic linear stapler and 45 mm no-knife stapler. The clinicopathological characteristics, surgical details, postoperative short-term outcomes, postoperative follow-up upper gastrointestinal radiography findings and endoscopy results were analyzed retrospectively.RESULTSAll SILS+1/L operations were performed by SILS+1/L TLDG successfully. The patient population included 13 men and 8 women with a mean age of 48.2 years (ranged from 40 years to 70 years) and median body mass index of 22.8 kg/m2. There were no conversions to open laparotomy, and no other port was placed. The mean operation time was 146 min (ranged 130-180 min), and the estimated mean blood loss was 54 mL (ranged 20-110 mL). The mean duration to flatus and discharge was 2.3 (ranged 1-3.5) and 7.3 (ranged 6-9) d, respectively. The mean number of retrieved lymph nodes was 42 (ranged 30-47). Two patients experienced mild postoperative complications, including surgical site infection (wound at the navel incision) and mild postoperative pancreatic fistula (grade A). Follow-up upper gastrointestinal radiography and endoscopy were carried out at 3 mo postoperatively. No patients experienced moderate or severe food stasis, alkaline gastritis or bile reflux during the follow-up period. No recanalization of the biliopancreatic limb was found.CONCLUSIONSILS+1/L TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery.

Simultaneous Sigmoid Colectomy, Bilobar Liver Resection and Lung Metastasectomy via a Transdiaphragmatic Approach for Stage IV Colonic Adenocarcinoma

Current evidence supports the curative resection of colorectal cancer and synchronous liver and lung metastases in selected patients.1,2 This video shows simultaneous left colectomy, bilobar liver resection, and lung metastasectomy via a transdiaphragmatic approach for stage IV colorectal cancer.3 PATIENT: A 57-year-old man with a stage IV colonic adenocarcinoma was considered for simultaneous resection of primary, liver, and lung metastases without thoracic incision. The tumor mutational status was KRAS, NRAS, and BRAF wild-type, and the patient underwent preoperative chemotherapy. After performing a midline laparotomy, atypical liver resection of segments 8/4a was performed under the guidance of intraoperative ultrasonography and intermittent Pringle maneuver using the two-surgeon's technique. A small capsular lesion in segment 3 also was intraoperatively detected and resected. Lung metastasectomy of the right lower lobe was performed via a transdiaphragmatic approach using an endoscopic stapler. Sigmoid colectomy with transanal circular-stapled anastomosis was performed. Duration of surgery and blood loss were 358min and 400ml, respectively. Histopathological examination showed metastatic colonic adenocarcinoma with negative surgical margins and final stage was T3N2aM1b. The patient was discharged on postoperative day 6without complication. He was alive and free of disease at 90-day follow-up. Simultaneous colon, liver, and lung resection via a transdiaphragmatic approach is a feasible and safe surgical strategy in selected patients with peripheral lung metastases and favorable tumor biology.4 This surgical strategy avoids thoracic incision, multiple operations, and may reduce the healthcare costs and the recovery time to early implement postoperative therapy.

Effect of different pancreatic stump closure techniques after distal pancreatectomy on frequency and severity of acute postoperative pancreatitis

Objective: to study the effect of different pancreatic stump closure techniques and diameter of the main pancreatic duct on frequency and severity of acute postoperative pancreatitis after distal pancreatectomy. Material and Methods. Distal pancreatectomy was performed on 126 patients with neoplasms of body and/or tail of the pancreas. Patients were distributed among four groups based upon the pancreatic stump closure technique applied after distal pancreatectomy: group 1 (control) included the patients with isolated suturing of the main pancreatic duct in the pancreatic stump with its subsequent sealing by the gastrocolic omentum or hemostatic sponge; group 2 patients underwent isolated suturing of the main pancreatic duct in the pancreatic stump with its subsequent sealing with 2-octyl cyanoacrylate biological glue; group 3 patients had their pancreatic stump closure performed with endoscopic linear cutter stapler; group 4 was composed of the patients with external transduodenal transnasal drainage of enlarged (D&gt;3 mm) main pancreatic duct in the pancreatic stump. Results. The occurrence of acute postoperative pancreatitis in the control group amounted to 45.8%, while, in groups 2, 3 and 4, the frequencies were 44.4, 9.7 and 15.0(%), correspondingly. Besides, the control group was characterized by declined occurrence of the moderately severe form of acute postoperative pancreatitis. Use of endoscopic linear cutter stapler and external transduodenal transnasal drainage of the enlarged main pancreatic duct caused lower acute postoperative pancreatitis frequency in the patients with main pancreatic duct in their pancreatic stumps below 5 mm in diameter. Conclusion. Use of proposed pancreatic stump closure techniques after distal pancreatectomy resulted in lower frequencies of occurrence and severity of acute postoperative pancreatitis.

PMD13 A REAL-WORLD COST-MINIMIZATION ANALYSIS COMPARING THE USE OF DIFFERENT ENDOSCOPIC STAPLERS IN THORACOSCOPIC LOBECTOMY

Public hospitals in China are under increasing pressure to control healthcare expenditure growth. This has led to a tendency to procure consumable medical supplies based on acquisition price. However, procurement decisions should be based on an economic evaluation of the whole episode of care instead. This study aimed to investigate the overall impact of different endoscopic staplers on hospitalization costs of thoracoscopic lobectomy. This study used data from electronic medical records (EMR) of one of the largest research hospitals in Anhui Province. Patients who underwent VATS from 2016 to 2017 were selected. Based on types of stapler and cartridge used, patients were retrospectively grouped into two cohorts. Baseline characteristics of the two cohorts were evaluated to identify any significant differences. Hospitalization cost components were used as input for a cost-minimization analysis (CMA) model to calculate an episodic cost differential between the two cohorts. A probabilistic sensitivity analysis was performed to assess robustness of base case results. Base case analysis showed that lower overall episodic costs were achieved in the cohort with more expensive staplers. The mean episodic cost differential was more than $300. Sensitivity analysis indicated that the cohort with more expensive staplers had lower overall episodic costs in more than 85% of cases. This cost-minimization study has demonstrated that the economic impact of different medical supplies went beyond acquisition costs and extended to the overall hospitalization cost. This signifies that procurement decisions based solely on price may have unintended consequences. Hospital management would benefit from comprehensive value assessments when deciding on procurement strategies for consumable medical supplies.

Functional Outcomes of Delta-Shaped Anastomosis After Laparoscopic Distal Gastrectomy

BackgroundWe invented a simple and secure method of intracorporeal gastroduodenostomy, the delta-shaped anastomosis (DA), using endoscopic linear stapler only and standardized the DA procedure by resecting two-thirds of the stomach based on the anatomical landmarks. This study aimed to evaluate the feasibility of the standardized DA as the standard reconstruction procedure after a laparoscopic distal gastrectomy assessing functional outcomes including postoperative complications, body weight loss, nutritional status, and endoscopic findings. MethodsThe medical records of 349 patients with gastric cancer who underwent laparoscopic distal gastrectomy from April 2011 to December 2017 at our hospital were retrospectively reviewed. Functional outcomes were assessed according to nutritional status and endoscopic findings. ResultsThe operation time was shorter and complication rate was lower in the standardized DA than those in Billroth-II (BII) and Roux-en-Y (RY). The body weight loss in DA was 10% 1 year postoperatively and remained stable during the follow-up period, which showed no significant difference. The endoscopic findings showed the ratio of residual food in DA was lower than that in RY (DA:RY = 13.3%:13.6% and 8.4%:33.3% at 1 and 3 years postoperatively, respectively). Severe gastritis was extremely rare in DA (6.7% at 1 year and 15.6% at 3 years postoperatively). Bile reflux was more often found in DA than RY (DA:RY = 19.9%:4.8% and 26.6%:0% at 1 and 3 years postoperatively, respectively). Reflux esophagitis was found 10% of DA only. ConclusionsFunctional outcomes of the standardized DA were satisfactory and feasible. Our intracorporeal Billroth-I reconstruction, by resecting two-thirds of the stomach, can be one of the standard reconstruction methods after a laparoscopic distal gastrectomy.

The Impact of Endoscopic Stapler Selection on Bleeding at the Vascular Stump in Pulmonary Artery Transection.

ObjectiveTo assess bleeding following transection of the pulmonary artery with powered and manual endoscopic staplers.MethodsCases of video-assisted and open-chest thoracic surgical procedures for non-small cell lung cancer at Ishikawa Prefectural Central Hospital were reviewed between 2012 and 2018. Three stapler groups were assessed: Group 1 – Ethicon ECHELON FLEXTM Powered Vascular Stapler (PVS), Group 2 – Medtronic Endo-GIATM iDriveTM powered stapler, Group 3 – Ethicon and Medtronic manual staplers.ResultsOf 239 patients, 82 cases (34.3%) were Group 1, 94 cases (39.3%) were Group 2 and 63 cases (26.4%) were Group 3. Mean age was 68.3 years (range 36–88 years), and most patients received video-assisted right upper lobectomy (82.8%). Bleeding occurred in 24 cases: 17 (70.8%) in Group 2 and 7 (29.2%) cases in Group 3. No bleeding occurred in Group 1. The loaded ECHELON FLEXTM PVS and Endo-GIATM iDriveTM with gray cartridge combinations had the greatest and smallest closed anvil jaw gaps (>0.63 µm and <0.15 µm, respectively); Endo-GIATM iDriveTM gray cartridge combinations resulted in ruptures of inner and middle membranes of the pulmonary artery. No ruptures were observed using the ECHELON FLEXTM PVS.ConclusionAn excessively narrow gap between cartridge and anvil may damage the blood vessel wall and lead to bleeding following transection. This study provides preliminary evidence that the use of the ECHELON FLEXTM PVS and tan cartridges for pulmonary artery stapling may help to prevent tissue damage and intraoperative bleeding.

Reduced anastomotic complications with intracorporeal esophagojejunostomy using endoscopic linear staplers (overlap method) in laparoscopic total gastrectomy for gastric carcinoma.

With advances in surgical technique and instrumentation, intracorporeal anastomosis is increasingly being performed for laparoscopic total gastrectomy (LTG). However, the benefits of intracorporeal anastomosis in reducing postoperative complications have not been demonstrated, although its technical feasibility has been proven in many studies. In this study, we investigated the impact of intracorporeal anastomosis in reducing postoperative complications after LTG. We analyzed 410 consecutive gastric cancer patients who underwent LTG between 2008 and 2018. Of these, 118 underwent intracorporeal anastomosis using linear staplers (overlap method), while 292 underwent extracorporeal anastomosis using a circular stapler. Short-term surgical outcomes including postoperative complications were compared between the two groups. The two groups showed no significant differences in age, sex, comorbidity, and abdominal surgery history. D2 lymph node dissection was more frequently performed in the intracorporeal group because of the presence of more advanced cancer stages. The overall morbidity in the intracorporeal and extracorporeal group was 23.7% and 27.7%, respectively (p = 0.405). However, the intracorporeal group showed a significantly lower incidence of late complications (0.8% vs. 7.5%, p = 0.008). Concerning complications, the incidence of anastomotic bleeding (0% vs. 5.5%, p = 0.008) and anastomotic stenosis (0% vs. 4.5%, p = 0.024) was significantly lower in the intracorporeal group. In univariate and multivariate analyses, American Society of Anesthesiologists score and operative bleeding were independent predictive factors for postoperative complications in patients who underwent intracorporeal anastomosis. Intracorporeal anastomosis using linear staplers reduced anastomotic bleeding and stenosis compared to extracorporeal anastomosis after LTG. Future research will be required to determine the ideal method for intracorporeal anastomosis in LTG.

Transoral Stapling Technique for Zenker's Diverticulum

Zenker's diverticulum (ZD) is a rare disorder that has a reported annual incidence of about 2 cases per 100,000. It is a pulsion (false) diverticulum that develops in an area of natural anatomic weakness called Killian's triangle. This is located between the inferior pharyngeal constrictor and the cricopharyngeus muscles. The exact etiology and pathophysiology of ZD is not known. Cricopharyngeal discoordination, spasm, or hypertension have all been implicated as underlying mechanisms leading to herniation of the hypopharyngeal mucosa and submucosa and consequently the formation of a ZD. Gastroesophageal reflux has also been implicated as a potential underlying mechanism in the development of ZD. Patients typically will present with symptoms of oropharyngeal dysphagia, food regurgitation, and in severe cases aspiration pneumonia. Cricopharyngeal myotomy is the mainstay of surgical treatment of symptomatic ZD. The traditional surgical approach to ZD includes an open cervical cricopharyngeal myotomy. However, starting with Collard's initial report of endoscopic stapling in 1993, the endoscopic approach to ZD treatment has been popularized. Since then, increasing reports have described utilizing a variety of endoscopic techniques for management of ZD. Herein we present our current preferred endoscopic approach to treatment of ZD.

Clinical Outcomes And Cost-Effectiveness Of Different Staplers For Lung Lobectomy With Video-Assisted Thoracic Surgery.

PurposeThe aim of this study was to compare intra-operative adverse events (AE), post-operative outcomes, and costs of three different types of Echelon staplers (manual activated SC45A and electrical power-activated PSE45A & PSEE60A) used during video-assisted thoracic surgery (VATS) for lung lobectomy.Patients and methodsWe carried out a retrospective chart review of patients undergoing VATS lobectomies using one of three staplers (SC45A, PSE45A, or PSEE60A) during a 2-year period at our institution. We compared intra-operative AEs, post-operative outcomes (drainage volume, chest tube duration, prolonged air leaks [PALs]), endoscopic product costs [ECs], and hospitalization costs [HCs]) amongst the three stapler groups.ResultsIn all 204 peripheral lung cancer patients were included in the study (95 in the SC45A group, 72 in the PSE45A group, and 37 in the PSEE60A group). We observed intra-operative AEs in 6 patients of the SC45A group, in 4 of the PSE45A group, and in 1 of the PSEE60A group (P>0.05). Drainage volumes among the three groups were similar. The mean chest tube duration was shorter]st in the PSE45A group followed by those in the PSEE60A and SC45A groups (P<0.05). PALs were lowest in the PSE45A group and highest in the SC45A group (P<0.05). The mean EC in the PSEE60A group was significantly higher than those in the other two groups (P<0.05). We found no statistically significant differences in terms of HCs among groups.ConclusionThe three endoscopic staplers had similar incidences of intra-operative AEs when used for lobectomy with VATS. Use of the PSE45A stapler was associated with the shortest chest tube duration and least PALs, while use of the PSEE60A resulted in the highest EC rate.

Hybrid Laparoscopic and Endoscopic Partial Gastrectomy for Ulcerated GIST: Surgical Technique with Video.

Gastrointestinal stromal tumors of the gastric cardia pose several technical difficulties to their resection because they are difficult to access, and they must be removed respecting oncological principles, and due to their proximity to the gastroesophageal junction, excessive removal of gastric tissue may cause deformation with gastric dysfunction, or gastroesophageal reflux. Hybrid laparoscopic endoscopic partial gastrectomy is a technique that avoids these problems making use of three principles. First the tumor is pinpointed, marked, and resected under combined laparoscopic and endoscopic control to assure that it is completely resected without compromising the structure of the gastroesophageal junction. Second, a dissection of the abdominal esophagus is performed as during a Nissen fundoplication in order to increase the distance between the tumor and the gastroesophageal junction. Third the lesser curvature of the stomach is dissected, and the terminal branches of the left gastric vessels are controlled from the gastric incisura to the gastroesophageal junction exposing the lesser curvature and the posterior wall of the stomach. The tumor is resected under endoscopic control, tangentially with an endoscopic stapler applied parallel to the lesser curvature similarly to a sleeve partial gastrectomy. No abdominal drain is used, and a nasogastric tube is left in place for the first 24h after surgery. The patient receives fluid diet on the first postoperative day, is discharged on the second postoperative day, and is followed up in the outpatient department for a week. In this technical paper, the procedure is described in detail and demonstrated with video.

Video-assisted thoracoscopic treatment of pneumothorax

In the last three decades, minimally invasive techniques have progressively gained acceptance, as shown by the numerous studies published in the literature. Before the 1990s, video-assisted thoracoscopic surgery (VATS) was considered feasible almost exclusively for the diagnosis of pleural diseases. The availability of better instruments and endoscopic stapling devices allowed thoracoscopy to evolve into a new “therapeutic era”. Nowadays, VATS is considered the approach of choice for the treatment of pneumothorax and other lung, mediastinal and esophageal diseases, replacing traditional approaches as thoracotomy and sternotomy. The use of ports through small incisions (one to three-four) for the camera and surgical instruments allows the surgeon to explore the pleural cavity and work easily on the lung parenchyma. This approach translates into less discomfort for the patient, reduced morbidity, shorten hospital stay and faster functional recovery. The optimal treatment of pneumothorax certainly refers thoracoscopy as the approach of choice maintaining the same indications as for open surgery.

Clinical and economic benefits associated with the use of powered and tissue-specific endoscopic staplers among the patients undergoing thoracoscopic lobectomy for lung cancer

Background: Thoracoscopic lobectomy for lung cancer is a complex procedure where endoscopic staplers play a critical role in transecting the lung parenchyme, vasculature, and bronchus. This retrospective study was performed to investigate the economic benefits of powered and tissue-specific endoscopic staplers such as gripping surface technology (GST) and powered vascular stapler (PVS) compared to standard staplers.Methods: Two hundred and seventy-five patients who received a thoracoscopic lobectomy between 2008 and 2016 were included. Group 1 (n = 117) consisted of patients who received the operation with manual endoscopic staplers, whereas Group 2 (n = 158) consisted of patients who received the operation with GST and PVS.Results: Patient demographics and clinical characteristics were comparable, except smoking history, pulmonary function, and pleural adhesion. All patients received the operation successfully without mortalities and broncho-pleural fistula. Operation time and blood loss were higher in Group 1. Pleurodesis was performed less in Group 2 than in Group 1 (18.0% vs 3.8%, p < 0.0001). Group 2 had statistically significant lower adjusted hospital costs (Korean Won, 14,610,162 ± 4,386,628 vs 12,876,111 ± 5,010,878, p < 0.0001), lower adjusted hemostasis related costs (198,996 ± 110,253 vs 175,291 ± 191,003, p = 0.0101); lower cartridge related adjusted costs (1,105,091 ± 489,838 vs 839,011 ± 307,894, p < 0.0001) compared to Group 1. As well, Group 2 showed ∼12% lower adjusted total hospital costs compared to Group 1. Multivariable analysis revealed that Group 1 was related to increased hospital costs.Conclusions: This study showed that thoracoscopic lobectomy with powered and tissue-specific endoscopic staplers were associated with better clinical outcomes and reduced adjusted hospital costs when compared in Korean real-world settings.

Step by Step Total Laparoscopic Hysterectomy with Uterine Arteries Ligation at the Origin

Study ObjectiveTo reveal principles and the feasibility of a total laparoscopic hysterectomy (TLH) with uterine artery ligation at the origin. DesignStep-by-step demonstration and explanation of technique using videos from patients. SettingGynecologic oncology unit at a university hospital. PatientA 54-year-old woman with uterine fibromatosis and metrorrhagia. InterventionTLH has 7 common components. First, round ligaments are coagulated and cut to enter the retroperitoneum. The ureter is identified. Second, pararectal spaces are entered between the ureter and the internal iliac artery. This maneuver allows the identification of the uterine artery as it leaves its origin from the internal iliac artery. The uterine vessels are stapled with a vascular endoscopic stapler at their origin from the hypogastric vessels or sealed with a bipolar device. Third, adnexal structures are separated from the uterine corpus for subsequent preservation or removal. Fourth, the blood supply is dissected, occluded, and divided before extirpation of the uterine corpus. Fifth, the cardinal ligament complex is transected with colpotomy, and the cervix is amputated from the vaginal apex. Sixth, the specimen is removed. Finally, the vaginal cuff is closed [1]. Measurements and Main ResultsLaparoscopic hysterectomy was first described by Reich et al. [2] in 1989 and has slowly gained popularity. Today, hysterectomy is the most common gynecologic procedure performed. TLH is where the entire operation (including suturing of the vaginal vault) is performed laparoscopically and there is no vaginal component except for the removal of the uterus. Currently, hysterectomies are performed by different approaches, and individual surgeons have different indications for the approach to hysterectomy based largely on their own array and patient characteristics. TLH requires the highest degree of laparoscopic surgical skills [3], and knowledge of pelvic anatomy defines a safe space for sharp entry into the retroperitoneum and safe identification of pelvic vasculature. ConclusionWe present an educational video with step-by-step explanation of the technique to highlight the anatomic landmarks that guides the procedure.