Jul. 08, 2024
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This study showed no difference in intraoperative performance and the chronic healing response in JJs between D- and B-shaped staples. Based on these findings, the D-shaped staple elicits a normal healing response in jejunostomies and offers the possibility of clinical use of this advance in staple design.
Twenty-three animals had 40 anastomoses (23 &#;D&#; and 17 &#;B&#; staple anastomoses) with no intraoperative mortalities. One &#;D&#; staple application required a manual extension of the cut. Acute hemostasis was 100 %. Group 1 (n = 5) compared white staples in JJs (D staple n = 5; B staple n = 5; 14-day survival = 100 %). Group 2 (n = 12) compared white staples in JJs (D staple n = 12; B staple n = 6; 34-day survival = 92 %). One animal died on day 4 for a non-staple related cause. Group 3 (n = 6) compared blue staples in JJs (D staple n = 6; B staple n = 6; 84 day survival = 84 %). One animal died on day 18 due to an obstruction at the B staple JJ caused by stricture. There were no other bleeding, leaks or strictures in any of the groups. Gross pathology and histology were unremarkable in all JJs.
Jejunojejunal anastomoses (JJ) were performed via mini-laparotomy in a swine model. White & blue D- and B-shaped staples were studied in three groups (planned survival 14&#;84 days). Intraoperative assessment included completeness of staple line, hemostasis, and need for intervention. Postoperatively, animals were evaluated for complications. At the time of sacrifice, gross pathological and histological assessments were performed.
Surgical staplers currently all rely on the same staple form&#;the &#;B&#; which necessitates a high delivery profile (12 mm). A novel &#;D&#; shape staple allows for an extremely low profile of the applicator. The acute and long-term efficacy of a D-shaped staple (Cardica, Redwood City, CA, USA) was compared to conventional B-form staples (Covidien, Norwalk, CN, USA) in an animal model for intestinal transections and anastomoses.
The modern surgical stapler is 55 years old this year. It evolved from the very first surgical stapler developed in by Dr. Hümer Hültl (&#;) which had resemblances of a &#;B&#;-shaped staple along with staggered rows [11]. Ever since, medical and most non-medical staplers have been designed and iterated around the &#;B&#;-shaped staple. Today, staplers are used in virtually all surgical disciplines and have become the gold standard for the transection and anastomosis of tissues. Surgical staplers are absolutely essential instruments for surgeons worldwide [3].
Over the past 20 years, there have been concentrated efforts by the surgical community to further reduce the invasiveness of their surgical procedures. This started with trocar-based laparoscopic and thoracoscopic procedures using cameras and specialized instruments that could be applied through various size access ports. More recently, surgeons have introduced the concepts of single-port surgery, minilaparoscopy, or natural orifice translumenal endoscopic surgery (NOTES), always driven by the desire to reduce the size of the skin incisions and the invasiveness of the procedures [2, 9, 10, 12, 15, 16].
As a result, the majority of surgical instruments are now available with 5- or 8-mm shaft diameters and offer various degrees of articulation. This includes standard surgical instruments such as graspers, scissors, or irrigation and suction devices. It also includes more sophisticated instruments such as energy-based instruments or clip appliers [14]. However, in regards to surgical stapling, until recently, universally applicable instruments have only been available with a 12-mm or larger diameter shaft.
Traditional laparoscopic staplers utilize cartridges containing multiple rows of wire-formed staples. The unformed staples are shaped in a U configuration (Fig. ). They are available in different sizes to accommodate different tissue thicknesses. The thicker the tissue, the longer the staple tine needs to be. Based on the current designs, this tine length dictates the minimum size of cartridge that can be realized (Fig. ). These staples are loaded &#;on end&#; into individual pockets in the cartridge. In order to deploy the staple a wedge that passes underneath the staple pockets and pushes individual &#;drivers&#; or &#;pushers&#; upward, the staples advance sequentially out of the cartridge pockets and into the tissue clamped between the cartridge and the anvil (Fig. ). The tines of the staples then engage with the anvil and buckle into a B shape, which compresses and secures the tissue. With most staplers, the tissue is simultaneously divided with a knife in the center of multiple rows of staples. Because of this design, and with staple tine lengths approximately 3&#;5 mm, the conventional stapler cannot be reduced to less than 12 mm in overall diameter (Fig. ).
The current study evaluates a new type of stapler designed around a fundamentally different staple shape, the D shape. Similar to the conventional B-shaped staples, this new staple is provided with different tine lengths compatible with thin (white cartridge) and medium thickness tissues (blue cartridge).
In contrast to a conventional B-shaped staple, which is formed from constant diameter titanium wire and individually loaded into pockets in the cartridge, the D-shaped staple is placed in multiple rows and is stamped from 316 stainless steel sheet metal as one piece, essentially a strip of staples. The stamping allows for variations in the staple cross section to strengthen sections that are subjected to more force to provide greater resistance to unforming under high tissue loads. In addition, the stainless steel is twice as strong as the titanium wire used to manufacture the B-shaped staples. During deployment, the staples are individually sheared off the strip. The D shape allows the staple to arc through the tissue during deployment and deflect into a closed form by interacting with pockets in the anvil (Fig. ). This particular design avoids the need for a cartridge housing with pockets for individual staples and &#;drivers&#; or &#;pushers&#; to translate the force from the wedge onto the staples. Instead the wedge interacts directly with the staple. All of this allows the overall cartridge and anvil diameter to be decreased to 5 mm while accommodating staples capable of securing tissues associated with typical white and blue cartridges.
This study was designed to determine if a 5-mm stapler designed with this new D-shaped staple would be comparable to a conventional B-shaped stapler in a survival model. Outcome included the rate of successful deployments, an assessment of staple forms at the time of deployment, staple-line leakage, and the incidence of staple-line bleeding. Longer term outcome variables included postoperative complications including leaks, bleeding strictures, and death. At the time of sacrifice, a blinded histological assessment of the anastomosis was made.
Surgical stapling equipment allows the small-animal surgeon to perform a variety of challenging abdominal surgical procedures more quickly and consistently than with conventional, hand-suturing techniques. This article will summarize the use of these devices.
Dr. Michael M. Pavletic
I use the following surgical stapling devices routinely for abdominal surgery: skin staplers, Surgiclips, the Ligate-Divide Stapler, the Thoracoabdominal Stapler, the Gastrointestinal Anastomosis Stapler, and the End-to-End Anastomosis Stapler (Tyco Healthcare/Kendall Animal Health). Each device has specific advantages. For small patients, small laparoscopic staplers can also be used during a standard laparotomy approach.
Skin staplers are quite useful to quickly close long, abdominal incisions. In thin skin, application of a standard surgical glue to the incision line after staple application helps to stabilize skin staples and minimize occasional postoperative staple movement or rotation. Vascular clips can be used to secure multiple vascular pedicles quickly in a variety of surgical procedures, including bowel resection and anastomosis, splenectomy, partial liver resection, and tumor removal. Surgiclips apply single, flat clips to small vessels, whereas the Ligate-Divide Stapler applies two curved vascular clips simultaneously while the blade within the cartridge divides the vessel between the clips. The long, narrow silhouette of Surgiclip staplers is effective in ligating vessels in recessed areas where hand ligatures are difficult or impossible to apply, such as in the removal of adrenal tumors (Figure 1). The larger Ligate-Divide Stapler is useful for ligating multiple, exposed vascular pedicles rapidly, such as in splenectomies (Figure 2).
Figure 1: Surgiclip device. Compressing the scissors mechanism will apply a single, flat staple to a small vessel. Upon release, a staple is automatically reloaded for the next application.
The Thoracoabdominal Stapler and Gastrointestinal Anastomosis Stapler apply linear rows of staples. The Thoracoabdominal Stapler, the most commonly used linear stapler, applies two rows of staggered staples (Figures 3a & 3b). The Thoracoabdominal Stapler is particularly useful for gastrotomy incision closure, partial splenectomies, and liver lobectomies. The Gastrointestinal Anastomosis Stapler applies four rows of staggered staples; the most commonly used cartridge contains a blade that divides the tissue between the second and third staple rows. The Gastrointestinal Anastomosis Stapler can staple two edges of divided tissue in a single application (Figures 4a & 4b). The Gastrointestinal Anastomosis Stapler is especially effective for partial gastrectomy in cases of necrosis secondary to gastric torsion. In conjunction with the Thoracoab-dominal Stapler, the Gastrointestinal Anastomosis Stapler can be used to perform rapid, functional end-to-end anastomosis after small bowel resection.
In contrast, the End-to-End Anastomosis Stapler applies two rows of surgical staples in a circular configuration&#;ideal for the end-to-end anastomosis of the larger diameter colon and esophagus in small animals. The Autosuture Pursestring 65 device (Tyco Healthcare/Kendall Animal Health) is used in conjunction with the End-to-End Anastomosis Stapler. The Autosuture Pursestring devise applies a pursestring suture to the cut end of each opposing bowel segment. Each pursestring suture is then tied to the central shaft of the End-to-End Anastomosis Stapler. Closure of the End-to-End Anastomosis Stapler aligns, apposes, and staples the segments together; the circular cutting blade located within the disposable End-to-End Anastomosis Stapler cartridge removes the pursestring and redundant tissue borders.
Figure 2: Ligate-Divide Stapler unit. Each cartridge contains 15 pairs of curved vascular clips. Compression of the handle will apply two clips to a vessel as a blade cuts between them. This device is especially useful for complete splenectomies.
All three devices come in various lengths and diameters; staple sizes also vary. Today, most internal staples are made of titanium. Thoracoabdominal Staplers are available in three basic cartridge lengths: 30 mm, 55 mm, and 90 mm, depending on the length of staples required. They use two basic staple sizes: 3.5 mm and 4.8 mm. The larger 4.8-mm staples are usually used for the thicker gastric tissues, whereas smaller 3.5-mm staples are most commonly used for the small and large intestines. The Thoracoabdominal Stapler 30 can use a vascular cartridge (V3 cartridge) that applies three rows of fine staples to larger vascular pedicles in a staggered configuration.
Figure 3a : Thoracoabdominal Stapler 55 with the green (4.8 mm) and blue (3.5 mm) staple cartridges. Two rows of staples are applied in a staggered configuration.
Surgical staplers can be used alone or in conjunction with other stapling devices.
Table 1
lists the stapling devices commonly used for small-animal abdominal procedures. Of the various procedures listed in
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Table 1
, surgical staplers are especially useful for the following surgical procedures:
At Angell Animal Medical Center, staplers are the preferred tools for these specific surgeries. With other surgical procedures, the surgeon's preference varies and may depend on the patient's size and the surgeon's experience.
Figure 3b : Thoracoabdominal Stapler 30 with the white vascular cartridge. Three rows of staples are applied in a staggered configuration. This device is ideal for securing larger vascular pedicles, such as the renal vessels during nephrectomy.
Veterinary practices with an active surgical caseload will benefit the most from the use of surgical stapling equipment. However, clinicians can easily master the use of skin staplers, Surgiclips, and the Ligate-Divide Stapler with little formal training. These affordable instruments can save considerable time, reduce anesthesia time (particularly important in emergency or critical care cases), and improve the doctor's clinical productivity.
Veterinarians inexperienced in stapling are naturally reluctant to purchase the Thoracoabdominal Stapler, Gastrointestinal Anastomosis Stapler, Ligate-Divide Stapler, and End-to-End Anastomosis Stapler. But mastering these devices isn't difficult. The manufacturers of these devices provide training courses throughout the United States to accelerate the learning process. The Thoracoabdominal Stapler and Ligate-Divide Stapler are mastered easily, whereas surgeons find training or assistance invaluable in refining their use of the Gastrointestinal Anastomosis Stapler and End-to-End Anastomosis Stapler. The End-to-End Anastomosis Stapler is used the least, but it is indispensable for the more challenging procedures listed in Table 1.
Figure 4a : The Gastrointestinal Anastomosis Stapler closed with cartridge. This stapler applies four rows of staples in a staggered configuration. A cartridge blade cuts between rows two and three.
Linear (Thoracoabdominal, Gastrointestinal Anastomosis) and circular (End-to-End Anastomosis) staplers must be used correctly or dehiscence can result. Each stapler must engage the full thickness of the two organ walls (e.g., stomach and intestine) stapled together. As with conventional suturing techniques, staplers will fail if improperly applied or used to close tissues severely compromised by trauma or disease. Details on correct application can be found in the recommended sources.
Figure 4b : The Gastrointestinal Anastomosis Stapler uncoupled with the cartridge.
Surgical stapling devices have greatly facilitated abdominal surgery in small-animal practice. Speed, efficiency, and ease of application are the primary reasons for their widespread acceptance by veterinary surgeons. Vascular clips (Surgiclips, Ligate-Divide Staplers) and skin staplers are mastered easily with minimal training. Veterinarians will benefit from a basic training course to master the use of linear and circular staplers.
Table 1: Common Stapling Procedures in Abdominal Surgery
Pavletic, M.M. (ed.): Surgical Stapling.
Vet. Clin. North Am. 24(2), .
Rousch, J.K.: Biomaterials and Surgical Implants. Textbook of Small Animal Surgery, 3rd Ed. (D. Slatter, ed.). W.B. Saunders, Philadelphia, Pa., ; pp 141-148.
Dr. Michael M. Pavletic is the director of surgical services at the Angell Animal Medical Center in Boston. He received his DVM degree in from the University of Illinois. Dr. Pavletic is a diplomate of the American College of Veterinary Surgeons. He is the author of W.B. Saunders' Atlas of Small Animal Reconstructive Surgery and has written numerous articles on wound management, reconstructive surgery, and surgical stapling.
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