Linear Stapling Device Research Articles

Laparoscopic Technique and Initial Experience with Knotless, Unidirectional Barbed Suture Closure for Staple-Conserving, Delta-Shaped Gastroduodenostomy after Distal Gastrectomy

a a c h Since laparoscopy-assisted distal gastrectomy was first reported by Kitano and colleagues in 1994, laparoscopic gastrectomy (LG) for early gastric cancer (EGC) has been increasing rapidly and gaining popularity worldwide because it is associated with earlier patient recovery compared with open surgery. Improvements in instruments and aparoscopic technique have allowed for widespread accepance of LG, not only for various types of gastric resection ut also for totally laparoscopic procedures. In general, LG can be divided into laparoscopy-assisted and totally laparoscopic techniques. With laparoscopyassisted gastrectomy, although lymph node dissection is performed laparoscopically, transection of the stomach and the anastomosis are performed thorough an epigastric minilaparotomy. Performing the anastomosis in the narrow and restricted space is frequently difficult, especially for obese patients with thick abdominal walls or for patients with a small remnant stomach. Avoiding minilaparotomy also improves cosmesis, and performing all of the processes laparoscopically, including reconstruction of the digestive tract intracorporeally using laparoscopic linear stapling devices, offers the prospect of further improvements in quality of life. Recent results of retrospective studies have demonstrated the feasibility, safety, and efficiency of totally laparoscopic gastrectomy (TLG) when performed by high-volume laparoscopic surgeons, even with a relatively prolonged operating time. However, TLG as the disadvantages of technical difficulties in intracor-

Unilateral and Bilateral Laparoscopic Ovariectomy in 157 Mares: A Retrospective Multicenter Study

To evaluate surgical techniques, perioperative complications and outcome of laparoscopic surgery for unilateral and bilateral ovariectomy in mares. Retrospective multicenter case series. Mares (n = 157). Indications for surgery were neutering, fertility problems, elimination of hormone-related abnormal behavior, ovarian tumors as well as nonregressive ovarian hematomas or cysts. Ovariectomy (n = 206) were performed by a standard laparoscopic procedure in 157 standing sedated mares. Dissection and hemostasis were achieved by using either (1) a linear stapling device, (2) bipolar electrosurgical instruments, with or without a modified Roeder knot, (3) a vessel-sealing system, or (4) a diode-laser with ligation. For some larger ovarian masses (>20 cm diameter), a 2-step surgical procedure was used with standing flank laparoscopic ovariectomy followed by ovarian retrieval through a median celiotomy. Surgical techniques, outcome, and perioperative complications of each method were recorded and analyzed. Laparoscopic dissection of the ovary was accomplished in all mares. Because of the size of the ovarian tumor (n = 7) or in 1 mare with behavioral problems (n = 1), the dissected ovary was removed through a median celiotomy under general anesthesia. Seventeen mares (10.8%) developed postoperative complications (eg, incisional drainage, incisional infection, seroma formation, dehiscence, transient fever and mild abdominal discomfort). All mares with flank incisional problems had ovarian size >12 cm and in 15 (88%) of these mares electrosurgical instruments were used for mesovarial dissection. Laparoscopic ovariectomy in standing sedated mares provides good surgical access and is associated with low morbidity.

Endoscopy-assisted anastomosis: a modified technique for laparoscopic side-to-side esophagojejunostomy following a total gastrectomy

Esophagojejunostomy with a circular stapling device is sometimes difficult to perform in a laparoscopic setting. On the other hand, a side-to-side anastomosis with a linear stapling device is technically challenging. Between June 2002 and March 2008, 10 consecutive patients underwent a laparoscopy-assisted total gastrectomy using a side-to-side anastomosis technique. Of these patients, four underwent a laparoscopy-assisted total gastrectomy with a modified anastomosis technique. A small wound was created on the antimesenteric side of the jejunum 5 cm distal to the resected portion and then in the lower esophagus. A peroral endoscope was advanced to the hole, and the cartridge fork was introduced into the lower esophagus under endoscopic guidance. The device (45 mm, blue) was fired to create an antiperistaltic side-to-side anastomosis. The common entry hole was closed by transecting the jejunum and the esophagus with another linear stapler and by using an endoscope as a stent. Four patients underwent the modified procedure and did not require an open procedure. One patient developed a pancreatic fistula, which was treated conservatively. The average operative time, reconstruction time and blood loss were 483 ± 133 minutes, 139 ± 31 minutes, and 199 ± 121 mL, respectively. An introduction of the stapler into the lower esophagus and a closure of the common entry hole were performed safely without any stress. Although several techniques must be compared to determine the ideal procedure for laparoscopic esophagojejunostomy, the modified side-to-side anastomosis technique may be useful in clinical settings.

The importance of precompression time for secure stapling with a linear stapler

One prerequisite for the safe stapling of anastomoses is the formation of perfectly aligned B-shaped staples. Using an animal model, this study investigated whether precompression enhances secure staple formation. A 45-mm linear stapler with a blue cartridge (staple leg length, 3.5 mm) was used on three portions each of six porcine stomachs (cardia, center, and pylorus). Staple shape and height were examined according to the precompression time (0, 1, or 5 min) before firing. The shape was classified as optimal or suboptimal, and the heights of the staples were measured individually. The completeness of the proximal staple lines also was compared with the distal lines. The optimal staple rate in the 5-min group (52.7%) was significantly higher than in the 1-min group (28.7%; p<0.001) or the 0-min group (17.1%; p=0.002). The optimal staple rate in the 5-min group for the cardiac portion (mean wall thickness, 2.7 mm) reached 98.9%. However, this rate was less than 50% in the center (5.3 mm) and pylorus (4.2 mm) portions regardless of the precompression time. Compared with the root side, the top side of the cartridge had a lower optimal rate (45.3 vs. 18.7%; p<0.001). A high correlation of completeness was observed between the distal and proximal sides of the stump. When a linear stapling device is used, proper staple formation is correlated with intestinal wall thickness, and a sufficient amount of precompression time is effective for gaining the secure staple formation.

A New Method for Intraluminal Gastrointestinal Stromal Tumor Resection Using Laparoscopic Seromuscular Dissection Technique

Introduction: It is difficult to confirm the location of an intraluminal gastrointestinal stromal tumor (GIST) and to laparoscopically determine the appropriate resection line. We report a new technique for the resection of GISTs using the laparoscopic seromuscular dissection (LSD) technique, which can be preformed regardless of the tumor location. Methods: Since 2009, 5 patients have undergone LSD technique for the resection of an intraluminal GIST. The tumor location was confirmed endoscopically, and the exact resection line was marked laparoscopically. After 10% glycerin was injected into the submucosal layer, LSD was performed circumferentially. The tumor was exteriorized into the abdominal cavity and dissected using a linear stapling device. Results: The average operation time for this procedure was 134.4 ± 18.6 min, and the mean estimated blood loss was 10 ± 8.9 ml. None of the 5 cases required open surgery. There was no tumor rupture or disruption or any other perioperative complications using this technique. Conclusion: We conclude that the LSD technique may be a safe and minimally invasive method for the resection of intraluminal GISTs, regardless of the tumor location.

Standing Hand‐Assisted Laparoscopic Ovariectomy in 65 Mares

To review the efficacy and safety of unilateral ovariectomy by use of a standing hand-assisted laparoscopic approach and evaluate the effect of ovary size on posttransection hemorrhage after application of a linear stapling device. Case series. Horses (n=65) aged 2-20 years. Medical records of mares that had ovariectomy performed by use of a standing hand-assisted laparoscopic approach were reviewed. Data retrieved were signalment, ovary removed (left, right), ovarian size, ovarian pathology, intraoperative and postoperative complications, and length of hospitalization. Mean ovarian diameter was 17 cm. Histopathology (52 mares) confirmed 41 granulosa cell tumors (79%), 8 ovarian cysts (15%), 1 teratoma (2%), and 2 ovaries (4%) without abnormalities. Hemorrhage was observed laparoscopically in 16 mares after transection of the mesovarium. Complications encountered during surgery included 1 mare collapsing in the stocks and 1 mare that hemorrhaged excessively from the incision. Postoperative complications included 2 cases of mild colic. Overall complication rate was 6%. All attempts to remove the target ovary were successful. The approach is safe for the mare, as complications encountered were similar to those recently reported for other approaches.

Three Cases of Synchronous Laparoscopic Resection for Gastric and Colonic Cancer

Case 1 was an 84-year-old female who suffered from a superficial elevated lesion within depressed area (0 IIc+IIa) from the lesser curvature to the posterior wall at the middle corpus of the stomach and a depressed lesion with a circumferential embankment (type 2) at the sigmoid colon. Case 2 was a 70-year-old male who suffered from a superficial depressed lesion (0 IIc) at the lesser curvature of the gastric angle and a superficial elevated lesion (0 IIa) at the cecum. Case 3 was a 58-year-old male who suffered from a superficial depressed lesion (0 IIc) from the lesser curvature to the posterior wall at the middle corpus of the stomach, and an elevated lesion (type 1) and a depressed lesion with a circumferential embankment (type 2) at the sigmoid colon. In 3 cases, we first inserted 5 or 6 trocars and performed laparoscopic distal gastrectomy with groups 1 and 2 lymph node dissection according to the Japanese Classification of Gastric Carcinoma. Subsequently, in case 1, 1 additional port was inserted at the right lower quadrant for sigmoidectomy; in case 2, two trocars were added for ileocecal resection; and in case 3, one additional port was inserted at the median hypogastric region for sigmoidectomy. In cases 1 and 2, Billroth II reconstruction was performed using a laparoscopic linear stapling device (endo-GIA) and, in case 3, Roux-en-Y reconstruction was performed using endo-GIA, after distal gastrectomy. The double stapling technique using a conventional circular stapling device was performed after pulling out the specimen from the paraumbilical port after colectomy in case 1, whereas an end-to-end triangular suture using endo-GIA was used extracorporeally through the paraumbilical port in case 2 and the median hypogastric port in case 3. The operative durations of cases 1, 2, and 3 were 315, 340, and 495 minutes and the amounts of blood loss were 80, 300, and 440 mL, respectively. Except for the need to retain the drain until the tenth postoperative day because of serous discharge in case 1, no postoperative complications occurred. The postoperative commencement of oral feeding was on the fifth day in case 1 and on the third day in cases 2 and 3. All cases made a quick recovery and they were discharged from hospital on the nineteenth, thirteenth, and tenth day after operation, respectively. Double cancer patients with gastric and colonic carcinomas were thought to be very suitable for laparoscopic surgery because by avoiding a total median skin incision, there is less wound pain and quicker postoperation recovery.

Transgastric small bowel resection by using hybrid technique — Experimental study

Abstract Introduction:The Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an abdominal operation carried out with flexible endoscopic instruments and their advanced versions via natural orifices. The NOTES causes theoretically less pain, operative stress, shorter hospitalization, quicker recovery and it is scarless. The aim of this investigation was to evaluate the feasibility and safety of transgastric small bowel resection. Materials and methods: Seven domestic pigs were investigated and entered the study; body weight 25 kg in average. General anesthesia was performed. One trocar was used for laparoscopic observations during gastrotomy and transgastric penetration with the gastroscope, later for assistance with a grasper for manipulation of the bowel loops and for the application of the linear stapling device. Then the needle knife was used to complete a 1.5 cm long incision in the gastric wall. The gastroscope was advanced into the peritoneal cavity and a small bowel loop was identified and elevated with a flexible grasper. Through the second channel of the scope a coag grasper was used to dissect the mesentery. Then a linear stapler was inserted through the assisting trocar and the resection was performed. Afterwards the bowel ends were opened with the needle knife and the stapler was reinserted for a side-to-side anastomosis. The specimen was removed via the stomach. Gastric closure was completed by laparoscopic mini-instruments through the stapler-port. All special events and all problems were prospectively documented. Follow-up was performed over 2 weeks and body weight was recorded. Then a laparoscopy was performed to document adhesions or abscess formation. Finally the animals were sacrificed to evaluate further evidence of infection or adhesions. Results: The operations were carried without complications, there was no case of letal outcome. On the 12th day the abdominal laparoscopic revision was carried out, after the revision in one case adhesion could be detected, no other kinds of complications were noticed. Conclusion: According to our results, the transgastric small bowel resection is a safe procedure, but further special instruments are needed. These experimental procedures should be evaluated carefully and critically in clinical practice.

LAPAROSCOPIC APPENDECTOMY AS A CARE MODEL OF "FAST TRACK SURGERY"

Fast track is a model of care pathway that is gradually replacing and incorporating all the other models so far applied in surgery. In particular, this is possible thanks to minimally invasive procedures widely disseminated for the several benefits they offer. The authors present a preliminary study of laparoscopic appendectomy using endo-GIA as a model of fast track surgery. At the Department of Pediatric Surgery of the University of Siena, from December 2008 to May 2009 were carried out 10 surgery procedures of laparoscopic appendectomy. Patients were subjected to emergency surgery for acute appendicitis diagnosed by clinical examination, laboratory tests and ultrasound study. The mean age was 10.8 years (range 7-14 years). All procedures were performed under general anesthesia with the patient in supine decubitus and using three trocars. The first 12 mm, was introduced through the umbilical incision with open approach, the second, 12 mm in the left iliac fossa and the third, 5 mm, in sovrapubic seat. In each patient the appendectomy was carried out with endo-GIA (a linear stapling device) that can be used for the section of appendix and vessels. Results: Any patient needed to convert to “open surgery”. The duration of surgery procedure was in mean 80 minutes (range 60-90 minutes). In any case intraoperative complications were observed. In 1 patient (10%) further surgery procedure with technique open was necessary due to presence of purulent exudate in peritoneal cavity, depending to severity of endo-abdominal infection. The hospitalization was in mean 4.3 days (range 3-10 days) with intestinal canalization on the 1st post-operative day. Laparoscopic appendectomy is a feasible and safe method with advantages for patients such as lower incidence of septic complications (better toilet of peritoneal cavity and possible placement of drainage), reduced time of hospitalization and convalescence, better control of postoperative pain, and better aesthetic results. Binder/section of appendix with endo-GIA appears more secure in severe peritonitis compared to other systems of ligation, preventing the spread of faecal material, as the apyretic trend in postoperative shows. In conclusion, beyond the known advantages of VLS, the use of Stapler allows further decrease of hospitalization that amortizes the modest increase in cost of instruments and the comfort for the surgeon

LAPAROSCOPIC APPENDECTOMY AS A CARE MODEL OF "FAST TRACK SURGERY"

"Fast track surgery" is a model of care pathway that is gradually replacing and incorporating all the other models so far applied in surgery. In particular, this is possible thanks to minimally invasive procedures widely disseminated for the several benefits they offer. The authors present a preliminary study of laparoscopic appendectomy using endo-GIA as a model of fast track surgery. At the Department of Pediatric Surgery of the University of Siena, from December 2008 to May 2009 were carried out 10 surgery procedures of laparoscopic appendectomy. Patients were subjected to emergency surgery for acute appendicitis diagnosed by clinical examination, laboratory tests and ultrasound study. The mean age was 10.8 years (range 7-14 years). All procedures were performed under general anesthesia with the patient in supine decubitus and using three trocars. The first 12 mm, was introduced through the umbilical incision with "open" approach, the second, 12 mm in the left iliac fossa and the third, 5 mm, in sovrapubic seat. In each patient the appendectomy was carried out with endo-GIA (a linear stapling device) that can be used for the section of appendix and vessels. Results: Any patient needed to convert to &ldquo;open surgery&rdquo;. The duration of surgery procedure was in mean 80 minutes (range 60-90 minutes). In any case intraoperative complications were observed. In 1 patient (10%) further surgery procedure with technique "open" was necessary due to presence of purulent exudate in peritoneal cavity, depending to severity of endo-abdominal infection. The hospitalization was in mean 4.3 days (range 3-10 days) with intestinal canalization on the 1st post-operative day. Laparoscopic appendectomy is a feasible and safe method with advantages for patients such as lower incidence of septic complications (better toilet of peritoneal cavity and possible placement of drainage), reduced time of hospitalization and convalescence, better control of postoperative pain, and better aesthetic results. Binder/section of appendix with endo-GIA appears more secure in severe peritonitis compared to other systems of ligation, preventing the spread of faecal material, as the apyretic trend in postoperative shows. In conclusion, beyond the known advantages of VLS, the use of Stapler allows further decrease of hospitalization that amortizes the modest increase in cost of instruments and the comfort for the surgeon

Increased Incidence of Pancreatic Fistulas after the Introduction of a Bioabsorbable Staple Line Reinforcement in Distal Pancreatic Resections

Pancreatic fistula is a major cause of morbidity after distal pancreatic resection. When resections are performed with linear stapling devices, the use of bioabsorbable staple line reinforcement has been suggested to decrease the rate of pancreatic fistula. Our objective was to investigate the incidence of pancreatic fistula when using the Gore Seamguard staple line reinforcement in stapled distal pancreatic resections. A retrospective review of 30 consecutive patients with stapled distal pancreatectomy was conducted. A broad definition of pancreatic fistula was used. Clinicopathologic factors and outcomes were compared between groups. Pancreatic fistula was diagnosed in 11 of 15 patients (73%) and three of 15 patients (20%) in the Seamguard and non-Seamguard groups, respectively (P = 0.002). Pancreatic parenchymal transection at the neck of the gland was associated with pancreatic fistula, whereas laparoscopic procedures, splenic preservation, or additional organ resection were not. On multivariate analysis, the association between Seamguard use and pancreatic fistula was significant (P = 0.005). In conclusion, after introduction of the Gore Seamguard bioabsorbable staple line reinforcement, we experienced a significant increase in the rate of pancreatic fistula. This experience raises concern about the efficacy of this device in limiting pancreatic fistula after stapled distal pancreatic resection.

Laparoscopic Sleeve Gastrectomy: An Indian Experience—Surgical Technique and Early Results

Obesity has been observed to be on the rise in the Indian subcontinent. We report our early experience with the laparoscopic sleeve gastrectomy (LSG) for treating morbid obesity in the Indian population along with description of the surgical technique. The data of 75 patients who underwent LSG for the treatment of morbid obesity at the Minimal Access, Metabolic and Bariatric Surgery Centre, Sir Ganga Ram Hospital, Delhi, from November 2006 to February 2009, were retrospectively reviewed from prospective database. The gastric sleeve is created laparoscopically using sequential firings of a linear stapling device applied alongside a 36-Fr calibrating bougie. The data collected included age, gender, initial body mass index (BMI) and excess weight, the co-morbidity status, and preoperative investigations. Perioperative parameters and follow-up details [weight, BMI, excess weight loss (%EWL), resolution of co-morbidities, and postoperative investigations] were noted. All procedures were completed laparoscopically. There was no major procedure-related morbidity. Hemorrhage requiring blood transfusion was observed in four patients. One patient died at 2weeks postoperatively due to pulmonary embolism. There was a steady rise in %EWL from 31.2% at 3months to 52.3% at 6months, 59.13% at 1year, and 65% at 2years. Type II diabetes was resolved in 81.2%, hypertension in 93.75%, and dyslipidemia in 85% at 1year. Although long-term results are necessary to determine the benefits of the procedure, early results indicate that LSG may be a safe and feasible option for treating the morbidly obese patients.

Use of Endo-GIA Versus Endo-loop for Securing the Appendicular Stump in Laparoscopic Appendicectomy

To systematically analyze the trials on laparoscopic appendicectomy (LA) that has evaluated the effectiveness of endo-loop and/or endo-GIA (a linear stapling device) to secure the stump of the appendix. Clinical trials on LA were selected from the electronic database and analyzed to generate summative data. Five randomized trials on 622 patients were analyzed. In both fixed and random effect models, operative time for endo-loop group was longer than endo-GIA group. There was no difference in total hospital stay and in the incidence of intra-abdominal abscess formation between 2 groups. In the fixed effect model, endo-loop technique was associated with higher complication rate. Use of endo-loop to secure the appendicular stump during LA though takes longer than the use of endo-GIA but it is associated with equal hospital stay, perioperative complication rate, and incidence of intra-abdominal abscess. Endo-loop may be used safely and preferably to secure the appendicular stump.

Successful Thoracoscopic Resection of Pulmonary Metastasis Less Than 1 cm in Size Utilizing Preoperative CT-Guided Wire Localization

Preoperative computer tomography (CT) guidance localization utilizing a percutaneous guidewire before thoracoscopic resection is safe and beneficial in children with pulmonary nodules less than 1 cm in size or located deep in the pleural surface. This paper describes a successful thoracoscopic resection of a little subpleural pulmonary metastasis of a Wilm's tumor in a 5-year-old child utilizing preoperative CT-guided wire localization of the lesion. The thoracoscopic procedure was performed with the use of two ports, the nodule was easily localized,and the pulmonary wedge resection was made by the use of an endo-GIA linear stapling device after guidewire removal. The operating time was 45 minutes and the chest tube was removed after 48 hours. The postoperative course was uneventful, and the child was discharged on postoperative day 5. This technique allows the surgeon to resect little pulmonary nodules, avoiding the need of more invasive procedures as standard thoracotomy without adjunctive morbidity and with good cosmetic results.

Stapled closed technique for laryngectomy and pharyngeal repair

Total laryngectomy is a recognised treatment for advanced laryngeal carcinoma. Traditionally, pharyngeal repair is performed with layered sutures. We describe our experience with a technique of closed pharyngoplasty using a linear stapler device. Ten total laryngectomies were performed from July 2002 to July 2004, using an Ethicon TLC 75 linear stapler for pharyngeal closure. Data collected included age, sex, staging, endoscopic assessment, surgical margins and post-operative course (including complications and swallowing). Patients comprised eight men and two women. The mean age was 55.4 years. Six patients had stage T4 endolaryngeal carcinoma and four had stage T3. Four patients underwent pre-operative radiotherapy. Clear surgical margins were achieved in all patients. One patient developed a pharyngocutaneous fistula. Patients resumed oral intake at 48 hours, or at 72 hours if they had undergone pre-operative radiotherapy. Patients' mean hospital stay was seven days. This stapled closed technique for pharyngoplasty is efficient and eliminates the risk of wound contamination, thus theoretically reducing the risk of tumour seeding. In addition, we were able to commence patients on oral fluids at a mean of 48 hours after surgery. The mean hospital stay was seven days. We recommend this technique as an alternative for repairing the pharynx in patients undergoing total laryngectomy for endolaryngeal carcinoma.

Transvaginal endoscopic partial gastrectomy in porcine models: the role of an extra endoscope for gastric control

Transvaginal natural orifice translumenal endoscopic surgery (NOTES) gastrectomy is technically challenging, because wide perigastric dissection under appropriate tissue triangulation is unfeasible with current endoscopic instruments alone. The aim of this study was to investigate the feasibility of transvaginal NOTES gastrectomy with the use of an extra endoscope as a retracting device of the stomach. This acute in vivo feasibility study was performed under the approval of the Institutional Animal Care and Use Committee (IACUC). Four female 40-kg pigs received general anesthesia and underwent transvaginal endoscopic partial gastrectomy. Under laparoscopic guidance, the uterus was fixed anteriorly and transvaginal access was established in a standard fashion. The perigastric ligaments were dissected with needle knife/insulation-tipped electrosurgical knife (IT) via transvaginally placed double-channel endoscope. This step was assisted with the second, CO(2)-insufflating endoscope advanced in the stomach (i.e., so-called endoscopic gastric control). A linear stapling device with a flexible shaft was then passed transvaginally, and the anterior gastric wall was partially resected. The specimen was isolated and retrieved through the vagina. Concluding endoscopy was carried out to confirm the absence of mucosal damage due to endoscopic gastric control. This was further confirmed at necropsy immediately after sacrifice. All animals underwent successful transvaginal NOTES gastrectomy. Endoscopic gastric control greatly facilitated perigastric dissection by providing appropriate tissue countertraction on the ligaments. Use of transabdominal (laparoscopic) graspers was thus minimized. There were no intraoperative complications directly related to use of the primary (transvaginal) endoscope or the additional (gastric) endoscope. Distention of downstream bowel after gastric insufflation was minimal with CO(2). No major injuries were noted on gastric mucosa at postmortem investigations. Transvaginal NOTES partial gastrectomy is feasible in porcine models. Use of an extra endoscope to retract the stomach is effective to minimize transabdominal assistance. Further studies on human subjects are necessary to establish this as a safe and attractive ancillary technique in NOTES.

Prevention of Postoperative Pancreatic Fistula After Total Gastrectomy

Pancreatic fistula (PF) is still one of the serious complications after total gastrectomy (TG). The purpose of this study was to identify risk factors for PF after TG and to evaluate our attempts to prevent PF. From August 1992 to July 2006, 740 consecutive patients with gastric neoplasm underwent TG at the National Cancer Center Hospital East. Univariate and multivariate analyses of potential risk factors for the development of PF and the effectiveness of operative procedures to prevent PF were performed. Postoperative PF was identified in 130 patients (18%). On multivariate analysis, body mass index (P < 0.001) and the operative procedure (TG with pancreaticosplenectomy) (P = 0.001) were independent risk factors. In TG with splenectomy (pancreas-preserving method), total preservation of the splenic artery was significantly correlated with a lower incidence of PF (P < 0.001). In TG with pancreaticosplenectomy, the use of a linear stapling device was an effective surgical technique for closure of the cut end of the pancreas, but there was no significant difference from conventional methods. Recently, the incidence decreased significantly for TG overall and TG with splenectomy. PF after TG is more likely to occur in obese patients undergoing TG with pancreaticosplenectomy. When TG with splenectomy (pancreas-preserving method) is performed, the splenic artery should be totally preserved. If TG with pancreaticosplenectomy is performed, the use of a linear stapling device for closure of the cut end of the pancreas should be suggested. These improvements in surgical techniques are useful to prevent PF.

Intracorporeal Billroth 1 Reconstruction by Triangulating Stapling Technique After Laparoscopic Distal Gastrectomy for Gastric Cancer

As the laparoscopic operations for gastric cancer have increased, the intracorporeal reconstruction of the digestive tract has received attention because the procedure offers a good visual field regardless of the patient's figure. We performed laparoscopic gastrectomies with regional lymph node dissection on 586 gastric cancer patients between March 1998 and June 2006: 465 distal gastrectomies, 42 proximal gastrectomies, and 79 total gastrectomies. Intracorporeal anastomosis was carried out in 303, 36, and 69 of the above cases, respectively. The intracorporeal Billroth 1 reconstruction was performed in 226 out of the 303 cases who underwent distal gastrectomy and intracorporeal anastomosis. The "triangulating stapling technique" (TST) that uses laparoscopic linear stapling devices was adopted for 196 of these 226 cases; in the remaining 30, circular stapling devices for conventional open gastrectomy (CEEA) were used. In the initial 115 cases of distal gastrectomy, hand-assisted laparoscopic surgery (HALS) was used, and then we shifted to totally laparoscopic distal gastrectomy (TLDG) without HALS. In this paper, we concentrated on the techniques and results of intracorporeal Billroth 1 reconstruction by TST. Reducing postoperative wounds was possible TLDG by TST, compared with HALS and the extracorporeal anastomosis, that is, laparoscopy-assisted distal gastrectomy. Complications from anastomosis resulted in leakage in 2 HALS-TST patients and in 1 TLDG-TST patient, and anastomotic stenosis and bleeding were observed in each 1 case of reconstruction that used CEEA. Intracorporeal Billroth 1 reconstruction by TST is a safe procedure that provides a good visual field regardless of the patient's figure and a feasible technique for reconstruction after laparoscopic distal gastrectomies.

Total Laparoscopic Pancreaticoduodenectomy and Reconstruction for a Cholangiocarcinoma of the Bile Duct

In this paper, we report on our experience with a totally laparoscopic pancreatico-duodenectomy performed for a cholangiocarcinoma of the lower third of the bile duct. The patient was placed in the steep reverse Trendelenberg, Lloyd-Davis position. The procedure was performed with six laparoscopic ports, using similar steps to the open approach, with the use of an ultrasonic cutting and coagulating instrument for dissection and endoscopic linear stapling devices for the bile duct, intestinal, and gastroduodenal artery division. Reconstruction was done on a single loop by an intracorporeally sutured pancreaticojejunostomy, hepaticojejunostomy, and a stapled gastroenterostomy. The resection specimen was placed in a bag and retrieved through a 5-cm Pfannenstiel incision. Histology confirmed a T3 N1 R0 cholangiocarcinoma with the involvement of 1 of 17 lymph nodes. Twelve months following surgery, he remains well, having completed a course of adjuvant chemotherapy. Although the operation was technically demanding, it can be safely performed with a good oncologic result.

A new stapler-based full-thickness transgastric access closure: results from an animal pilot trial

Reliable closure of the transluminal incision is the crucial step for natural orifice transluminal endoscopic surgery (NOTES) procedures. The aim of this study was to evaluate the feasibility and effectiveness of transgastric access closure with a flexible stapling device in a porcine survival model. We carried out four experiments (two sterile and two nonsterile) on 50 kg pigs. The endoscope was passed through a gastrotomy made with a needle knife and an 18-mm controlled radial expansion dilating balloon. After peritoneoscopy, a flexible linear stapling device (NOLC60, Power Medical Interventions, Langhorne, Pennsylvania, USA) was perorally advanced over a guide wire into the stomach, positioned under endoscopic guidance, and opened to include the site of gastrotomy between its two arms; four rows of staples were fired. One animal was sacrificed 24 hours after the procedure (progression of pre-existing pneumonia). The remaining animals were survived for 1 week and then underwent repeat endoscopy and postmortem examination. Peroral delivery and positioning of the stapling device involved some technical difficulties, mostly due to the short length (60 cm) of the stapling device. The stapler provided complete leak-resistant gastric closure in all pigs. None of the surviving animals had any clinical signs of infection. Necropsy demonstrated an intact staple line with full-thickness healing of the gastrotomy in all animals. Histologic examination confirmed healing, but also revealed intramural micro-abscesses within the gastric wall after nonsterile procedure. Gastrotomy closure with a perorally delivered flexible stapling device created a leak-resistant transmural line of staples followed by full-thickness healing of the gastric wall incision. Increasing the length of the instrument and adding device articulation will further facilitate its use for NOTES procedures.