Staplers

A linear anastomotic stapler (e.g., Endo GIATM, USSC) is one of the most frequently used disposable instruments in colorectal laparoscopy. The working end of Endo GIATM consists of two jaws, one that accommodates the staple cartridge and one that is the anvil. Several jaw lengths are available: 30, 45, and 60 mm. In the cartridge are two rows of triple-staggered staples, eight in each row; the two rows are separated by a single groove through which a small sharp knife blade advances when the stapler is fired (Figure 2.15). The staples are made of 0.21-mm titanium wire, have a backspan length of 3 mm, and a leg length of 2.0, 2.5, 3.5, and 4.8 mm, for vascular, regular, and thick bowel tissue, respectively. For safe stapling, it is critical to select adequate set of staples (cartridge) for specific organs. To staple and divide the bowel, the bowel is slid between the jaws (cartridge and anvil) and the instrument is closed and activated. Activation drives both rows of triple-staggered staples through the tissue and drives the knife to divide the intestine. The knife stops one-and-a-half staples short of the end of the staple line. Thus, both ends of intestine are divided and closed in an everted mucosa-to-mucosa manner with a triple row of staples on each side.

Although the conventional GIATM instruments contain only two rows of double staples, we believe that the third row added to the Endo staplers probably increases their safety, which is especially important in laparoscopic surgery because the minimal access to the peritoneal cavity does not readily allow defective or bleeding intestinal anastomoses to be repaired.

Recently, articulating (roticulating) stapling devices (Endo GIATM Roticulator, USSC) have become available. With a roticulating function, the usability of staplers has been much improved in certain laparo-scopic procedures such as splenectomy and gastrectomy. However, in rectal procedures, it is still technically challenging to place staplers in the optimal direction deep inside the pelvis to transect the distal rectum. Further improvement in instrumentation is necessary to make distal rectal stapling easy and reliable.

Laparoscopic Gastrectomy Cutter
Figure 2.15. Endo GIATM Universal stapler (USSC, Norwalk, CT).
Circular Staplers

Figure 2.16. SurgASSIST™ computerized gastrointestinal stapling devices (Power Medical Interventions, New Hope, PA) A Straight linear cutter (SLC) 55 and 75 mm, B Circular stapler (CS) 25, 29, and 33 mm, C Right-angled linear cutter (RALC) 45 mm, which places four rows of stapler, cutting between the second and third rows.

Figure 2.16. SurgASSIST™ computerized gastrointestinal stapling devices (Power Medical Interventions, New Hope, PA) A Straight linear cutter (SLC) 55 and 75 mm, B Circular stapler (CS) 25, 29, and 33 mm, C Right-angled linear cutter (RALC) 45 mm, which places four rows of stapler, cutting between the second and third rows.

A significant change in the means whereby staples are delivered in intestinal tissues is being developed by a new company, Power Medical Inc. (New Hope, PA). Using a 170-cm-long computer-driven cable, which attaches to a wide variety of stapling cartridges, this equipment permits the surgeon to pass certain linear staples through laparoscopic ports (straight linear cutter, SLCTM 55 and 75 mm) and angle the stapler tip over a wide range of angles (up-down and right-left). The staplers may be fired using push-button technology with a hand-held remote controller. In addition to the SLCTM stapler, there is a right-angled linear cutting device (RALCTM 45 mm) that fires four rows of staples, cutting automatically between the second and third rows. There is also a circular stapler technology, similar in some ways to the commercially available models in sizes 25, 29, and 33 mm. Advantages of this circular stapler are that it can be fired using a remote device, and also it can be passed transanally high into the large intestine, so that theoretically even right-sided end-to-end anastomoses could be made (Figure 2.16).

Trocar Wound Closure Devices

Closing small fascial defects left by trocars can be a difficult, time-consuming, and occasionally hazardous task especially in obese patients with thick abdominal walls. Inadequate closure of those wounds can lead to significant morbidities such as evisceration, incisional hernia,

Endo Close
Figure 2.17. Endo Close™ (USSC, Norwalk, CT) and Suture Passer (Storz, Tuttlingen, Germany) abdominal well closure devices.

and at worst, incarcerated (Richter) hernia.17,18 Trocar wound closure devices are commercially available in both disposable and reusable fashion (Figure 2.17). We routinely place through-and-through sutures at 10/12 mm trocar sites using Suture Passer™ (Karl-Storz). Although details of our technique are to be described later, one key is to place these sutures before trocar removal.

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Responses

  • HALFRED MAGGOT
    What is a roticulating endo stapler?
    8 years ago

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