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1.  Improved access and visibility during stapling of the ultra-low rectum: a comparative human cadaver study between two curved staplers 
The purpose of this study was to compare in human cadavers the applicability of a commonly used stapling device, the CONTOUR® curved cutter (CC) (Ethicon Endo-Surgery, Cincinnati, OH) to a newly released, curved stapler, the Endo GIA™ Radial Reload with Tri-Staple™ Technology (RR) (Covidien, New Haven, CT)
Four experienced surgeons performed deep pelvic dissection with total mesorectal excision (TME) of the rectum in twelve randomized male cadavers. Both stapling devices were applied to the ultra-low rectum in coronal and sagittal configurations. Extensive measurements were recorded of anatomic landmarks for each cadaver pelvis along with various aspects of access, visibility, and ease of placement for each device.
The RR reached significantly lower into the pelvis in both the coronal and sagittal positions compared to the CC. The median distance from the pelvic floor was 1.0 cm compared to 2.0 cm in the coronal position, and 1.0 cm versus 3.3 cm placed sagitally, p < 0.0001. Surgeons gave a higher visibility rating with less visual impediment in the sagittal plane using the RR Stapler. Impediment of visibility occurred in only 10% (5/48) of RR applications in the coronal position, compared to a rate of 48% (23/48) using the CC, p = 0.0002.
The RR device performed significantly better when compared to the CC stapler in regards to placing the stapler further into the deep pelvis and closer to the pelvic floor, while causing less obstructing of visualization.
PMCID: PMC3539907  PMID: 23148602
2.  Staple Line Failure Using the Proximate® 100 mm Linear Cutter 
Diseases of the Colon and Rectum  2008;51(8):1275-1278.
An incomplete linear staple line that was discovered during the stapling of an ileal pouch alerted us to evaluate potential usage concerns with linear cutters. This study was designed to assess the integrity of the staple line of three different sizes of linear staplers.
In an animal model three different lengths of linear cutters (Proximate®, Ethicon Endo-Surgery) were used to cross-staple and transect the large bowel of one pig to check for the integrity of the proximal end of the staple line.
Cross-stapling and transecting across the pig’s large bowel demonstrated that if the tissue is advanced up to the highest number on the scale of the 100 mm stapling device, insufficient overlap between the proximal end of the staple line and the proximal end of the cut line occur.
Although a more than 100 mm staple line is delivered, the 100 mm cutter may not produce a double-staggered row of staples at the most proximal end of the staple line if the tissue is advanced past the 9.5 cm mark. Ethicon Endo-Surgery has agreed to add indicator markers to the scale label on the instrument to provide the user with additional guidance for tissue placement.
PMCID: PMC2491405  PMID: 18523825
Linear cutter; Stapler; Anastomotic leakage; Anastomotic insufficiency; Colorectal surgery
3.  Rectal eversion and double-stapled ileal pouch anal anastomosis in familial adenomatous polyposis syndrome 
Surgery is the only treatment option for familial adenomatous polyposis (FAP). Aim of surgery in FAP is to minimize colorectal cancer risk without need for permanent stoma. There are especially two operation options; Total colectomy with ileorectal anastomosis (IRA) and total proctocolectomy with ileo-pouch anal anastomosis (IPAA). We report here a patient with FAP who had resection via rectal eversion just over the dentate line under direct visualization and ileoanal-J pouch anastomosis by double-stapler technique.
A 40 yr. old female patient with FAP underwent surgery. Firstly, colon and the rectum mobilized completely, and then from the 10 cm. proximal to the ileo-caecal valve to the recto-sigmoid junction total colectomy was performed. Rectum was everted by a grasping forceps which was introduced through the anus and then resection was performed by a linear stapler just over the dentate line. A stapled J-shaped ileal reservoir construction followed by intraluminal stapler-facilitated ileoanal anastomosis. Follow up at six months anal sphincter function was found normal.
There is only surgical management option for FAP patients up to now. Total colectomy with IRA and restorative proctocolectomy with IPAA is surgical options for FAP patients that avoid the need for a permanent stoma. Anorectal eversion may be used in the surgical treatment of FAP, chronic ulcerative colitis and early stage distal rectal cancer patients.
J-pouch ileoanal anastomosis can safely be performed by rectal eversion and double stapler technique in FAP patients.
PMCID: PMC4245705  PMID: 25305601
Rectal eversion; Familial adenomatous polyposis; Double-stapler technique
4.  Sacro-femoral-pubic angle: a coronal parameter to estimate pelvic tilt 
European Spine Journal  2011;21(4):719-724.
Pelvic tilt is an established measure of position which has been tied to sagittal plane spinal deformity. Increased tilt is noted in the setting of the aging spine and sagittal malalignment syndromes such as flatback (compensatory mechanism). However, the femoral heads are often poorly visualized on sagittal films of scoliosis series in adults, limiting the ability to determine pelvic incidence and tilt. There is a need to establish a coronal plane (better visualization) pelvic parameter which correlates closely with pelvic tilt.
This is a retrospective review of 71 adult patients (47 females and 24 males) with full-length standing spine radiographs. Visualization of all spinal and pelvic landmarks was available coronally and sagittally (including pelvis and acetabuli). Pelvic tilt was calculated through validated digital analysis software (SpineView®). A new parameter, the sacro-femoral-pubic angle (midpoint of S1 endplate to centroid of acetabuli to superior border of the pubic symphysis) was analyzed for correlation (and predictive ability) with sagittal pelvic tilt.
The sacro-femoral-pubic angle (SFP angle) was highly correlated to PT, and according to this analysis, pelvic tilt could be estimated by the formula: PT = 75 − (SFP angle). A Pearson’s correlation coefficient of 0.74 (p < 0.005) and predictive ability of 76% accuracy was obtained (±7.5°). The correlation and predictive ability was greater for males compared to females (male: r = 0.87 and predictive model = 93%; female: r = 0.67 and predictive model = 67%).
The pelvic tilt is an essential measure in the context of radiographic evaluation of spinal deformity and malalignment. Given the routinely excellent visibility of coronal films this study established the SFP as a coronal parameter which can reliably estimate pelvic tilt. The high correlation and predictive ability of the SFP angle should prompt further study and clinical application when lateral radiographs do not permit assessment of pelvic parameters.
PMCID: PMC3326127  PMID: 22113529
Sagittal alignment; Pelvic tilt; Spine; Coronal; Radiographic evaluation
5.  Retrograde stapling of a free cervical jejunal interposition graft: a technical innovation and case report 
BMC Surgery  2014;14:78.
Free jejunal interposition is a useful technique for reconstruction of the cervical esophagus. However, the distal anastomosis between the graft and the remaining thoracic esophagus or a gastric conduit can be technically challenging when located very low in the thoracic aperture. We here describe a modified technique for retrograde stapling of a jejunal graft to a failed gastric conduit using a circular stapler on a delivery system.
Case presentation
A 56 year-old patient had been referred for esophageal squamous cell carcinoma at 20 cm from the incisors. On day 8 after thoracoabdominal esophagectomy with gastric pull-up, an anastomotic leakage was diagnosed. A proximal-release stent was successfully placed by gastroscopy and the patient was discharged. Two weeks later, an esophagotracheal fistula occurred proximal to the esophageal stent. Cervical esophagostomy was performed with cranial closure of the gastric conduit, which was left in situ within the right hemithorax. Three months later, reconstruction was performed using a free jejunal interposition. The anvil of a circular stapler (Orvil®, Covidien) was placed transabdominally through an endoscopic rendez-vous procedure into the gastric conduit. A free jejunal graft was retrogradely stapled to the proximal end of the conduit. Microvascular anastomoses were performed subsequently. The proximal anastomosis of the conduit was completed manually after reperfusion.
This modified technique allows stapling of a jejunal interposition graft located deep in the thoracic aperture and is therefore a useful method that may help to avoid reconstruction by colonic pull-up and thoracotomy.
PMCID: PMC4202252  PMID: 25319372
Gastric pull-up; Esophageal cancer; Conduit; Esophageal reconstruction
6.  Comparison of standard 4-row versus 6-row 3-D linear cutter stapler in creation of gastrointestinal system anastomoses: a prospective randomized trial 
Clinics  2012;67(9):1035-1038.
This prospective study was conducted to compare the clinical outcomes of a 6-row 3-D linear cutter with the standard 4-row linear cutter in patients who underwent elective gastrointestinal surgery anastomosis.
Patients who underwent elective open gastrointestinal surgery that included stapled anastomosis using a linear cutter (Proximate®, Ethicon Endo-Surgery, Cincinnati, OH) between January 2011 and May 2011 were included in the study. The patients were randomly assigned to two groups according to the linear cutter that was used in the surgery: the standard 4-row cutter (the S group) or the new 6-row cutter (the N group). The groups were compared based on the patient demographic data, the laboratory parameters, the preoperative diagnosis, the surgery performed, the operation time, intra- or postoperative complications, the time to oral tolerance and the length of the hospital stay.
The S group included 11 male and nine female patients with a mean age of 65±12 (35-84) years, while the N group included 13 male and eight female patients with a mean age of 62±11 (46-79) years (p = 0.448, p = 0.443, respectively). Anastomotic line bleeding was observed in eight (40%) patients in the S group and in one (4.7%) patient in the N group (p = 0.006). Dehiscence of the anastomosis line was observed in two (10%) patients in the S group and none in the N group (p = 0.131). Anastomotic leakage developed in three (15%) patients in the S group and in one (4.7%) patient in the N group (p = 0.269). The mean hospital stay was 12.65±6.1 days in the S group and 9.52±2.9 days in the N group (p = 0.043).
The 6-row 3-D linear cutter is a safe and easily applied instrument that can be used to create anastomoses in gastrointestinal surgery. The new stapler provides some usage benefits and is also superior to the standard linear cutter with regard to anastomotic line bleeding.
PMCID: PMC3438243  PMID: 23018300
Anastomosis; Linear Stapler; 4-Row Staple Line; Gastrointestinal Surgery
7.  The pull-through: back to the future 
Il Giornale di Chirurgia  2013;34(11-12):293-301.
Historically, coloanal pull-through (P-T) has been the first surgical procedure adopted to facilitate a handmade lower anastomosis. Very popular around mid twentieth century, P-T has had poor diffusion, mainly as a consequence of the technical simplifications brought by staplers. Recent literature seems poor on this specific topic, despite description of P-T appears in published series during the reconstructive phase of total laparoscopic protectomies. A comeback of P-T has also been observed as an option with deferred anastomosis, to allow and protect a coloanal anastomosis in situations at greater risk of dehiscence, avoiding a temporary faecal diversion.
After reviewing the most significant aspects of classic techniques of P-T, we report our experience with transanal laparoscopic P-T for distal rectal cancer, presenting a new, modified P-T with deferred anastomosis aimed at improving defecatory compliance.
Patients and methods
Between January 2008 and June 2011 we operated in 258 rectal cancers (0–14 cm from the anal verge), 62.79% of which by laparoscopic access (VL), with 218 restorative procedures (84.49%). The coloanal anastomoses (CAA) were globally 68 (26.35%), of which 48 in VL procedures (70.58%). In 27 of these CAAs we utilised the P-T procedure, with immediate CAA (I-CAA) in 11 cases (all VL) and delayed CAA (D-CAA) in 16 (2 VL), by selective indications. All CAAs were manually fashioned; 6 D-CAA had the addition of a transverse coloplasty. Site of tumor was the lower rectum in 24 patients, with 21 patients receiving preoperative chemoradiation.
There was no operative mortality. Early morbidity: D-CAA: 3 pelvic abscesses with stoma formation. I-CAA: 1 intraoperative re-resection and coloanal anastomosis with stoma formation for defective distal vascular supply. Late morbidity: anastomotic stenosis in 5/12 I-CAA and 4/14 D-CAA controlled by mechanical dilation. Function: 4/7 D-CAA and 4/6 I-CAA nearly complete functional recovery (Kirwan’s 1 or 2).
There are selective indications to P-T, when resection and anastomosis is not feasible in one step, or also as a primary restorative option in elective cases when a covering stoma is refused or dangerous.
PMCID: PMC3926465  PMID: 24342154
Pull-through; Laparoscopic; Transanal; Rectal cancer; Delayed coloanal anastomosis; Sphincter function
8.  Risk factors associated with delayed gastric emptying after subtotal gastrectomy with Billroth-I anastomosis using circular stapler for early gastric cancer patients 
Gastric surgery may potentiate delayed gastric emptying. Billroth I gastroduodenostomy using a circular stapler is the most preferable reconstruction method. The purpose of this study is to analyze the risk factors associated with delayed gastric emptying after radical subtotal gastrectomy with Billroth I anastomosis using a stapler for early gastric cancer.
Three hundred and seventy-eight patients who underwent circular stapled Billroth I gastroduodenostomy after subtotal gastrectomy due to early gastric cancer were analyzed retrospectively. One hundred and eighty-two patients had Billroth I anastomosis using a 25 mm diameter circular stapler, and 196 patients had anastomosis with a 28 or 29 mm diameter circular stapler. Clinicopathological features and postoperative outcomes were evaluated and compared between the two groups. Delayed gastric emptying was diagnosed by symptoms and simple abdomen X-ray with or without upper gastrointestinal series or endoscopy.
Postoperative delayed gastric emptying was found in 12 (3.2%) of the 378 patients. Among all the variables, distal margin and circular stapler diameter were significantly different between the cases with delayed gastric emptying and no delayed gastric emptying. There were statistically significant differences in sex, body mass index, comorbidity, complication, and operation type according to circular stapler diameter. In both univariate and multivariate logistic regression analyses, only the stapler diameter was found to be a significant factor affecting delayed gastric emptying (P = 0.040).
In this study, the circular stapler diameter was one of the most significant predictable factors of delayed gastric emptying for Billroth I gastroduodenostomy. The use of a 28 or 29 mm diameter circular stapler rather than a 25 mm diameter stapler in stapled gastroduodenostomy for early gastric cancer can reduce postoperative delayed gastric emptying associated with anastomosic stenosis or edema with relative safety.
PMCID: PMC3491229  PMID: 23166886
Gastric emptying; Gastrectomy; Billroth-I; Gastric neoplasms
9.  Stapled Mucosectomy: An Alternative Technique for the Removal of Retained Rectal Mucosa after Ileal Pouch-Anal Anastomosis 
Gut and Liver  2011;5(4):539-542.
Restorative proctocolectomy (RPC), when performed with a stapled ileal pouch-anal anastomosis (IPAA), allows the retention of the rectal mucosa above the dentate line and can result in disease persistence or recurrence, as well as neoplastic lesions in patients with ulcerative colitis (UC). We report the case of a patient with chronic UC who underwent staple mucosectomy, which is an alternative technique that evolved from stapled hemorrhoidopexy, rather than more traditional procedures. The patient had undergone laparoscopic RPC with a stapled IPAA 2 cm above the dentate line and a temporary loop ileostomy. Because the histopathology showed low-grade dysplasia in the proximal rectum, stapled mucosectomy with a 33-mm circular stapler kit at the time of ileostomy closure was scheduled. Following the application of a purse-string suture 1 cm above the dentate line, the stapler was inserted with its anvil beyond the purse-string and was fired. The excised rectal tissue was checked to ensure that it was a complete cylindrical doughnut. Histopathology of the excised tissue showed chronic inflammation. There were no complications during a follow-up period of 5 months. Because it preserves the normal rectal mucosal architecture and avoids a complex mucosectomy surgery, stapled mucosectomy seems to be a technically feasible and clinically acceptable alternative to the removal of rectal mucosa retained after RPC.
PMCID: PMC3240802  PMID: 22195257
Ulcerative colitis; Retained rectal mucosa; Stapled mucosectomy; Surgical technique
10.  Progression from laparoscopic-assisted to totally laparoscopic distal gastrectomy: comparison of circular stapler (i-DST) and linear stapler (BBT) for intracorporeal anastomosis 
Surgical Endoscopy  2012;27(1):325-332.
Billroth I (B-I) gastroduodenostomy is an anastomotic procedure that is widely performed after gastric resection for distal gastric cancer. A circular stapler often is used for B-I gastroduodenostomy in open and laparoscopic-assisted distal gastrectomy. Recently, totally laparoscopic distal gastrectomy (TLDG) has been considered less invasive than laparoscopic-assisted gastrectomy, and many institutions performing laparoscopic-assisted distal gastrectomy are trying to progress to TLDG without markedly changing the anastomosis method. The purpose of this report is to introduce the technical details of new methods of intracorporeal gastroduodenostomy using either a circular or linear stapler and to evaluate their technical feasibility and safety.
Seventeen patients who underwent TLDG with the intracorporeal double-stapling technique using a circular stapler (n = 7) or the book-binding technique (BBT) using a linear stapler (n = 10) between February 2010 and April 2011 were enrolled in the study. Clinicopathological data, surgical data, and postoperative outcomes were analyzed.
There were no intraoperative complications or conversions to open surgery in any of the 17 patients. The usual postoperative complications following gastroduodenostomy, such as anastomotic leakage and stenosis, were not observed. Anastomosis took significantly longer to complete with DST (64 ± 24 min) than with BBT (34 ± 7 min), but more stapler cartridges were needed with BBT than with DST.
TLDG using a circular or linear stapler is feasible and safe to perform. DST will enable institutions performing laparoscopic-assisted distal gastrectomy with circular staplers to progress to TLDG without problems, and this progression may be more economical because fewer stapler cartridges are used during surgery. However, if an institution has already been performing δ anastomosis in TLDG but has been experiencing certain issues with δ anastomosis, converting from δ anastomosis to BBT should be beneficial.
Electronic supplementary material
The online version of this article (doi:10.1007/s00464-012-2433-y) contains supplementary material, which is available to authorized users.
PMCID: PMC3532722  PMID: 22733199
Laparoscopic distal gastrectomy; Totally laparoscopic gastrectomy; Intracorporeal anastomosis; Intracorporeal DST; Book-binding technique
11.  Anterior resection of the rectum--a simplified stapling technique. 
The use of a double stapling technique in anterior resection of the rectum eliminates the necessity for a rectal stump pursestring and removes the problem of tissue pouting on the spindle of the circular EEA stapler when a voluminous rectum is pulled onto it with the pursestring. We have used this technique in 20 patients with tumours in the middle and lower thirds of the rectum without complication. This technique may reduce contamination in the pelvis and certainly shortens operating time. Cost effectiveness of the technique should be evaluated in busy centres where the benefit would appear to be greatest.
PMCID: PMC2499526  PMID: 4051423
12.  Risk factors for anastomotic leakage after laparoscopic low anterior resection with DST anastomosis 
Surgical Endoscopy  2014;28(10):2988-2995.
Laparoscopic rectal surgery involving rectal transection and anastomosis with stapling devices is technically difficult. The aim of this study was to evaluate the risk factors for anastomotic leakage (AL) after laparoscopic low anterior resection (LAR) with double-stapling technique (DST) anastomosis.
This was a retrospective single-institution study of 154 rectal cancer patients who underwent laparoscopic LAR with DST anastomosis between June 2005 and August 2013. Patient-, tumor-, and surgery-related variables were examined by univariate and multivariate analyses. The outcome of interest was clinical AL.
The overall AL rate was 12.3 % (19/154). In univariate analysis, tumor size (P = 0.001), operative time (P = 0.049), intraoperative bleeding (P = 0.037), lateral lymph node dissection (P = 0.009), multiple firings of the linear stapler (P = 0.041), and precompression before stapler firings (P = 0.008) were significantly associated with AL. Multivariate analysis identified tumor size (odds ratio [OR] 4.01; 95 % confidence interval [CI] 1.25–12.89; P = 0.02) and precompression before stapler firings (OR 4.58; CI 1.22–17.20; P = 0.024) as independent risk factors for AL. In particular, precompression before stapler firing tended to reduce the AL occurring in early postoperative period.
Using appropriate techniques, laparoscopic LAR with DST anastomosis can be performed safely without increasing the risk of AL. Important risk factors for AL were tumor size and precompression before stapler firings.
PMCID: PMC4186976  PMID: 24853855
Rectal cancer; Anastomotic leakage; Double-stapling technique; Laparoscopic low anterior resection
13.  Laparoscopic Vascular Control Techniques in Donor Nephrectomy: Effects on Vessel Length 
Various techniques for vascular control have been used during urologic laparoscopic procedures. The importance of optimizing the vessel length and securing reliable vascular control are critical for procedures like laparoscopic donor nephrectomy. We aimed to determine the length of vessel lost by using 4 common techniques of vascular control in a fresh human cadaveric vascular model.
The techniques include application of 2 nonabsorbable polymer-ligating clips (10-mm Hem-o-Lok MLX Weck Closure Systems, Research Triangle Park, NC), Endo-GIA II stapler (30-mm length, 2.5-mm staples, Auto Suture, US Surgical, Norwalk, CT), Endopath ETS35 stapler (35mm length, 2.5mm staples, Ethicon Endo-Surgery), and the Endo Ta-30 stapler (30-mm length, 2.5-mm staples, Auto Suture, US Surgical, Norwalk, CT).
The Endo-TA-30 stapler and the polymer clips resulted in significantly less compromise of the vessel length, when compared with the other methods of vascular control.
The Endo-TA-30 stapler and the polymer clips can be applied during laparoscopic procedures where optimizing vascular length is important.
PMCID: PMC3016141  PMID: 16882408
Stapler; Vascular; Laparoscopy; Donor; Nephrectomy
14.  Laparoscopically Assisted Low Anterior Resection for Lower Rectal Endometriosis: Usefulness of Laparoscopic Surgery 
Case Reports in Gastroenterology  2009;3(3):318-323.
A 34-year-old woman presented with pain during menstruation and was diagnosed with endometriosis of the lower rectum. Despite treatment with an LH-RH agonist, she was unable to become pregnant and surgical removal of her endometriosis was recommended. Preoperative magnetic resonance imaging revealed endometriosis localized between the neck of the uterus and rectum with indentation and scuffing. Laparoscopically assisted low anterior resection was performed. Exfoliation was started from the right side of the rectum to the presacral and retrorectal space, and the rectococcygeus ligament was transected. Exfoliation of the retrorectal space was continued to the levator ani muscle and mobilization of the right side of the rectum was performed. In front of the rectum, exfoliation was started posterior to the wall of the vagina, but layers became unclear near the tumor as the tissue was solid in this region. The left hypogastric nerve close to the tumor was inflamed and it was cut. The layer of the exfoliation was connected to the right side of the rectum, the tumor was isolated from the vagina, and the lower rectum was transected at a point 1 cm distal to the tumor with a 60-mm linear stapler. Reconstruction with a 31-mm circular stapler was performed using the double stapling technique. Operative time was 520 min with a blood loss of 320 ml. On the 9th post operative day, a rectovaginal fistula occurred, and ileostomy was performed. The patient was discharged from the hospital on the 25th postoperative day, and 4 months later, stoma closure was performed.
PMCID: PMC2988924  PMID: 21103248
Colorectal endometriosis; Lower rectum; Laparoscopically assisted low anterior resection
15.  Efficacy of the modified anvil grasper for laparoscopic intra-corporeal circular stapled anastomosis 
The traditional anvil grasper may be difficult to use for connecting the stem of an anvil with the centre rod of a circular stapler because the grasper holds the anvil completely still. In addition, the head angle is fixed and cannot handle the anvil head delicately in a tight pelvic space. Many surgeons use a grasper designed for holding the bowel or a dissector for holding the anvil during intra-corporeal circular stapled anastomosis during low anterior resection, sigmoidectomy, left hemi colectomy and know that it is difficult to connect segments with these instruments due to slipping. A new modified anvil grasper was developed with curved blades that can easily grasp the stem of an anvil and smoothly connect it with the centre rod of the circular stapler. This grasper should be useful for surgeons performing laparoscopic intra-corporeal circular stapled anastomoses, which are the most challenging part of laparoscopic colorectal surgery.
PMCID: PMC3523458  PMID: 23248448
Anvil grasper; Intra-corporeal circular stapled anastomosis; colorectal cancer
16.  Colovaginal anastomosis: an unusual complication of stapler use in restorative procedure after Hartmann operation 
Rectovaginal fistula is uncommon after lower anterior resection for rectal cancer. The most leading cause of this complication is involvement of the posterior wall of the vagina into the staple line when firing the circular stapler.
Case presentation
A 50-year-old women underwent resection for obstructed carcinoma of the sigmoid colon with Hartmann procedure. Four months later she underwent restorative surgery with circular stapler. Following which she developed rectovaginal fistula. A transvaginal repair was performed but stool passing from vagina not per rectum. Laporotomy revealed colovaginal anastomosis, which was corrected accordingly. Patient had an uneventful recovery.
Inadvertent formation of colovaginal anastomosis associated with a rectovaginal fistula is a rare complication caused by the operator's error. The present case again highlights the importance of ensuring that the posterior wall of vagina is away from the staple line.
PMCID: PMC1315324  PMID: 16285887
17.  Transanal natural orifice transluminal endoscopic surgery total mesorectal excision in animal models: endoscopic inferior mesenteric artery dissection made easier by a retroperitoneal approach 
We report the performance of natural orifice transluminal endoscopic surgery (NOTES) low anterior resection in animals using transanal total mesorectal excision (TME) with laparoscopic assistance and endoscopic inferior mesenteric artery (IMA) dissection.
Four pigs weighing 45 kg each, and one dog weighing 25 kg, underwent surgery via a transanal approach. The rectum was occluded transanally using a purse-string suture, approximately 3-4 cm from the anal verge. The rectal mucosa was incised circumferentially just distal to the purse-string. A SILS or GelPOINT port was inserted transanally. Transanal TME was assisted by laparoscopy and proceeded up to the peritoneal reflection. More proximal dissection, including IMA dissection, was performed along the retroperitoneal avascular plane by endoscopy alone and facilitated by CO2 insufflation. The IMA was clipped and divided endoscopically. The mobilized rectosigmoid were exteriorized transanally and transected. A colorectal anastomosis was performed using a circular stapler with a single stapling technique.
Endoscopic dissection of the IMA was successful in all five animals. The mean operation time was 125 minutes (range, 90-170 minutes). There were no intraoperative complications or hemodynamic instability. The mean length of the resected specimen was 14.4 cm (range, 12-16 cm).
A NOTES retroperitoneal approach to the IMA with CO2 insufflation and intact peritoneal covering overcame the difficulties of retraction and exposure of endoscopic dissection in animals.
PMCID: PMC4091439  PMID: 25025019
Natural orifice transluminal endoscopic surgery; Retroperitoneal approach; Total mesorectal excision; Inferior mesenteric artery
18.  Functional outcome after perineal stapled prolapse resection for external rectal prolapse 
BMC Surgery  2010;10:9.
A new surgical technique, the Perineal Stapled Prolapse resection (PSP) for external rectal prolapse was introduced in a feasibility study in 2008. This study now presents the first results of a larger patient group with functional outcome in a mid-term follow-up.
From December 2007 to April 2009 PSP was performed by the same surgeon team on patients with external rectal prolapse. The prolapse was completely pulled out and then axially cut open with a linear stapler at three and nine o'clock in lithotomy position. Finally, the prolapse was resected stepwise with the curved Contour® Transtar™ stapler at the prolapse's uptake. Perioperative morbidity and functional outcome were prospectively measured by appropriate scores.
32 patients participated in the study; median age was 80 years (range 26-93). No intraoperative complications and 6.3% minor postoperative complications occurred. Median operation time was 30 minutes (15-65), hospital stay 5 days (2-19). Functional outcome data were available in 31 of the patients after a median follow-up of 6 months (4-22). Preoperative severe faecal incontinence disappeared postoperatively in 90% of patients with a reduction of the median Wexner score from 16 (4-20) to 1 (0-14) (P < 0.0001). No new incidence of constipation was reported.
The PSP is an elegant, fast and safe procedure, with good functional results.
Trial registration
PMCID: PMC2843648  PMID: 20205956
19.  Dynamic Magnetic Resonance Imaging Demonstrates the Integrity of Perineal Reconstruction following Cylindrical Abdominoperineal Excision with Reconstruction of the Pelvic Floor Using Porcine Collagen 
Case Reports in Medicine  2012;2012:752357.
A 72-year-old female presented with a six-month history of increased frequency of defecation, rectal bleeding, and severe rectal pain. Digital rectal examination and endoscopy revealed a low rectal lesion lying anteriorly. This was confirmed histologically as adenocarcinoma. Radiological staging was consistent with a T3N2 rectal tumour. Following long-course chemoradiotherapy repeat staging did not identify any metastatic disease. She underwent a laparoscopic cylindrical abdominoperineal excision with en bloc resection of the coccyx and posterior wall of the vagina with a negative circumferential resection margin. The perineal defect was reconstructed with Permacol (biological implant, Covidien) mesh. She had no clinical evidence of a perineal hernia at serial followup. Dynamic MRI images of the pelvic floor obtained during valsalva at 10 months revealed an intact pelvic floor. A control case that had undergone a conventional abdominoperineal excision with primary perineal closure without clinical evidence of herniation was also imaged. This confirmed subclinical perineal herniation with significant downward migration of the bowel and bladder below the pubococcygeal line. We eagerly await further evidence supporting a role for dynamic MR imaging in assessing the integrity of a reconstructed pelvic floor following cylindrical abdominoperineal excision.
PMCID: PMC3270543  PMID: 22312372
20.  Surgical stapling device–tissue interactions: what surgeons need to know to improve patient outcomes 
The introduction of both new surgical devices and reengineered existing devices leads to modifications in the way traditional tasks are carried out and allows for the development of new surgical techniques. Each new device has benefits and limitations in regards to tissue interactions that, if known, allow for optimal use. However, most surgeons are unaware of these attributes and, therefore, new device introduction creates a “knowledge gap” that is potentially dangerous. The goal of this review is to present a framework for the study of device– tissue interactions and to initiate the process of “filling in” the knowledge gap via the available literature. Surgical staplers, which are continually being developed, are the focus of this piece. The integrity of the staple line, which depends on adequate tissue compression, is the primary factor in creating a stable anastomosis. This review focuses on published studies that evaluated the creation of stable anastomoses in bariatric, thoracic, and colorectal procedures. Understanding how staplers interact with target tissues is key to improving patient outcomes. It is clear from this review that each tissue type presents unique challenges. The thickness of each tissue varies as do the intrinsic biomechanical properties that determine the ideal compressive force and prefiring compression time for each tissue type. The correct staple height will vary depending on these tissue-specific properties and the tissue pathology. These studies reinforce the universal theme that compression, staple height, tissue thickness, tissue compressibility, and tissue type must all be considered by the surgeon prior to choosing a stapler and cartridge. The surgeon’s experience, therefore, is a critical factor. Educational programs need to be established to inform and update surgeons on the characteristics of each stapler. It is hoped that the framework presented in this review will facilitate this process.
PMCID: PMC4168870  PMID: 25246812
stapler; anastomosis; bariatric; colorectal; thoracic; education
21.  The Use of Bovine Pericardial Buttress on Linear Stapler Fails to Reduce Pancreatic Fistula Incidence in a Porcine Pancreatic Transection Model 
HPB Surgery  2011;2011:624060.
We investigate the effectiveness of buttressing the surgical stapler to reduce postoperative pancreatic fistulae in a porcine model. As a pilot study, pigs (n = 6) underwent laparoscopic distal pancreatectomy using a standard stapler. Daily drain output and lipase were measured postoperative day 5 and 14. In a second study, pancreatic transection was performed to occlude the proximal and distal duct at the pancreatic neck using a standard stapler (n = 6), or stapler with bovine pericardial strip buttress (n = 6). Results. In pilot study, 3/6 animals had drain lipase greater than 3x serum on day 14. In the second series, drain volumes were not significantly different between buttressed and control groups on day 5 (55.3 ± 31.6 and 29.3 ± 14.2 cc, resp.), nor on day 14 (9.5 ± 4.2 cc and 2.5 ± 0.8 cc, resp., P = 0.13). Drain lipase was not statistically significant on day 5 (3,166 ± 1,433 and 6,063 ± 1,872 U/L, resp., P = 0.25) or day 14 (924 ± 541 and 360 ± 250 U/L). By definition, 3/6 developed pancreatic fistula; only one (control) demonstrating a contained collection arising from the staple line. Conclusion. Buttressed stapler failed to protect against pancreatic fistula in this rigorous surgical model.
PMCID: PMC3202096  PMID: 22114365
22.  Comparative Study of Hand-Sutured versus Circular Stapled Anastomosis for Gastrojejunostomy in Laparoscopy Assisted Distal Gastrectomy 
Journal of Gastric Cancer  2012;12(2):120-125.
Mechanical stapler is regarded as a good alternative to the hand sewing technique, when used in gastric reconstruction. The circular stapling method has been widely applied to gastrectomy (open orlaparoscopic), for gastric cancer. We illustrated and compared the hand-sutured method to the circular stapling method, for Billroth-II, in patients who underwent laparoscopy assisted distal gastrectomy for gastric cancer.
Materials and Methods
Between April 2009 and May 2011, 60 patients who underwent laparoscopy assisted distal gastrectomy, with Billroth-II, were enrolled. Hand-sutured Billroth-II was performed in 40 patients (manual group) and circular stapler Billroth-II was performed in 20 patients (stapler group). Clinicopathological features and post-operative outcomes were evaluated and compared between the two groups.
Nosignificant differences were observed in clinicopathologic parameters and post-operative outcomes, except in the operation times. Operation times and anastomosis times were significantly shorter in the stapler group (P=0.004 and P<0.001).
Compared to the hand-sutured method, the circular stapling method can be applied safely and more efficiently, when performing Billroth-II anastomosis, after laparoscopy assisted distal gastrectomy in patients with gastric cancer.
PMCID: PMC3392323  PMID: 22792525
Laparoscopy; Gastric cancer; Billroth-II; Staple
23.  Structure of the Perineal Membrane in Females: Gross and Microscopic Anatomy 
Obstetrics and gynecology  2008;111(3):686-693.
To re-examine the anatomy of the perineal membrane and its anatomical relationships in whole-pelvis and histological serial section as well as gross anatomical dissection.
Serial trichrome-stained histologic sections of 5 female pelvic specimens (0 to 37 years old) were examined. Specimens included the urethra, perineal membrane, vagina and surrounding structures. Macroscopic whole pelvis sections of 3 adults 28 to 56 years in axial, sagittal and coronal sections were also studied. Dissections of 6 female cadavers 48 to 90 years were also performed.
The perineal membrane is composed of 2 regions, one dorsal and one ventral. The dorsal portion consists of bilateral transverse fibrous sheets that attach the lateral wall of the vagina and perineal body to the ischiopubic ramus. This portion is devoid of striated muscle. The ventral portion is part of a solid 3-dimensional tissue mass in which several structures are embedded. It is intimately associated with the compressor urethrae and the urethrovaginal sphincter muscle of the distal urethra with the urethra and its surrounding connective. In this region the perineal membrane is continuous with the insertion of the arcus tendineus fascia pelvis. The levator ani muscles are connected with the cranial surface of the perineal membrane. The vestibular bulb and clitoral crus are fused with the membrane's caudal surface.
The structure of the perineal membrane is a complex 3-dimensional structure with two distinctly different dorsal and ventral regions; not a simple trilaminar sheet with perforating viscera.
PMCID: PMC2775042  PMID: 18310372
perineal membrane; urogenital diaphragm; pelvic floor dysfunction; pelvic organ prolapse; anatomy; female
24.  Laparoscopic Anterior Resection: New Anastomosis Technique in a Pig Model 
Background and Objectives:
Bowel anastomosis after anterior resection is one of the most difficult tasks to perform during laparoscopic colorectal surgery. This study aims to evaluate a new feasible and safe intracorporeal anastomosis technique after laparoscopic left-sided colon or rectum resection in a pig model.
The technique was evaluated in 5 pigs. The OrVil device (Covidien, Mansfield, Massachusetts) was inserted into the anus and advanced proximally to the rectum. A 0.5-cm incision was made in the sigmoid colon, and the 2 sutures attached to its delivery tube were cut. After the delivery tube was evacuated through the anus, the tip of the anvil was removed through the perforation. The sigmoid colon was transected just distal to the perforation with an endoscopic linear stapler. The rectosigmoid segment to be resected was removed through the anus with a grasper, and distal transection was performed. A 25-mm circular stapler was inserted and combined with the anvil, and end-to-side intracorporeal anastomosis was then performed.
We performed the technique in 5 pigs. Anastomosis required an average of 12 minutes. We observed that the proximal and distal donuts were completely removed in all pigs. No anastomotic air leakage was observed in any of the animals.
This study shows the efficacy and safety of intracorporeal anastomosis with the OrVil device after laparoscopic anterior resection.
PMCID: PMC4208905  PMID: 25392669
Laparoscopic anterior resection; Anastomosis; Pig model; OrVil
25.  The C-seal trial: colorectal anastomosis protected by a biodegradable drain fixed to the anastomosis by a circular stapler, a multi-center randomized controlled trial 
BMC Surgery  2012;12:23.
Anastomotic leakage is a major complication in colorectal surgery and with an incidence of 11% the most common cause of morbidity and mortality. In order to reduce the incidence of anastomotic leakage the C-seal is developed. This intraluminal biodegradable drain is stapled to the anastomosis with a circular stapler and prevents extravasation of intracolonic content in case of an anastomotic dehiscence.
The aim of this study is to evaluate the efficacy of the C-seal in reducing anastomotic leakage in stapled colorectal anastomoses, as assessed by anastomotic leakage leading to invasive treatment within 30 days postoperative.
The C-seal trial is a prospective multi-center randomized controlled trial with primary endpoint, anastomotic leakage leading to re-intervention within 30 days after operation. In this trial 616 patients will be randomized to the C-seal or control group (1:1), stratified by center, anastomotic height (proximal or distal of peritoneal reflection) and the intention to create a temporary deviating ostomy. Interim analyses are planned after 50% and 75% of patient inclusion. Eligible patients are at least 18 years of age, have any colorectal disease requiring a colorectal anastomosis to be made with a circular stapler in an elective setting, with an ASA-classification < 4. Oral mechanical bowel preparation is mandatory and patients with signs of peritonitis are excluded. The C-seal student team will perform the randomization procedure, supports the operating surgeon during the C-seal application and achieves the monitoring of the trial. Patients are followed for one year after randomization en will be analyzed on an intention to treat basis.
This Randomized Clinical trial is designed to evaluate the effectiveness of the C-seal in preventing clinical anastomotic leakage.
Trial registration
PMCID: PMC3558481  PMID: 23153188

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