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.
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.
Linear cutter; Stapler; Anastomotic leakage; Anastomotic insufficiency; Colorectal surgery
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.
Larynx; Total laryngectomy; Autosuture; Semi-closed technique
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.
Anastomosis; Linear Stapler; 4-Row Staple Line; Gastrointestinal Surgery
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.
Anvil grasper; Intra-corporeal circular stapled anastomosis; colorectal cancer
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.
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.
Laparoscopic distal gastrectomy; Totally laparoscopic gastrectomy; Intracorporeal anastomosis; Intracorporeal DST; Book-binding technique
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.
Ulcerative colitis; Retained rectal mucosa; Stapled mucosectomy; Surgical technique
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.
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.
Colorectal anastomosis; diverticulitis; Hartmann’s procedure; EEA stapler; reverse stapling technique
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.
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.
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.
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.
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.
The Transtar procedure is technically demanding, with good functional results similar to the conventional STARR.
STARR; obstructive defecation syndrome; constipation; internal rectal prolapse; rectocele; incontinence
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.
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.
Inguinal hernia; laparoscopic anterior resection; surgical incision
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.
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.
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.
Laparoscopy; Gastric cancer; Billroth-II; Staple
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.
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.
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.
Laparoscopic-assisted transvaginal sigmoidectomy and rectocolpopexy is a feasible option that appears to be associated with little incisional pain and rapid recovery.
Laparoscopy; Transvaginal; Sigmoidectomy; Rectocolpopexy
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.
Stapler; Vascular; Laparoscopy; Donor; Nephrectomy
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.
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.
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.
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.
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.
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.
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.
definition of the rectum; level of peritoneal reflection; anatomy of the rectum
Background and Objectives:
An experimental study was undertaken to evaluate whether a previously described technique for laparoscopic sigmoid resection with intracorporeal resection-anastomosis and specimen removal via a suprapubic incision could be facilitated and applied to the rectum.
Ten domestic pigs (median weight 41 kg) underwent low anterior resection of the rectum, which was transected with an articulating endoscopic stapler. Pursestring sutures were fashioned intracorporeally with a laparoscopic pursestring clamp. The anvil of a circular stapler was inserted through a 33 mm port into the colon and pursestring tied intracorporeally. A circular gun with a spike fixed to its shaft was introduced per anum and a double-stapled anastomosis performed.
Complete doughnuts were obtained in all cases and anastomoses were all methylene blue tight. All porcine subjects had an uneventful 5-week postoperative course. The median anastomotic level from the anal verge was 5.2 cm. Histology of colorectal anastomoses revealed healing mucosa.
The use of articulating endoscopic stapler, laparoscopic pursestring clamp, and circular stapler with a spike fixed to its shaft seems to facilitate a previously described intracorporeal approach to sigmoid resection which was safely applied to the rectum in a porcine model.
Anastomosis; Colorectal surgery; Laparoscopy; Surgical technique
Cervical esophagogastrostomy is currently the most common method for esophageal reconstruction after esophagectomy. The advantages and disadvantages of hand-sewn, linear-stapled, or circular-stapled anastomoses have been subject to debate in recent years. We explored a new method of end-to-side anastomosis using a circular stapler that embeds the anastomosis and the remaining esophageal tissue into the gastric cavity to reduce the occurrence of anastomotic leakage and to prevent gastroesophageal reflux.
In 127 patients with esophageal carcinomas, end-to-side anastomoses with esophageal embedding were performed by connecting the anvil and body of the circular stapler inside the stomach before firing and embedding the anastomosis and remaining esophagus into the stomach after esophagectomy. Retrospective investigations on postoperative complications such as leakage, stricture, and gastroesophageal reflux were conducted.
A total of 123 patients (96.9 %) had successful surgery, and 4 patients (3.3 %) developed anastomotic leakage, with the total morbidity of 20 of 123 (16.3 %) and in-hospital mortality of 1 of 123 (0.8 %). The incidence of stricture (<1 cm) affected 14 of 123 patients (11.4 %). Eight patients underwent dilatation treatment as a result of severe dysphagia (6.5 %). Half of the patients [62 of 123 (50.4 %)] experienced postoperative heartburn, 11 of 123 patients (8.9 %) experienced acid regurgitation, and 16 of 123 patients (13.0 %) experienced nocturnal cough.
Embedded cervical esophagogastrostomy with circular stapler is a simple and convenient method, with low incidence of anastomotic leakage and a good antireflux effect.
Laparoscopic suturing is a tedious procedure which has a long learning curve. Hence, we sought to develop an alternative simple and reliable technique for laparoscopic tissue approximation to enhance laparoscopic reconstructive procedures. In this video, we present our method for using newly developed, nonperforating titanium clips (U.S. Surgical Inc., Norwalk, CT) to perform a Ureteroureterostomy.
Ten piglets underwent a unilateral laparoscopic Ureteroureterostomy. Preoperative endoscopic ureteral stenting was first performed. After achieving a pneumoperitoneum, the retroperitoneal space was accessed, and the proximal ureter was dissected, opposite the lower pole of the kidney. Transection of the ureter was performed, and a Ureteroureterostomy was accomplished with a laparoscopic endovascular stapler (VCS). Tissue approximating forceps (AF) were used to bring the two edges of the ureter together. For application of staples to the posterior surface of the ureter, the tissue approximator forceps were used to rotate the ureter, after which VCS clips could be applied to the posterior surface. A total of 11-14 staples were applied.
The procedure was successful in all animals without any intraoperative complications. The operative time was significantly shorter with the use of the newly developed laparoscopic tissue approximator.
Laparoscopic Ureteroureterostomy using VCS clips appears to be a promising method for reconstructive ureteral surgery.
INTRODUCTION: Low pelvic anastomoses are associated with a high leak rate. Therefore, defunctioning loop ileostomies are being increasingly fashioned to protect against the consequences of a leak. However, the reported complication rates of such stoma creation and closure is between 5.7-69%. AIMS: To determine the outcome associated with construction and side-to-side closure of loop ileostomies in one specialist unit. PATIENTS AND METHODS: Data were obtained from a computer audit and case note analysis. RESULTS: Between 1994 and 1998, 71 patients (41 M, 30 F) with a median age of 51 years (range 19-88 years) had a loop ileostomy constructed for: (i) 26 ileoanal pouches; (ii) 36 left colonic and rectal resections; and (iii) 9 for other reasons. Side-to-side stoma closure was achieved using a GIA linear stapler through a parastomal incision. The median hospital stay following stoma creation was 12 days (range 7-63 days) and stoma closure was 7 days (range 6-16 days). The median time to closure was 140 days (range 10-790 days). There were no ileostomy-related deaths. There were 10 (13.8%) ileostomy-related complications, 4 following creation and 6 following closure. CONCLUSIONS: Loop ileostomy is easy to create and close and is associated with a low morbidity. Therefore, we recommend a defunctioning ileostomy as a procedure of choice for temporary faecal diversion for complex colorectal surgery.