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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 
Background
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)
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1750-1164-6-11
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.
Purpose
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1007/s10350-008-9305-5
PMCID: PMC2491405  PMID: 18523825
Linear cutter; Stapler; Anastomotic leakage; Anastomotic insufficiency; Colorectal surgery
3.  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.
OBJECTIVE:
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.
METHOD:
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.
RESULTS:
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).
CONCLUSION:
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.
doi:10.6061/clinics/2012(09)09
PMCID: PMC3438243  PMID: 23018300
Anastomosis; Linear Stapler; 4-Row Staple Line; Gastrointestinal Surgery
4.  Linear stapler closure of the pharynx during total laryngectomy: a 15-year experience (from closed technique to semi-closed technique) 
Summary
Personal experience in performing linear stapler closure of the pharynx during 70 total laryngectomies is reported. Laryngeal staplers (55 and 60 cm) with an angled handle were used, permitting vertical closure with 19 or 20 metal staples in a double row. A closed technique was initially used, but, over the years, this has gradually been replaced by the semi-closed technique to avoid trapping the suprahyoid part of the epiglottis between the jaws of the stapler. The stapler is inserted below the larynx after having separated it from all muscular and neurovascular connections, and after performing a mini-pharyngotomy at the vallecula epiglottica in order to extract the epiglottis, evert it ventrally and suture it to the hyothyroepiglottic space. The jaws of the stapler are closed and the staples are fired while the flaps of the mini-pharyngotomy are raised above the jaws. The scalpel is inserted above the stapler to remove the larynx. When the stapler is opened, the vertical linear suture of the pharynx is evident and can be examined. This procedure takes only a few minutes to perform. It guarantees a long-term stable watertight closure, dramatically reduces contamination of the operating field by pharyngeal secretions, and permits rapid healing time, greatly lowering patient management costs. In the cases presented here, there was a 1.8% rate of pharyngocutaneous fistulae in patients who were not radiated, whereas the rate was 13.1% in pre-radiated patients. In agreement with the international literature, this procedure does not increase the rate of fistulae and, in fact, it seems to reduce it. Moreover, it is particularly indicated for pre-radiated patients. Nevertheless, the Authors recommend reserving this type of procedure to cases in which, based on meticulous pre-operative assessment by means of endoscopy and imaging, the endolaryngeal site of the tumour has been assessed and there is no need for peri-operative exploration of the pharynx or tongue base.
PMCID: PMC2640047  PMID: 17883187
Larynx; Total laryngectomy; Autosuture; Semi-closed technique
5.  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.
doi:10.4103/0972-9941.103132
PMCID: PMC3523458  PMID: 23248448
Anvil grasper; Intra-corporeal circular stapled anastomosis; colorectal cancer
6.  Functional outcome after perineal stapled prolapse resection for external rectal prolapse 
BMC Surgery  2010;10:9.
Background
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.
Methods
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.
Results
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.
Conclusions
The PSP is an elegant, fast and safe procedure, with good functional results.
Trial registration
ISRCTN68491191
doi:10.1186/1471-2482-10-9
PMCID: PMC2843648  PMID: 20205956
7.  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.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1007/s00464-012-2433-y
PMCID: PMC3532722  PMID: 22733199
Laparoscopic distal gastrectomy; Totally laparoscopic gastrectomy; Intracorporeal anastomosis; Intracorporeal DST; Book-binding technique
8.  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.
doi:10.5009/gnl.2011.5.4.539
PMCID: PMC3240802  PMID: 22195257
Ulcerative colitis; Retained rectal mucosa; Stapled mucosectomy; Surgical technique
9.  A New Laparoscopic Surgical Procedure to Achieve Sufficient Mesorectal Excision in Upper Rectal Cancer 
Objective. Mesorectal excision corresponding to the location of a tumor, termed tumor-specific mesorectal excision (TSME), is commonly performed for resection of upper rectal cancer. We devised a new laparoscopic procedure for sufficient TSME with rectal transection followed by mesorectal excision. Operative Technique. After mobilization of the sigmoid colon and ligation of inferior mesenteric vessels, we dissected the mesorectum along the layer of the planned total mesorectal excision. The rectal wall was carefully separated from the mesorectum at the appropriate anal side from the tumor. After the rectum was isolated and transected using an endoscopic linear stapler, the rectal stump drew immediately toward the anal side, enabling the mesorectum to be identified clearly. In this way, sufficient TSME can be performed easily and accurately. This technique has been successfully conducted on 19 patients. Conclusion. This laparoscopic technique is a feasible and reliable procedure for achieving sufficient TSME.
doi:10.1155/2011/708439
PMCID: PMC3263670  PMID: 22312519
10.  Laparoscopic Vascular Control Techniques in Donor Nephrectomy: Effects on Vessel Length 
Background:
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.
Methods:
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).
Results:
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.
Conclusions:
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
11.  Reverse Transrectal Stapling Technique Using the EEA Stapler: An Alternative Approach in Difficult Reversal of Hartmann’s Procedure 
The introduction of circular end-to-end stapling devices (CEEA OR EEA stapler) into colorectal surgery have revolutionised anastomotic techniques. The EEA stapler is generally regarded as an instrument that is safe, reliable, and simple to operate. Despite it’s popularity, very little information is available regarding the technical difficulties encountered during surgery. The routine technique to perform an end-to-end circular colonic anastomosis is to introduce the instrument distally through the anus (transrectal/transanal approach) and attach it to the anvil which is purse stringed at the distal end of the proximal bowel to be anastomosed. Two cases of reversal of Hartmann’s procedure for perforated diverticulitis are described in the present study, where difficulty was experienced while using the EEA stapler in the routine method. Hence, an alternative reverse technique which was used is presented.
doi:10.4103/2006-8808.73618
PMCID: PMC3214281  PMID: 22091338
Colorectal anastomosis; diverticulitis; Hartmann’s procedure; EEA stapler; reverse stapling technique
12.  Colovaginal anastomosis: an unusual complication of stapler use in restorative procedure after Hartmann operation 
Background
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.
Conclusion
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.
doi:10.1186/1477-7819-3-74
PMCID: PMC1315324  PMID: 16285887
13.  Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomsis 
Journal of Thoracic Disease  2013;5(6):895-897.
We retrospectively analyzed the clinical data of 112 patients who underwent esophagectomy for esophageal carcinoma and gastro-esophageal anastomosis in right thoracic cavity from October 2011 to June 2013. First, the gastric tube was created with the aid of linear stapling device by removing the stomach and dissecting lymph nodes under laparoscopy and making a 3-4 cm incision through the subxiphoid area in the upper abdomen. Second, the thoracic esophagus and lymph nodes were dissected during thoracoscopic procedure. Gastric tube was inserted into the chest cavity and placed in the posterior mediastinum. The thoracic gastro-esophageal anastomosis was stapled with a circular stapler. Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis is technically feasible and safe, with minimized trauma, less operative blood loss and quick recovery.
doi:10.3978/j.issn.2072-1439.2013.12.11
PMCID: PMC3886844  PMID: 24416509
Laparoscopic; thoracoscopic; esophagectomy; esophagogastric anastomosis; esophageal carcinoma
14.  STARR with Contour® Transtar™: prospective multicentre European study 
Colorectal Disease  2009;11(8):821-827.
Objective
The stapled transanal rectal resection (STARR) in patients with defecation disorders is limited by the shape and capacity of the circular stapler. A new device has been recently developed, the Contour® Transtar™ stapler, in order to improve the safety and effectiveness of the STARR technique. The study has been designed to confirm this declaration.
Method
From January to June 2007 a prospective European multicentre study of consecutive patients with defecation disorder caused by internal rectal prolapse underwent the new STARR technique. The assessment of perioperative morbidity and functional outcome after 6 weeks, 3 and 12 months was documented by different scores.
Results
In all 75 patients, median age 64, the Transtar procedure was performed with 9% intraoperative difficulties, 7% postoperative complications and no mortality. The mean reduction of the ODS score was −15.6 (95%−CI: −17.3 to −13.8, P < 0.0001), mean reduction of SSS was −12.6 (95%−CI: −14.2 to −11.2; P < 0.0001). 41% stated improvement of their continence status by CCF score, only 4 patients (5%) had deterioration.
Conclusion
The Transtar procedure is technically demanding, with good functional results similar to the conventional STARR.
doi:10.1111/j.1463-1318.2008.01714.x
PMCID: PMC2774156  PMID: 19175625
STARR; obstructive defecation syndrome; constipation; internal rectal prolapse; rectocele; incontinence
15.  Total mesorectal excision: technical aspects 
Canadian Journal of Surgery  2004;47(2):130-137.
Total mesorectal excision (TME) is a precise dissection of the rectum and all pararectal lymph nodes within an oncologic package: the mesorectal envelope. This article is a brief description of the technical aspects of the dissection, illustrated by cadaver dissection. Here the TME dissection is organized into 6 steps to facilitate learning: (1) left retroperitoneum; (2) superior rectal and inferior mesenteric vessels; (3) upper mesorectum; (4/5) right and left mid-mesorectum; and (6) distal mesorectum and anorectal junction. The relationship of the autonomic nerves, blood vessels and adjacent organ structures are described at each step. The 6 steps are recommended for learning and performing TME dissection in cadavers and patients.
PMCID: PMC3211930  PMID: 15132469
16.  Anastomosis Procedure through an Inguinal Hernia Incision in Simultaneous Laparoscopic Anterior Resection and Inguinal Hernia Repair 
For laparoscopic anterior resection, an additional small incision is usually placed in the left lower quadrant or the suprapubic portion. As a left inguinal hernia incision is close to both the left lower quadrant and the suprapubic portion, such an incision can be used for anastomosis in laparoscopic anterior resection, without additional incisions. We report a laparoscopic anterior resection using a left inguinal hernia incision for colorectal anastomosis, in a patient who underwent concomitant left inguinal hernia repair. After a total mesorectal excision was performed laparoscopically, the distal portion of the rectum was transected by a stapler. A 4 cm skin incision was made in the left inguinal region and carried down to the peritoneum through the hernia sac. The bowel resection was performed extracorporeally, and an anvil was placed at the proximal end of the colon over a purse-string suture. After colorectal anastomosis was performed using a circular stapler inserted through the anus, the inguinal hernia was repaired with a mesh. The inguinal wound healed without surgical site infection, and the patient was discharged ten days after surgery.
doi:10.4103/2006-8808.78468
PMCID: PMC3192511  PMID: 22022651
Inguinal hernia; laparoscopic anterior resection; surgical incision
17.  Left-Sided Hepatectomy With a Linear Stapling Device: An Experimental Study on Pigs 
HPB Surgery  1992;6(1):51-55.
Thirteen pigs underwent resection of the left liver lobe. By random selection, the animals were resected either with the aid of an RLG 90R linear stapling device or by the conventional finger-fracture technique. There was one postoperative death due to anaesthetic complications. The median operative time using the stapler was 27 min (range 19–40 min) which was significantly shorter (p = 0.0065) than that required for resection by the finger-fracture technique (42.5 min; range 37–55 min).
The median blood loss, estimated by counting the number of gauze swabs used, was 425 ml and 275 ml for the finger-fracture resected and stapler resected groups, respectively (ranges 275–550 ml versus 175– 300 ml; p = 0.015).
The animals were sacrificed and examined one week after the operative procedure. Except for a small bile pseudo-cyst in one pig operated upon with conventional resection, no sign of bleeding or biliary leakage was revealed.
This study demonstrates the feasibility of stapling the liver to facilitate resection.
doi:10.1155/1992/84680
PMCID: PMC2443013  PMID: 1467316
18.  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
19.  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.
Purpose
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.
Results
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).
Conclusions
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.
doi:10.5230/jgc.2012.12.2.120
PMCID: PMC3392323  PMID: 22792525
Laparoscopy; Gastric cancer; Billroth-II; Staple
20.  Haemothorax following bullectomy caused by a sharp edge of the Endoloop 
A 22-year old man presented with a massive haemothorax 25 days after bullectomy for a spontaneous pneumothorax. Thoracoscopic surgery revealed ongoing bleeding from the chest wall caused by a sharp edge of the Endoloop Ligature (Ethicon Endo-Surgery) used to resect the remaining small part of the lung at the earlier staple bullectomy. The point where bleeding was occurring was clipped and covered using a collagen patch coated with human fibrinogen and thrombin. The protruding sharp edge of the Endoloop was excised together with the surrounding lung tissue, using a stapler. Although prevention of this type of complication is difficult, awareness of the potential problem may help in managing such extremely rare events.
doi:10.1093/icvts/ivt047
PMCID: PMC3630437  PMID: 23407693
Postoperative haemothorax; Endoloop; Video-assisted thoracic surgery; Bullectomy
21.  Laparoscopic-Assisted Transvaginal Approach for Sigmoidectomy and Rectocolpopexy 
Background and Objectives:
Laparoscopic-assisted colonic resection has been well described for multiple surgical indications. This typically requires an abdominal incision for specimen removal that is associated with the majority of postoperative pain. We describe the first laparoscopic-assisted transvaginal approach for sigmoidectomy and rectocolpopexy for the treatment of rectal prolapse.
Methods:
Mobilization of the sigmoid colon was performed laparoscopically using a 12-mm vaginal port and 3 additional 5-mm abdominal ports. A laparoscopic stapler was used through the vaginal port to transect the distal sigmoid colon. The specimen was subsequently externalized through the colpotomy to complete the resection and prepare the remaining bowel for intracorporeal, end-toend, stapled anastomosis. The colpotomy was then repaired, and the colorectal anastomosis and rectocolpopexy were completed laparoscopically.
Results:
Sigmoidectomy and rectocolpopexy were successfully performed laparoscopically by using a transvaginal approach without the need for an abdominal incision for specimen removal. The patient had an uncomplicated postoperative course, complained of minimal pain, and was discharged home on postoperative day 3.
Conclusions:
Laparoscopic-assisted transvaginal sigmoidectomy and rectocolpopexy is a feasible option that appears to be associated with little incisional pain and rapid recovery.
PMCID: PMC3015929  PMID: 19660219
Laparoscopy; Transvaginal; Sigmoidectomy; Rectocolpopexy
22.  STARR with CONTOUR® TRANSTAR™ device for obstructed defecation syndrome: one-year real-world outcomes of the European TRANSTAR registry 
Purpose
Stapled transanal rectal resection (STARR) in patients with obstructive defecation syndrome (ODS) is limited by the capacity of the circular stapler used. This prospective cohort study was conducted to assess real-world clinical outcomes of STARR with the new CONTOUR® TRANSTAR™ device, shortly named TRANSTAR, at 12 months postoperatively.
Methods
From January 2009 to January 2011, consecutive patients who underwent TRANSTAR in 22 European colorectal centers were enrolled in the study. Functional outcomes and quality of life were assessed by the changes in a number of scoring systems (Knowles-Eccersley-Scott-Symptom (KESS) score, ODS score, St. Mark’s score, Euro Quality of Life-5 Dimension (EQ-5D) score, and Patient Assessment of Constipation—Quality of Life (PAC-QoL) score), at 12 months as compared to baseline. All complications were recorded and analyzed.
Results
A total of 100 patients (98 % female), mean age 60 years, were entered in the study. Statistically significant improvements were seen in the KESS (median 18 vs. 6; p < 0.01), ODS (median 15 vs. 4; p < 0.01), and PAC-Qol scores (median 2.10 vs. 0.86; p < 0.01). St. Mark’s and EQ-5D scores improved nonsignificantly. Complications were reported in 11 % of patients, including bleeding (5 %), staple line complications (3 %), urinary retention (2 %), and persistent pain (1 %). No major complications or mortality occurred.
Conclusion
TRANSTAR facilitated a tailored, real circumferential full-thickness rectal resection, leading to improved patient functional and quality of life outcomes at 12 months postoperatively. It represents a safe and effective treatment for ODS in local clinical practice, although the sustainability of real-world results needs to be proven in the long-term follow-up.
doi:10.1007/s00384-014-1836-8
PMCID: PMC3996277  PMID: 24554148
STARR; Obstructive defecation syndrome; Constipation; Internal rectal prolapse; Rectocele; TRANSTAR
23.  Total laparoscopic distal pancreatectomy for a benign appearing tumor: a case report 
Cases Journal  2009;2:8468.
Introduction
Therapeutic laparoscopy of the pancreas is still described as experimental surgery by many surgeons. Many issues remain to be clarified in determining the future of this new method.
Case presentation
The objective of the present study was to present a case of a patient who underwent totally laparoscopic distal pancreatectomy for a benign appearing tumor in the tail of the pancreas and to critically discuss the treatment of the pancreatic remnant and the need to perform splenectomy with or without ligation of the splenic vessels.
Conclusion
Laparoscopic distal pancreatectomy is usually performed en-bloc along with resection of the spleen, for technical reasons, making the operation short and easy. However, it should only be performed in centers with expertise in both pancreatic surgery and advanced laparoscopy. Furthermore, the use of linear stapler to cut the pancreas (4.5-mm staples) seems to prevent fistula formation and ischemia of the pancreatic stump.
doi:10.4076/1757-1626-2-8468
PMCID: PMC2740077  PMID: 19830077
24.  Definition of the rectum and level of the peritoneal reflection – still a matter of debate? 
Introduction
Pathological lesions of the rectum are common and their management requires detailed knowledge of pelvic anatomy. There has been considerable debate as to the definition of the rectum and the variability of the level of the peritoneal reflection. The lack of a clear consensus was proven in the research by McCullen et al. regarding the current pattern of practice for the investigation of primary rectal cancer by general surgeons.
Aim
To carry out bibliographic research on the definition of the rectum and level of the peritoneal reflection.
Material and methods
A web-based published literature search of PubMed, Ovid Medline, Science Direct and Springer was made.
Results
The paper presents the current definitions of proximal and distal margin of the rectum and level of peritoneal reflection based not only on the results of tests on cadavers but also on living humans.
Conclusions
The results of tests on living humans allow more accurate qualification of patients for local excision, which is particularly important for patients with colorectal cancer.
doi:10.5114/wiitm.2011.34205
PMCID: PMC3796725  PMID: 24130630
definition of the rectum; level of peritoneal reflection; anatomy of the rectum
25.  Reconstruction of the esophagojejunostomy by double stapling method using EEA™ OrVil™ in laparoscopic total gastrectomy and proximal gastrectomy 
Here we report the method of anastomosis based on double stapling technique (hereinafter, DST) using a trans-oral anvil delivery system (EEATM OrVilTM) for reconstructing the esophagus and lifted jejunum following laparoscopic total gastrectomy or proximal gastric resection.
As a basic technique, laparoscopic total gastrectomy employed Roux-en-Y reconstruction, laparoscopic proximal gastrectomy employed double tract reconstruction, and end-to-side anastomosis was used for the cut-off stump of the esophagus and lifted jejunum.
We used EEATM OrVilTM as a device that permitted mechanical purse-string suture similarly to conventional EEA, and endo-Surgitie.
After the gastric lymph node dissection, the esophagus was cut off using an automated stapler. EEATM OrVilTM was orally and slowly inserted from the valve tip, and a small hole was created at the tip of the obliquely cut-off stump with scissors to let the valve tip pass through. Yarn was cut to disconnect the anvil from a tube and the anvil head was retained in the esophagus.
The end-Surgitie was inserted at the right subcostal margin, and after the looped-shaped thread was wrapped around the esophageal stump opening, assisting Maryland forceps inserted at the left subcostal and left abdomen were used to grasp the left and right esophageal stump. The surgeon inserted anvil grasping forceps into the right abdomen, and after grasping the esophagus with the forceps, tightened the end Surgitie, thereby completing the purse-string suture on the esophageal stump.
The main unit of the automated stapler was inserted from the cut-off stump of the lifted jejunum, and a trocar was made to pass through. To prevent dropout of the small intestines from the automated stapler, the automated stapler and the lifted jejunum were fastened with silk thread, the abdomen was again inflated, and the lifted jejunum was led into the abdominal cavity.
When it was confirmed that the automated stapler and center rod were made completely linear, the anvil and the main unit were connected with each other and firing was carried out. Then, DST-based anastomosis was completed with no dog-ear.
The method may facilitate safe laparoscopic anastomosis between the esophagus and reconstructed intestine. This is also considered to serve as a useful anastomosis technique for upper levels of the esophagus in laparotomy.
doi:10.1186/1477-7819-9-55
PMCID: PMC3118377  PMID: 21599911
Esophagojejunostomy; Double stapling method; EEA™ OrVil™

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