Hybrid uniportal robotic-assisted thoracoscopic surgery using video-assisted thoracoscopic surgery staplers: technical aspects and results

Background

The clinical efficacy of robot-assisted thoracic surgeries has been explored by numerous recent studies. Nonetheless, since current standard robotic systems (da Vinci Xi system) were intended for multiportal surgical processes and robotic staplers were still unavailable in the developing world, obstacles still remain concerning the feasibility of uniportal robotic surgeries.

Methods

A hybrid uniportal robotic-assisted thoracoscopic surgery (RATS) modality utilizing video-assisted thoracoscopic surgery (VATS) staplers was investigated in Shanghai Pulmonary Hospital. Clinicopathological characteristics and perioperative outcomes concerning patients receiving hybrid uniportal RATS between August 2022 and September 2022 were collected.

Results

A total of 40 patients were included in this study. Most of the patients (23/40, 57.5%) received hybrid uniportal RATS lobectomies. One conversion from uniportal RATS to biportal process was encountered due to extensive adhesions discovered intraoperatively. The median procedural duration was 76 min [interquartile range (IQR), 61-99 min], and the median blood loss volume was 50 mL (IQR, 50-50 mL). A median stay length of three days (IQR, 2-4 days) was recorded. Eleven patients (27.5%) developed Clavien-Dindo grade I-II postoperative complications, while no grade III-IV complications were observed. Aside from this, none of the patients were readmitted or died within 30 days post-surgery.

Conclusions

The feasibility of hybrid uniportal RATS procedures using VATS staplers has been preliminarily validated. For early-stage non-small cell lung cancer patients, such a procedure might clinical efficacy comparable to that of uniportal RATS utilizing robotic staplers.

A comparison between the da Vinci Xi EndoWrist Stapler and a conventional laparoscopic stapler in rectal transection: A randomized controlled trial

BACKGROUND

Distal rectal transection following robotic total mesorectal excision for rectal cancer is challenging. This can be performed with either a robotic stapler (RS) or laparoscopic stapler (LS). We compared the operative outcomes and ergonomic differences between RS and LS.

METHODS

Forty patients with rectal cancer who were planned for robotic rectal surgery were randomized to either RS or LS.

RESULTS

The mean number of stapler cartridges expended was similar between RS and LS (1.75 vs. 2.05, p = 0.082). Significantly less stapler adjustments were required in the RS group (1.55 vs. 2.75, p = 0.014). Results from the user experience survey showed that RS scored better.

CONCLUSION

The RS required less adjustments and resulted in a better user experience. While this complemented the use of robotics in rectal surgery, it did not result in a significant reduction in the number of stapler cartridges required for rectal transection.

Effect of Circular Stapler Diameter on Anastomotic Leakage Rate and Stenosis After Open Total Gastrectomy With Esophagojejunostomy: A Substantive Retrospective Propensity Score Matched Series

Background

Anastomotic leakage (AL) and stenosis (AS) are two of the most severe postoperative complications after total gastrectomy with esophagojejunostomy. The stapler diameter can be chosen by the surgeon. Therefore, this study aims to assess the correlation between the stapler size as main independent variable as well as other different risk factors and AL and AS.

Methods

We conducted a retrospective analysis of data from 356 patients who underwent open total gastrectomy between 2000 and 2018, mostly due to gastric cancer (96.9%). After propensity score matching the outcome parameters AL and AS were compared between the two stapler size groups. We also assessed different risk factors for AL and AS in cancer patients using multivariate analysis.

Results

Small circular stapler diameter (21/25 mm; n = 147 vs 28/29/31 mm; n = 209) was identified as a significant risk factor for the occurrence of AL (10% vs 4% for smaller vs larger staplers; P = 0.042). In multivariate analysis for the occurrence of AL an ASA score ≥ 3 could be identified as a risk factor (OR 2.85; 95% CI = 1.13-7.15; P = 0.026). Additionally, smaller stapler size could be identified as a risk factor for AS (OR small 1.00, OR large 0.24; 95% CI: 0.06-0.97; P = 0.045). AL was associated with lower survival (18.1 vs 38.16 months; P = 0.0119).

Conclusion

The application of a larger circular stapler for esophagojejunostomy in open total gastrectomy shows significantly lower rates of AL and stenosis. Therefore, the largest possible stapler diameter should be applied.

A new technique for introduction of a surgical stapler in robot-assisted lobectomy for lung cancer

BACKGROUND

The da Vinci Si version of robot lacks a vascular stapler that can be controlled by the operating surgeon at the surgical console for dividing the pulmonary vessels. Therefore, in order to initiate and safely perform robotic anatomical lobectomy for lung cancer, it is important to develop a safe method for introducing the surgical stapler.

METHOD

We performed a retrospective study of the first 42 consecutive patients who underwent robotic lobectomy for lung cancer at Nippon Medical School Hospital between January 2019 and December 2020.

RESULTS

Up to case 18, we performed Robot-assisted thoracoscopic surgery (RATS) lobectomy using the four-arm approach with two assistant ports. For dividing the pulmonary vessels, the surgical stapler was introduced through the assist ports. However, since this is not the port position usually used in video-assisted thoracoscopic surgery (VATS), there were many difficult situations.From case 19 onwards of RATS lobectomy, we began to use a total port approach using three robotic arms and two assistant ports. For resecting the pulmonary vessels or bronchi with endoscopic staplers, the port for the robotic arm was removed and the endoscopic staplers were placed through a 12-mm Xcel bladeless port. This change resulted in a shorter operation time, less blood loss, and less robotic arm interference. There has been no case that developed intraoperative complications during RATS lobectomy.

CONCLUSION

The new total port approach, with three robotic arms, for introducing surgical staplers during RATS using the da Vinci Si robotic system appears to be feasible.

Stapled versus robot-sewn ileo-ileal anastomosis during robot-assisted radical cystectomy: a review of outcomes in urinary bladder cancer patients

BACKGROUND

Whereas the literature has demonstrated an acceptable safety profile of stapled anastomoses when compared to the hand-sewn alternative in open surgery, the choice of intestinal anastomosis using sutures or staples remains inadequately investigated in robotic surgery. The purpose of this study was to compare the surgical outcomes of both anastomotic techniques in robotic-assisted radical cystectomy.

METHODS

A retrospective analysis of patients with urinary bladder cancer undergoing cystectomy with urinary diversion and with ileo-ileal intestinal anastomosis at a single tertiary centre (2012-2018) was undertaken. The robotic operating time, hospital stay and GI complications were compared between the robotic-sewn (RS) and stapled anastomosis (SA) groups. The only difference between the groups was the anastomosis technique; the other technical steps during the operation were the same. Primary outcomes were GI complications; the secondary outcome was robotic operation time.

RESULTS

There were 155 patients, of which 112 (73%) were male. The median age was 71 years old. A surgical stapling device was used to create 66 (43%) separate anastomoses, while a robot-sewn method was employed in 89 (57%) anastomoses. There were no statistically significant differences in primary and secondary outcomes between RS and SA.

CONCLUSIONS

Compared to stapled anastomosis, a robot-sewn ileo-ileal anastomosis may serve as an alternative and cost-saving approach.

The Comparative Analysis of Suture versus Linear Stapler Pharyngeal Closure in Total Laryngectomy: A Prospective Randomized Study

Objective

The aim of this study was to prospectively evaluate and compare the outcomes in patients undergoing pharyngeal closure with the linear stapler and suture techniques after total laryngectomy.

Methods

Forty-one patients who needed total laryngectomy for laryngeal cancer were enrolled in the study. Patients were randomized into two groups according to the pharyngeal closure technique: the linear stapler group (Group A) and the suture closure group (Group B). Rate of pharyngocutaneous fistula (PCF), nasogastric tube (NGT) removal time and pharyngeal closure time were analyzed and compared between the two groups.

Results

PCF developed in three patients in Group A (14.3%) and in seven patients in Group B (35%). Although the rate of PCF was lower in Group A, this did not represent a statistical difference (p:0.129). Median NGT removal time was 12 days (IQR=3) and 19.5 days (IQR=1) in Groups A and B, respectively. Median NGT removal time was not statistically different between the two groups (p:0.642). All patients were able to swallow liquids and solids without difficulty. Median pharyngeal closure time was 3 minutes (IQR=1) and 37.5 minutes (IQR=9) in Groups A and B, respectively. Median pharyngeal closure time was significantly lower in Group A (p:0.00).

Conclusion

The linear stapler technique in total laryngectomy is a reliable, safe, easy-to-apply and time-saving method. Closure with linear stapler significantly reduces pharyngeal closure time without adverse effect on NGT removal times and PCF rates.

Implementation of an Intraoperative Instructional Timeout Just Prior to Stapler Use Improves Proficiency of Surgical Stapler Usage by Surgery Residents

INTRODUCTION

With the fragmented rotational structure of training, exposure to surgical staplers is not uniform across surgical residents. Traditionally, educational sessions dedicated to instruction in surgical staplers have taken place outside the operating room. This study implemented and evaluated an intraoperative timeout immediately prior to stapler use in cases with surgical residents.

METHODS

During general surgery cases from June 1, 2017 until December 31, 2017, surgical teams, including the surgical attending, surgical resident, and scrub nurse participated in an intraoperative instructional timeout, during which proper use of linear or circular staplers was reviewed. At the conclusion of the timeout, residents were required to demonstrate proper stapler assembly and verbalize all technical steps involved in stapler use. Duration of each timeout was recorded. Immediately following the case, a pre-post survey was administered to each participating junior (R1-R2) or senior (R4-R5) surgical resident. The primary outcome was change in stapler use knowledge by surgical residents. Survey questions with Likert scale responses were analyzed using paired ttests, and responses from junior residents were compared to those from senior residents with independent t tests.

RESULTS

Forty-three general surgery cases involved stapler use during the study period and implemented an intraoperative instructional timeout. The educational intervention increased stapler use knowledge significantly in all surgical residents. Prior to the timeout, junior residents reported significantly higher anxiety related to stapler usage compared to their senior counterparts; anxiety scores in junior residents decreased significantly for use of both linear and circular staplers. The mean timeout duration was 2.9 minutes (standard deviation 0.9 minutes, range 1.2-4.6 minutes). All participating surgical residents recommended routine implementation of an instructional timeout prior to intraoperative stapler use.

CONCLUSIONS

An intraoperative timeout dedicated to stapler teaching is effective in increasing proficiency and easing anxiety in all levels of surgical residents. Further research is warranted to determine whether this educational intervention would translate into fewer stapler use errors and decreased intraoperative complications.

Laparoscopic repair using an endoscopic linear stapler for management of iatrogenic colonic perforation during screening colonoscopy

Introduction

Colonoscopy is a safe and effective procedure, but it is also an inevitably invasive one. Laparoscopic repair of colonoscopic perforations has been reported to be a safe and effective treatment.

Aim

We present our surgical technique and outcomes of laparoscopic repairs using an endoscopic linear stapler for iatrogenic colonic perforation during screening colonoscopy.

Material and methods

Laparoscopic repair using an endoscopic linear stapler for iatrogenic colonic perforation during screening colonoscopy was performed by two experienced laparoscopic surgeons on 14 consecutive patients between April 2010 and December 2017 at our hospital. Using prospectively collected data, an observational study was performed on a per protocol basis.

Results

The mean age of the 14 patients who underwent laparoscopic repair was 56.6 ±9.1 years. The most common perforation site was the sigmoid colon in 10 (71.4%) patients, followed by the rectosigmoid junction in 3 (21.4%) patients and the splenic flexure in 1 (7.1%) patient. The median perforation size was 10 (range: 5–30) mm. The mean operation time was 73.9 ±28.2 min. Postoperative complications occurred in 1 (7.1%) patient. There was no postoperative mortality or reoperation within 30 days after surgery. The median time to tolerance of a regular diet was 5 (range: 3–6) days. The median postoperative hospital stay was 8.5 (range: 5–15) days.

Conclusions

Laparoscopic repair using an endoscopic linear stapler is a safe, easy, and effective surgical technique to treat colonic perforation related to screening colonoscopy.

Preclinical quantification of air leaks in a physiologic lung model: effects of ventilation modality and staple design

Purpose

Thoracic air leaks are a common complication following pulmonary resections. Limitations in clinical studies and preclinical models have hindered efforts to understand the pathophysiology of air leaks. With an emphasis on staple-line specific air leaks, we hypothesize that ventilation modality – intraoperative positive pressure vs postoperative negative pressure – and stapler design may play a role in air leaks.

Methods

Using a novel physiologic lung model, air leaks associated with graduated and uniform staple designs were evaluated under positive and negative pressure ventilation, simulating perioperative breathing in porcine lungs. Air leak incidence, air leak volume, and air leak rate were captured along with ventilation pressure and tidal volume.

Results

In all cases, negative pressure ventilation was associated with a higher occurrence of leaks when compared to positive pressure ventilation. Lungs leaked more air and at a faster rate under negative pressure ventilation compared to positive pressure ventilation. Graduated staple designs were associated with higher occurrence of leaks as well as larger leak rates when compared to uniform staples. Tissue thickness was not associated with differences in air leaks when tested with appropriate staple heights.

Conclusion

Using a novel lung model to investigate the pathophysiology of air leaks, we have identified breathing modality and staple design as two important variables that may impact air leaks. This work will help guide device design and drive future studies in human tissue, and it may help inform clinical practice to ultimately improve patient outcomes.

Novel Asymmetrical Linear Stapler (NALS) for pathologic evaluation of true resection margin tissue

Background

The use of limited resection for lung cancer has increased with the accumulation of knowledge about early lung cancer. To decrease locoregional recurrence after a limited resection, it is important to confirm R0 resection at the true resection margin. In this study, we report a novel linear stapler that preserves the true resection margin tissue after organ resection.

Methods

We used a Novel Asymmetrical Linear Stapler (NALS) made by Meditulip. On the resected organ side of NALS, there is a single row of titanium fasteners. To verify the utility of NALS and to compare its preservation of the resection margin tissue to a conventional stapler, we performed wedge resection of the lung in a porcine animal model and examined the pathology of the true resection margin.

Results

Using NALS, we successfully divided and closed the lung tissues, as with the conventional stapler. There was no bleeding on either side or no air leakage from the remnant stapled tissue. The distance between the cutting edge and the titanium fasteners was 3.10 mm with NALS, which was sufficient to resect the true resection margin tissue for pathology evaluation. There was no squeezing artifact at the true resection margin on microscopic evaluation with NALS. With the conventional stapler, it is difficult to evaluate the pathology at the true resection margin due to the severe squeezing artifact.

Conclusions

NALS preserves the true resection margin tissue and thus should be useful for evaluating the resection margin with a frozen section biopsy in oncology surgery.

Secure overlap stapling using a linear stapler with bioabsorbable polyglycolic acid felt

INTRODUCTION

Despite the availability of various anastomosis techniques, postoperative anastomotic complications such as anastomosis failure and bleeding develop in some patients. Automatic suturing devices have been widely used for gastrointestinal anastomosis. However, overly thick or thin tissue, displacement of tissue, and the creation of a staple-on-staple site may lead to incomplete staple formation. These factors are considered to be related to postoperative complications such as anastomosis failure.

METHODS

The iDrive™ Ultra Powered Stapling System was used to fire the automatic suturing device. Two types of automatic suturing devices were employed: (i) the Endo GIA™ Reinforced Reload with Tri-Staple™ Technology with a cartridge with the reinforcement material Neoveil™; and (ii) the Endo GIA™ with Tri-Staple™ Technology with no reinforcement material. Stapling was performed using a two-stage crossing approach to make a staple-on-staple site.

RESULTS

The rates of complete formation with the Endo GIA™ with Tri-Staple™ Technology were 95.6 ± 0.6% for stomach tissue and 95.6 ± 2.3% for colon tissue, which is thinner than stomach tissue. In contrast, the rates of complete formation with the Endo GIA™ Reinforced Reload with Tri-Staple™ Technology were 99.3 ± 1.27% for stomach tissue and 100.0 ± 0.0% for colon tissue.

CONCLUSION

Our results showed that the Endo GIA™ Reinforced Reload with Tri-Staple™ Technology had higher rates of complete staple formation than the Endo GIA™ with Tri-Staple™ Technology, irrespective of tissue thickness and the presence of a staple-on-staple site.

Safety and efficacy of a novel linear staple device with bioabsorbable polyglicolic acid felt in laparoscopic colorectal surgery

INTRODUCTION

Laparoscopic surgery is widely used for the treatment of colorectal cancer, but it is often associated with postoperative anastomotic complications. Generally, gastrointestinal anastomosis for colorectal surgery is performed using mechanical anastomosis with a double stapling technique. Using the automatic suture device with bioabsorbable polyglycolic acid (PGA) felt is expected to adequately reinforce staple lines on fragile tissue, helping to prevent anastomotic complications, including leakage.

METHODS

This study included 17 patients who underwent laparoscopic surgery after a diagnosis of colorectal cancer. The rectosigmoidal colon was resected toward the dentate line with a novel automatic PGA-felt suture device.

RESULTS

None of the patients had any postoperative bleeding, and none developed grade III or higher postoperative complications based on the Clavien-Dindo classification. When the sigmoid colon, rectosigmoid, or rectum was anastomosed, holding the excess portion of the PGA felt, stapled with the automatic PGA-felt suture device, allowed us to adequately maneuver the part of the colon or rectum to be anastomosed. With this technique, we could easily and safely insert and remove the automatic anastomotic device. When the lower rectum was resected in a planned, two-step operation, the orientation of the PGA felt helped to determine the direction in which the automatic suture device was to be inserted in the second step. Thus, the resected rectum could easily be stapled in a straight line.

CONCLUSION

The automatic PGA-felt suture device is safe and effective for colorectal resections and anastomoses.

Optimal stapler cartridge selection according to the thickness of the pancreas in distal pancreatectomy

Stapling is a popular method for stump closure in distal pancreatectomy (DP). However, research on which cartridges are suitable for different pancreatic thickness is lacking. To identify the optimal stapler cartridge choice in DP according to pancreatic thickness.From November 2011 to April 2015, data were prospectively collected from 217 consecutive patients who underwent DP with 3-layer endoscopic staple closure in Seoul National University Hospital, Korea. Postoperative pancreatic fistula (POPF) was graded according to International Study Group on Pancreatic Fistula definitions. Staplers were grouped based on closed length (CL) (Group I: CL ≤ 1.5 mm, II: 1.5 mm < CL < 2 mm, III: CL ≥ 2 mm). Compression ratio (CR) was defined as pancreas thickness/CL. Distribution of pancreatic thickness was used to find the cut-off point of thickness which predicts POPF according to stapler groups.POPF developed in 130 (59.9%) patients (Grade A; n = 86 [66.1%], B; n = 44 [33.8%]). The numbers in each stapler group were 46, 101, and 70, respectively. Mean thickness was higher in POPF cases (15.2 mm vs 13.5 mm, P = 0.002). High body mass index (P = 0.003), thick pancreas (P = 0.011), and high CR (P = 0.024) were independent risk factors for POPF in multivariate analysis. Pancreatic thickness was grouped into <12 mm, 12 to 17 mm, and >17 mm. With pancreatic thickness <12 mm, the POPF rate was lowest with Group II (I: 50%, II: 27.6%, III: 69.2%, P = 0.035).The optimal stapler cartridges with pancreatic thickness <12 mm were those in Group II (Gold, CL: 1.8 mm). There was no suitable cartridge for thicker pancreases. Further studies are necessary to reduce POPF in thick pancreases.