What is the Advantage and Disadvantage of laparoscopic surgery stapler

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Abstract

Many techniques are described for the ligation of a difficult cystic duct (CD). The aim of this study is to assess the effectiveness and safety of stapling of a difficult CD in acute cholecystitis using Endo-GIA. From January to June , patients with cholelithiasis underwent laparoscopic cholecystectomy (LC) at the Department of General Surgery, Haydarpasa Numune Education and Research Hospital. Of these, 19 (0.62%) were identified as having a difficult CD and were ligated using an Endo-GIA stapler. All patients were successfully treated with a laparoscopic approach. The length of hospital stay was 3.4 days. There were umbilical wound infections in 4 patients (21%). The length of follow-up ranged from 1.0 to 50.4 months. In conclusion, Endo-GIA is a safe and easy treatment method for patients with a dilated and difficult CD. The cystic artery should be isolated and ligated if possible before firing the Endo-GIA stapler. If isolation and stapling are not possible, fibrin sealant can be applied to avoid bleeding. The vascular Endo-GIA can be applied in a large CD, but for acute cholecystitis with an edematous CD, the Endo-GIA roticulator 4.8 or 3.5 stapler is preferred.

Key words:

Cholecystectomy, Endo-GIA, Acute cholecystitis, Stapler

After the introduction of laparoscopic cholecystectomy (LC) in ,1 LC replaced open cholecystectomy as the gold standard for the treatment of cholelithiasis in international guidelines.2 LC was initially considered to be contraindicated for acute gallbladder inflammation, but it is currently a common procedure for acute cholecystitis.

Some of the difficult situations a surgeon is likely to face during the performance of a laparoscopic cholecystectomy include anatomic anomalies such as a sessile gallbladder or short cystic duct and pathologic entities such as an empyema, Mirizzi syndrome, or a frozen Calot's triangle secondary to infection and fibrosis.3

It is suggested that laparoscopic surgery should be carried out within 72 hours from the onset of the symptoms because after that time there are higher rates of conversion to open procedures, increased risks of complications, and longer operative times.4&#;6 The generally accepted procedure in patients whose symptoms started 72 hours before admission is to &#;cool down&#; the patient with appropriate medical therapy and to perform LC after a period of 6 to 12 weeks.7,8 This approach aims to avoid a potentially more difficult cholecystectomy during an emergency admission and to avoid the difficulties of access to an emergency room.9,10 However, more than 20% of patients may fail to respond to conservative treatment and require an urgent and rather more difficult cholecystectomy, and a further 25% of patients will require readmission with a severe acute complication of cholelithiasis while awaiting a cholecystectomy.11,12 The scar formation, distortion, and organized adhesions around the gallbladder occurring secondary to the chronic inflammation in Calot's triangle make the dissection difficult. The cystic duct (CD) is sometimes edematous, fibrous, or enlarged owing to inflammation and adhesions in acute cholecystitis and may be difficult to manage. Several methods were proposed for ligating the CD, including titanium or absorbable endoclip, endoloop, tie, ultrasonic or bipolar sealer, and the Endo-GIA stapler (Covidien, Mansfield, Massachusetts).13&#;19

This study proposes an effective, safe, and easy procedure for the stapling of dilated or difficult CD using the Endo-GIA.

Materials and Methods

From January to June , patients with cholelithiasis underwent LC at the Department of General Surgery, Haydarpasa Numune Education and Research Hospital. The generally accepted procedure in patients whose symptoms started 3 or 4 days before admission is to &#;cool down&#; the patient with appropriate medical therapy. However, 19 patients failed to respond to conservative treatment, and the clinical signs persisted or worsened; so they required an urgent LC. They were identified as having a difficult CD. A retrospective review was carried out to identify patients in whom stapling devices were used. The collected data included the patient age, sex, preoperative diagnosis, morbidity, and management. In addition to the history and physical examination, ultrasonography (US), endosonography (EUS), endoscopic retrograde cholangiopancreatography (ERCP), computed tomography (CT), or magnetic resonance cholangiopancreatography (MRCP) were performed for diagnosis. Patients with common bile duct (CBD) stones had the stones removed by ERCP before LC.

Four of the authors participated in the study. The decision to use a stapling device for cholecystectomy was always made intraoperatively when it was determined that further dissection would expose the patient to a higher risk of common bile duct injury.

The surgery was performed under general anesthesia using a standard 4-trocar technique. Completing the posterior dissection first is a cardinal principle in our department. After skeletonizing the cystic artery and duct, a medium large titanium clip was used to ligate the duct and artery. When only the cystic duct was dilated and the anatomy was clear, we used large polymer clips or nonabsorbable suture for ligation with a knot pusher. The CD and cystic artery were identified, and if possible the artery was ligated first using titanium clips. The dilated CD was cleaned, and sufficient space existed to apply the Endo-GIA roticulator stapler (12 mm) with 4.8-mm (green) or 3.5-mm (blue) cartridges according to the tissue thickness and cystic artery ligation ( ). While the 3.5-mm cartridges were applied to the patients with difficult and edematous CD, the 4.8-mm cartridges were used for subtotal cholecystectomy. The Endo-GIA must be behind the CD, and the locking mechanism should be free of any intervening tissue before firing. Before firing the Endo-GIA, especially for the patients with milimetric stones, we squeezed the CD toward the gallbladder with a laparoscopic dissector to ensure there was no stone in the difficult CD. In some patients, the fundus-first method and subtotal cholecystectomies were performed for unclear anatomy of the Callot's triangle. In 3 patients, ligation of the cystic artery was not possible, and we used fibrin sealant (Tisseel Kit; Baxter Healthcare Corporation, Westlake Village, California) to avoid the possibility of bleeding. The gallbladder was dissected from the liver using electrocautery and removed with an endobag via the umbilical incision. Finally, the CD stump was carefully examined, and a soft drain was inserted via the 5-mm trocar incision and placed in the foramen of Winslow. We examined the gallbladder and cystic duct for the stapler line ( ).

Results

During the study period, 19 patients underwent LC with CD closure using the Endo-GIA roticulator. There were 12 men and 7 women ranging in age from 41 to 73 years, with a mean age of 62 years.

The preoperative diagnoses included symptomatic gallstones with or without CBD stones (10 patients), acute cholecystitis (7 patients), acute cholecystitis with acute cholangitis (1 patient), and biliary pancreatitis (1 patient). One patient with acute cholangitis, 1 patient with biliary pancreatitis, and 3 patients with symptomatic gallstones underwent preoperative ERCP. Four patients had CBD calculi extracted, and 1 patient with biliary pancreatitis was reported to have a normal examination.

The mean operation time was 91.3 minutes (range, 40&#;165 minutes). All patients were successfully treated with the laparoscopic approach, and none of the patients were converted to open surgery. Abdominal drains were used in all patients.

There were no deaths. Four patients (21%) with umbilical wound infections were treated with drainage and antibiotics. The umbilical wound infections occurred because an endobag was not used in the first 4 patients. The length of hospital stay was 3.4 days after operation.

The length of follow-up ranged from 1.0 to 50.4 months. No other complications were discovered during the follow-up period. The Endo-GIA roticulator 45-4.8 was the most frequently used stapler for closing the CD stump.

Discussion

LC was initially considered to be contraindicated for acute gallbladder inflammation, but it is currently a feasible and safe procedure for acute cholecystitis. It is advised mostly in the period known as the &#;golden 72 hours&#; from the onset of the symptoms.4,7,20&#;23 However, the treatment modality for patients admitted later than the golden 72 hours is still unclear. The widely accepted treatment modality for patients admitted in this period is an elective cholecystectomy, performed weeks after strict medical therapy called &#;cool down.&#; However, more than 20% of these patients failed to respond to the medical management or suffered from recurrent cholecystitis in the interval period, leading to one or more readmissions and to unplanned urgent surgery in more than 50%. One of the most significant problems in patients who have undergone cool-down treatment is dissection difficulty in Calot's triangle. According to a meta-analysis, the conversion rates for acute calculous cholecystitis in this group was 25.7%.24 The reason for the high conversion rates for interval laparoscopic cholecystectomy (ILC) groups in the literature can be explained by dense adhesions around Calot's triangle. Waiting for an inflamed gallbladder to cool down allows maturation of the surrounding inflammation and results in the organization of adhesions, which makes the dissection more difficult. Although inflammation in the early stages may not necessarily involve Calot's triangle, chronic inflammation often scars and distorts Calot's triangle, which makes dissection in this critical area more difficult.25

The laparoscopic subtotal cholecystectomy offers the advantages of the minimally invasive approach and definitive surgery for the &#;difficult&#; gallbladder. In the laparoscopic era, obscure anatomy accounts for a large number of conversions to conventional cholecystectomy.3

It is important to recognize the difficult gallbladder intraoperatively so that the decision to perform a laparoscopic subtotal cholecystectomy can be made early in the procedure.3 CD stones may be encountered during LC. Prior to a laparoscopic subtotal cholecystectomy, clearance of any stones is always performed. These stones are extracted by opening the duct if the stones are small, or by pulling up the large stones. Our study reports 19 patients with dilated and difficult CDs that were successfully ligated with the Endo-GIA. The posterior dissection to identify the angle between the infundibulum and the cystic duct is performed first. The creation of a window and the dissection of the gallbladder from the liver bed to ensure that no other structure returns to the porta hepatis is always performed, so the biliary anatomy is clearly identified. Avoidance of injury to the biliary duct is of great importance, especially during the performance of a difficult laparoscopic cholecystectomy.3 Indeed, our cases were not subtotal cholecystectomy, because dissection was brought to the cystic duct. It may be referred to as near total cholecystectomy.

Several methods have been proposed for ligating the CD during LC including a titanium or absorbable endoclip, an endoloop, a tie, an ultrasonic or bipolar sealer, and the Endo-GIA stapler.13&#;19

The CD joins the gallbladder to the common hepatic duct to form the common bile duct, and the diameter ranges from 1 to 5 mm.26 Ligating or clipping of the CD in acute cholecystitis is difficult because of its diameter, especially when the diameter is >1 cm. Multiple clips may be dangerous. Clip-related complications have been a problem with metallic clips. One study reported 9 bile leaks among 650 patients who underwent LC, and 3 of these leaks (0.46%) were caused by clip dysfunction.27 Some authors reported patients with obstructive jaundice and CBD stone formation resulting from the migration of metallic clips into the CBD.28,29

Knotting and suturing the CD is time consuming and cannot secure CD closure. Intracorporal suturing and knotting are more advanced laparoscopic skills.30

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Ultrasonic coagulation and electrothermal bipolar sealers are useful in dissecting dense tissues in cases with acute inflammation. However, ultrasonic coagulation and electrothermal bipolar sealers are dangerous and can cause bile leakage.19 In one study, bile leaks were reported in 9 of 331 patients (2.7%) when a harmonic scalpel was used alone.18 A study of 100 LCs performed using a harmonic scalpel recommended that additional cystic duct ligatures be used for a cystic diameter exceeding 5 mm. Although the harmonic scalpel is expensive, it can be used for the entire operation, including the cystic artery occlusion and gallbladder dissection, and it shortens the operating time.18,31

The endoloop may be an alternative, but for applying the endoloop you should divide the CD and then apply the endoloop. It is difficult to ligate if the CD is separated because the remnant CD can retract.13

Laparoscopic stapling devices have been applied in several operations, and they are reported to be a safe and feasible method of cystic duct closure. The division and clipping of the CBD have been widely discussed, and it is the most feared complication. One disadvantage of using endoscopic staplers in this setting is the need for larger ports (minimum 12-mm diameter) to introduce them.30,32

In many laparoscopic procedures, stapling devices are useful for safely dividing structures, ligating vessels, and creating anastomoses. The technical failure of staplers, resulting in uncontrolled bleeding or anastomotic leakage when the staple line fails to close securely, has been reported. However, these complications are rare. The advantages of laparoscopic stapling devices are their relative ease and speed of use, and the shorter operating time.19,30

The Endo-GIA is safe and easy to use. The CD anatomy should be clear, and adequate space should be left before firing the stapler device. A CD stone may slip into the CBD, so retraction is important; and before applying an Endo-GIA, the CD should be squeezed toward the gall bladder to prevent crushing a CD stone.32

Other studies have used the Endo&#;GIA vascular stapler. It may be used at a dilated CD, but we think it may be dangerous in acute cholecystitis because the CD is very edematous and thick. We prefer the Endo-GIA roticulator with a 4.8-mm or 3.5-mm thickness. In 16 cases, we isolated and ligated the cystic artery; but in the remaining 3 cases, we could not isolate the cystic artery and we divided the CD with a stapler. In these 3 cases, we used fibrin sealant to avoid bleeding. Three cases not in the fibrin-sealant group each had a small hematoma that resolved spontaneously.

The fundus-first dissection can be carried out during LC. Starting the dissection at the easiest site and obtaining the proper orientation is the most important principle in achieving a successful LC in difficult cases.32

The complication rates seem to be higher than other studies (36.8%). These complications are minor and include small hematomas at the surgical site and limited port-site infections. We routinely used abdominal ultrasound to examine patients for possible complications at the beginning and discovered small hematomas in some patients. At the beginning of the study, we did not use the endobag for the removal of the infected gallbladder, and gallbladder perforation occurred during the extraction. At the beginning of the study, the rate of wound infection was higher. We propose endobag usage in patients with an infected gallbladder.

The length of hospital stay was 3.4 days. The length of hospital stay is longer than standard laparoscopic cholecystectomy because at the beginning of the study, some patients stayed more than a week because of the fear of complication. After the 10th patient, the length of hospital stay decreased to 1 day, the same length as for non-stapled patients.

Conclusion

In conclusion, the Endo-GIA is a safe and easy treatment method for patients with a dilated and difficult CD. The cystic artery should be isolated and ligated if possible before firing the Endo-GIA stapler. If isolation and ligation is not possible, fibrin sealant can be applied to avoid bleeding. We recommend use of the endobag for stapled gall bladder to minimize port-site infection. The length of hospital stay is same as for the non-stapled group. The vascular Endo-GIA can be applied to a large CD, but for acute cholecystitis with an edematous CD, the Endo-GIA roticulator 4.8 or 3.5 stapler is preferred.

Acknowledgments

The authors declare that there is no conflict of interest.

Mehmet Odabasi, M. A. Tolga Muftuoglu, Erkan Ozkan, and Mehmet Kamil Yildiz performed surgical procedures. Sami Akbulut, Cengiz Eris, Emre Gunay, and Haci Hasan Abuoglu contributed to writing the article and reviewing the literature in a comprehensive literature search. Mehmet Odabasi designed and prepared the manuscript.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License ( http://creativecommons.org/licenses/by-nc-nd/3.0/ ), which permits for noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited and is not altered in any way.

INTRODUCTION

A decision on using stapling devices, electrosurgery-whether monopolar or bipolar-or suturing devices is dependent on the surgical situation and the surgeon's experience and skill. The goal should be a safe, efficient and relatively quick surgical procedure that benefits the patients and the surgeons alike.

Stapling Devices:

Stapling devices can provide an effective method for securing hemostasis. Single, inert, nonreactive titanium clips can be placed on a bleeding vessel with a reusable stainless steel laparoscopic applicator. These clip appliers can also be used in a disposable automatic system. The clips can be applied efficiently and quickly for individual bleeding sites where the application of any other form of energy source would jeopardize adjacent structures.1,2

Hemostasis can also be obtained along an entire line of staples with the use of a stapling device which applies 4-6 layers of titanium staples and uses a self-contained knife blade to divide between the staple.3 Tissue thickness is estimated and a staple cartridge which occludes to 1.5 mm or one which compresses to 1 mm may be used. When using the stapling device care must be taken to ensure that the jaws of the stapler are beyond the cannula and completely free before opening the device. In addition, it is essential to ensure that when the tissue is compressed it does not bunch up, which may result in the tissue being inadequately stapled. The jaws are closed by depressing the handle. Check to ensure that no unintended structures are included in the bite. The safety guard is then disengaged and the handles brought together to fire the staples. The dual staple lines must be carefully inspected to ensure that hemostasis is secured. Persistent bleeding may occur if the device is not correctly applied.4

During laparoscopic hysterectomy and oophorectomy, the linear stapling device can be effectively applied to the infundibulopelvic ligaments and ovarian vessels. The staples are particularly advantageous and time saving for securing the round ligament, tube and uterovarian ligament. Staple application to the uterine artery must only be attempted after the ureter has been dissected free.5

Stapling techniques offer the advantages of speed in simultaneously securing hemostasis and division of tissue. They are, however, expensive.

Endoscopic Suturing:

The use of sutures in laparoscopic surgery requires patience, persistence and practice. The development of advances in instrumentation have made suturing more accessible to surgeons whose are not comfortable with laparoscopic suturing. The aim of all laparoscopic suture techniques is to approximate tissue and ligate major blood vessels or tissue pedicles with the same degree of security as during open surgery.

The endo-loop is the simplest of suturing devices. In this system a pretied Roeder loop applied to a plastic shaft is positioned around the tissue to be ligated.3 When correctly positioned the tissue or pedicle is pulled up through the loop, which is then tightened. The ligature is cut after the loop has been applied. This system has been used for organs as large as the uterus in the process of performing supracervical hysterectomies, for vessels as large as the uterine artery and for structures such as the infundibulopelvic ligament after it has been isolated. The use of the endo-loop system requires only that the surgeon develop a knuckle or a pedicle in order to apply the loop.6

If it is necessary to pass suture through tissue and then tying it, the simplest method is an extracorporeal suture technique. Endosuture systems consist of a plastic shaft attached to a length of suture material and a straight or ski-shaped atraumatic needle. This system can be used to ligate vessels, reconstruct organs, approximate opposing tissue surfaces and suture anastomoses. The suture is grasped just below the swage point with a 3 mm needle holder and is inserted into an introducer so that the needle follows into the introducer. The introducer containing the needle and suture, is then brought into the body cavity through a 5 mm trocar. The needle is passed through the target tissue and retrieved. A Roeder knot or a square knot is tied and pushed into the abdominal cavity with a knot pusher. The technique for intracorporeal knot tying is very precise and similar to techniques for instrument ties in microscopic surgery.6

Reich developed an extracorporeal method for introducing large curved needles for laparoscopic suturing. To use this technique it is important to ensure that the lower quadrant secondary puncture incision is inserted lateral to the rectus muscle. The trocar should be inserted vertically, at right angles to the skin, to ensure the creation of a straight tract down the shortest distance into the body cavity. A large needle such as a CT 1 can be introduced with this method by removing the left 5 mm trocar sleeve and placing a finger over the incision to prevent the loss of pneumoperitoneum. The distal end of suture is grasped with the needle holder and backloaded through the trocar sleeve. The needle holder is reinserted into the sleeve and the suture is regrasped 2-4 cm from the swage. The needle holder is then inserted down the tract into the cavity, pulling the needle behind. Once the needle is inside the cavity the trocar is reinserted over the needle holder down the same tract. The needle is dropped, positioned and regrasped. When the needle has been passed through the desired tissue the needle is cut free and removed. The free end of the suture is then picked up with the needle holder and pulled up through the trocar sleeve. An extracorporeal half hitch is formed and pushed down to the operative site with the Clark-Reich knot pusher. A sufficient number of half hitches is placed to ensure integrity of the knot.7

Ingenious devices are being developed to allow surgeons to perform suturing techniques in a very safe and effective manner. Most of these devices require the use of 10 mm or 12 mm trocars reducing the advantage that suturing has over clips and staples in requiring a smaller port site. However, they provide the surgeon with an opportunity to place suture in a simpler manner. One of these devices developed by Laurus Medical and marketed by Ethicon Endosurgery (Somerset, NJ, USA) has been used for the laparoscopic Burch procedure and has been found to be very efficient in passing the needle through both Cooper's ligament and the para vaginal fascia.8 This device utilizes conventional needles, which are loaded into it. The device itself provides the rotational motion which is so difficult to produce in a laparoscopic procedure. This rotational effect thrusts the needle through the tissue against which it is applied.

Another ingenious device, the Endostitch, has been developed by Auto Suture (U.S. Surgical Corporation, Norwalk, CT, USA). This &#;sewing machine&#; like instrument allows for the transfer of a needle from one side of the tissue to the other creating a continuous line of suture. This device is especially useful for approximating tissues, repair of enterotomies and cystotomies, and performance of the laparoscopic Burch procedure.

Electrosurgery:

Both bipolar electrosurgical and monopolar electrosurgical energy can be used for coagulation. Bipolar coagulation techniques are preferred for large vessels. Monopolar techniques can also be used to coagulate large vessels if the vessel is first occluded with a grasper and monopolar cur-rent is then directed to the grasper coagulating the vessel.

Bipolar electrosurgery is an effective and inexpensive method of coagulating tissue prior to dissection.9 Bipolar coagulation has been applied effectively to vessels as large as the infundibulopelvic ligament and the uterine artery. The possibility of thermal spread must be considered when using either monopolar or bipolar unit. When a monopolar electrode was applied to rat bladder, under test conditions, there was an average increase of tissue temperature 19.9° C above core temperature. This increase is enough to cause protein denaturation. When bipolar energy was used, a rise of only 3.5° C was found.10 However, it has also been found that with 8 seconds of application of 50 watts power bipolar energy to the uterine artery, a temperature of 100° C can be detected 1 cm away from the application point.11 When bipolar electrocoagulation is applied to tissue, several stages are observed: blanching, boiling begins, boiling ceases, carbonization, and charring. The proper time to remove bipolar forceps from the tissue is the point at which boiling stops and before carbonization begins. The entire process is quite rapid and the window between these two critical stages is only a few seconds. For larger blood vessels apply bipolar electrocoagulation with Kleppinger forceps, which encircle, compress and fuse the vessel with the lowest degree of heating and least volume of fusion. Use 20-25 watts of high frequency electrodesiccation and determine by visual inspection when desiccation is complete.12 For larger vascular pedicles such as the infundibulopelvic ligament, the application of bipolar current is sequential, with repeated partial desiccation, and partial incision of the coagulated tissues. This method ensures minimum thermal spread through surrounding pelvic tissues and avoids inadvertent incision of incompletely coagulated tissues. Proper hemostasis is further ensured by viewing the field after the pneumoperitoneum pressure is decreased. It is also possible to reduce the incidence of thermal spread by passing fluid such as glycine down the cleaning channel of the bipolar coagulator to provide for cooling of the bipolar tips. It is most important that the stability of the vessel coagulum not be jeopardized by excessive heating.13

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