International Journal of Surgery 16 (2015) 42e43
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Editorial
The proper reload selection during laparoscopic sleeve gastrectomy
Keywords: Bariatric surgery Staples Echelon Ethicon Tissue thickness
Although the basic tenets of the bariatric surgery are similar between surgeons, a number of technical variations exists. The technology behind stapling devices has advanced considerably since their advent. The purpose of this communication is to reinforce the importance of following proper reload selection during laparoscopic sleeve gastrectomy, that involve the sealing and cutting of thicker tissue. Tissue thickness should be carefully evaluated before firing any stapler. Changes in tissue thickness of stomach at the fourth staple fires suggest stepwise alteration in staple cartridge color selection [1]. Linear cutters stapling devices are intended for transection, resection, and/or creation of anastomoses [2]. The instruments have application in multiple open or minimally invasive surgical procedures [3]. They provide remarkable speed and convenience in surgery in comparison to hand suturing. When choosing the appropriate stapling device, the issues of tissue thickness, staple line security and tissue tension should be taken into consideration [4]. As more advanced procedures shift to a laparoscopic approach, endocutter platforms are being more and more used in thick tissue applications. In minimally invasive procedures, smaller trocar diameters are preferred. A 12 mm trocar will limit the space available within the endocutter to house the unformed staple legs, along with the anvil and staple forming mechanisms [5]. As a result, the ability to deliver a closed staple height greater than 2.0 mm ta accommodate extra thick tissue has been limited due to the constraints of the 12 mm diameter of the endocutter delivery device. Ethicon Endo-Surgery (EES) has developed an improved laparoscopic stapler cartridge that can deliver a closed staple height of 2.3 mm with a heavier gauge wire, but still be compatible with a 12 mm trocar. This new cartridge is the ECR60T black cartridge [5]. There are six staggered rows of staples, three on either side of the cut line of the ECHELON 60 mm Endoscopic Linear Cutter Reloads Black. The ECHELON 60 instruments have a staple line that is approximately 60 mm long and a cut line that is approximately 57 mm long. The shaft can rotate freely in both directions and an articulation mechanism on articulating instruments enables bending the distal portion of the shaft to facilitate lateral access of the operative site. Because any given stapler reload performance may be stressed at tissue thicknesses that cannot comfortably http://dx.doi.org/10.1016/j.ijsu.2015.02.018 1743-9191/© 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
compress to a reload's closed staple height, moving towards larger staple reloads may improve performance in these thicker tissues. Echelon Black reload was specifically designed to meet the clinical needs for a thicker tissue application. EES overcame the challenge of incorporating a longer staple leg by slightly extending the ends of the pocket in which the staple is loaded. Staples normally reside in a pocket with their tips flush with or slightly below the cartridge surface. In the new cartridge, the staple leg extends above the main deck of the cartridge, but a rounded pocket extension has been added to extend the cartridge stabilization and protection of the staple leg tip. The pocket extensions prevent the staple tips from contacting tissue du ring stapler advancement and placement. The pocket extensions also prevent tissue from inadvertently bending the staple tins. A series of studies was conducted to determine whether the new extended pocket design produced any noticeably different tissue effect in comparison to the conventional flat-cartridge deck design. No substantial differences were observed between the test device with pocket extensions and the control device. Rawlins demonstrates that in male patients and with higher BMI have gastric tissue whose thicknesses in the antrum may be greater than surgeon experience would anticipate. Rawlins concludes that “Surgeons should consider using a thicker staple load, such as black, when these factors are present. Also, significant changes in tissue thickness at the fourth and fifth staple fires suggest stepwise alteration in staple cartridge color selection.” [6]. Ethical approval None required. Financial support None. Author contribution Radwan Kassir, Olivier Tiffet, Alexia Boueil-Bourlier and Pierre Blanc, Jean-Luc Berger, Karine Abboud, Joelle Dubois, Imed Ben Amor and Tarek Debs: reviewed the paper. Conflict of interest None.
Editorial / International Journal of Surgery 16 (2015) 42e43
Guarantor Dr Christophe Breton. References [1] Important Customer Notification: ECHELON ENDOPATH™ Endoscopic Linear Cutter Reloads in Sleeve Gastrectomy Procedures. Customer Notification for ECHELON ENDOPATH™ Endoscopic Linear Cutter Reloads ECR60G-2014-09. [2] R. Kassir, T. Debs, P. Blanc, J. Gugenheim, P. Lointier, E. Bachir, I. Ben Amor, O. Tiffet, Performing sleeve gastrectomy, Int. J. Surg. 13C (2014 Dec 9) 131e132. [3] R. Kassir, O. Tiffet, P. Blanc, I. Ben Amor, J. Gugenheim, Sleeve gastrectomy. A point of technique, Int. J. Surg. 12 (12) (2014 Dec) 1450e1451. [4] D.E. Bellanger, F.L. Greenway, Laparoscopie sleeve gastrectomy, 529 cases without a leak: short-terrn results and technical considerations, Obes. Surg. 21 (2011) 146e150. [5] Tamara Widenhouse, John F Cummings, Doug Sharpnack. Staple Cartridges with Pocket Extensions Have Similar Tissue Effects to Standard Cartridges. Hhicon Endo-Surgery, mc, 2011. [6] L. Rawlins, M. Rawlins, D. Teel II, et al., Human tissue thickness measurements from excised sleeve gastrectomy specimens, Surg. Endosc. 28 (2014) 811e814.
Radwan Kassir*, Alexia Boueil-Bourlier Department of General Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France Tarek Debs Department of Bariatric Surgery, Hospital Archet 2, Nice, France
43
Pierre Blanc Department of Bariatric Surgery, Clinique Chirurgicale Mutualiste, Saint Etienne, France Jean Gugenheim Department of Bariatric Surgery, Hospital Archet 2, Nice, France Jean-Luc Berger, Karine Abboud, Joelle Dubois Department of General Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France Imed Ben Amor Department of Bariatric Surgery, Hospital Archet 2, Nice, France Olivier Tiffet Department of General Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France * Corresponding author. Department of General Surgery, CHU Hospital, Jean Monnet University, Avenue Albert Raimond, 42270 Saint Etienne, France. E-mail address: [email protected] (R. Kassir).
20 January 2015 Available online 5 March 2015
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Editorial
The proper reload selection during laparoscopic sleeve gastrectomy
Keywords: Bariatric surgery Staples Echelon Ethicon Tissue thickness
Although the basic tenets of the bariatric surgery are similar between surgeons, a number of technical variations exists. The technology behind stapling devices has advanced considerably since their advent. The purpose of this communication is to reinforce the importance of following proper reload selection during laparoscopic sleeve gastrectomy, that involve the sealing and cutting of thicker tissue. Tissue thickness should be carefully evaluated before firing any stapler. Changes in tissue thickness of stomach at the fourth staple fires suggest stepwise alteration in staple cartridge color selection [1]. Linear cutters stapling devices are intended for transection, resection, and/or creation of anastomoses [2]. The instruments have application in multiple open or minimally invasive surgical procedures [3]. They provide remarkable speed and convenience in surgery in comparison to hand suturing. When choosing the appropriate stapling device, the issues of tissue thickness, staple line security and tissue tension should be taken into consideration [4]. As more advanced procedures shift to a laparoscopic approach, endocutter platforms are being more and more used in thick tissue applications. In minimally invasive procedures, smaller trocar diameters are preferred. A 12 mm trocar will limit the space available within the endocutter to house the unformed staple legs, along with the anvil and staple forming mechanisms [5]. As a result, the ability to deliver a closed staple height greater than 2.0 mm ta accommodate extra thick tissue has been limited due to the constraints of the 12 mm diameter of the endocutter delivery device. Ethicon Endo-Surgery (EES) has developed an improved laparoscopic stapler cartridge that can deliver a closed staple height of 2.3 mm with a heavier gauge wire, but still be compatible with a 12 mm trocar. This new cartridge is the ECR60T black cartridge [5]. There are six staggered rows of staples, three on either side of the cut line of the ECHELON 60 mm Endoscopic Linear Cutter Reloads Black. The ECHELON 60 instruments have a staple line that is approximately 60 mm long and a cut line that is approximately 57 mm long. The shaft can rotate freely in both directions and an articulation mechanism on articulating instruments enables bending the distal portion of the shaft to facilitate lateral access of the operative site. Because any given stapler reload performance may be stressed at tissue thicknesses that cannot comfortably http://dx.doi.org/10.1016/j.ijsu.2015.02.018 1743-9191/© 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
compress to a reload's closed staple height, moving towards larger staple reloads may improve performance in these thicker tissues. Echelon Black reload was specifically designed to meet the clinical needs for a thicker tissue application. EES overcame the challenge of incorporating a longer staple leg by slightly extending the ends of the pocket in which the staple is loaded. Staples normally reside in a pocket with their tips flush with or slightly below the cartridge surface. In the new cartridge, the staple leg extends above the main deck of the cartridge, but a rounded pocket extension has been added to extend the cartridge stabilization and protection of the staple leg tip. The pocket extensions prevent the staple tips from contacting tissue du ring stapler advancement and placement. The pocket extensions also prevent tissue from inadvertently bending the staple tins. A series of studies was conducted to determine whether the new extended pocket design produced any noticeably different tissue effect in comparison to the conventional flat-cartridge deck design. No substantial differences were observed between the test device with pocket extensions and the control device. Rawlins demonstrates that in male patients and with higher BMI have gastric tissue whose thicknesses in the antrum may be greater than surgeon experience would anticipate. Rawlins concludes that “Surgeons should consider using a thicker staple load, such as black, when these factors are present. Also, significant changes in tissue thickness at the fourth and fifth staple fires suggest stepwise alteration in staple cartridge color selection.” [6]. Ethical approval None required. Financial support None. Author contribution Radwan Kassir, Olivier Tiffet, Alexia Boueil-Bourlier and Pierre Blanc, Jean-Luc Berger, Karine Abboud, Joelle Dubois, Imed Ben Amor and Tarek Debs: reviewed the paper. Conflict of interest None.
Editorial / International Journal of Surgery 16 (2015) 42e43
Guarantor Dr Christophe Breton. References [1] Important Customer Notification: ECHELON ENDOPATH™ Endoscopic Linear Cutter Reloads in Sleeve Gastrectomy Procedures. Customer Notification for ECHELON ENDOPATH™ Endoscopic Linear Cutter Reloads ECR60G-2014-09. [2] R. Kassir, T. Debs, P. Blanc, J. Gugenheim, P. Lointier, E. Bachir, I. Ben Amor, O. Tiffet, Performing sleeve gastrectomy, Int. J. Surg. 13C (2014 Dec 9) 131e132. [3] R. Kassir, O. Tiffet, P. Blanc, I. Ben Amor, J. Gugenheim, Sleeve gastrectomy. A point of technique, Int. J. Surg. 12 (12) (2014 Dec) 1450e1451. [4] D.E. Bellanger, F.L. Greenway, Laparoscopie sleeve gastrectomy, 529 cases without a leak: short-terrn results and technical considerations, Obes. Surg. 21 (2011) 146e150. [5] Tamara Widenhouse, John F Cummings, Doug Sharpnack. Staple Cartridges with Pocket Extensions Have Similar Tissue Effects to Standard Cartridges. Hhicon Endo-Surgery, mc, 2011. [6] L. Rawlins, M. Rawlins, D. Teel II, et al., Human tissue thickness measurements from excised sleeve gastrectomy specimens, Surg. Endosc. 28 (2014) 811e814.
Radwan Kassir*, Alexia Boueil-Bourlier Department of General Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France Tarek Debs Department of Bariatric Surgery, Hospital Archet 2, Nice, France
43
Pierre Blanc Department of Bariatric Surgery, Clinique Chirurgicale Mutualiste, Saint Etienne, France Jean Gugenheim Department of Bariatric Surgery, Hospital Archet 2, Nice, France Jean-Luc Berger, Karine Abboud, Joelle Dubois Department of General Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France Imed Ben Amor Department of Bariatric Surgery, Hospital Archet 2, Nice, France Olivier Tiffet Department of General Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France * Corresponding author. Department of General Surgery, CHU Hospital, Jean Monnet University, Avenue Albert Raimond, 42270 Saint Etienne, France. E-mail address: [email protected] (R. Kassir).
20 January 2015 Available online 5 March 2015
