Gen Thorac Cardiovasc Surg DOI 10.1007/s11748-013-0361-y
HOW TO DO IT
Safe stapling technique for pulmonary vessels with the shortened introducers and curved tips in thoracoscopic surgery Eiki Mizutani • Kazuki Nakahara Shigeki Miyanaga • Ayako Seike
•
Received: 18 September 2013 / Accepted: 5 December 2013 Ó The Japanese Association for Thoracic Surgery 2013 TM
TM
Abstract Endo GIA curved tips with Tri-Stapler is more useful for the approach for pulmonary vessels than conventional straight staplers. Unless adequate space is maintained below the vessels, there is a risk of causing damage to the back of vessels with the curved tip without optional introducers. The recommended method involves passing silk thread through the back of the pulmonary vessels and ligating the thread to the introducer. However, the long introducer often applies tension to pulmonary vessels and can be caught in the tissues surrounding vessels. Therefore, we devised a new method. First, the introducer is shortened to a length of approximately 3 cm and attached to a curved tip. Second, a Penrose drain is passed through the back of the vessels. Last, the introducer is inserted into the drain and the stapler is guided. The vessels can be cut without removing the introducers and Penrose drains from staplers. Keywords
straight staplers have been used, and the approach for the TM vessels sometimes is risky. Endo GIA curved tips and TM introducers with Tri-Stapler (Covidien, Norwalk, CT) have recently been developed as a safer approach for the vessels [4]. The recommended method for employing the TM Endo GIA curved tip and an optional flexible introducer TM with the Tri-Stapler involves passing silk thread through the back of the pulmonary vessels and ligating the thread to the introducer of the curved tip. The weak point of this method is that it is often difficult to lead the long introducer to a target point, which applies tension to vulnerable pulmonary vessels and can result in the instrument becoming caught in the tissue surrounding the vessels, especially in thoracoscopic surgery due to the lack of complete solid vision. We herein report the usefulness and advantages of curved tips and shortened introducers for performing surgery on pulmonary vessels.
Curved tip Stapler Thoracoscopic surgery Materials and methods
Introduction The widespread use of video-assisted thoracic surgery (VATS) is supported by staplers, and pulmonary vessels are now often treated with staplers [1]. These fragile vessels have to be treated carefully, because repairing them is often difficult, and errors can be fatal [2, 3]. So far, only E. Mizutani K. Nakahara (&) S. Miyanaga A. Seike Department of Thoracic Surgery, Tokyo Teishin Hospital, 2-14-23 Fujimi, Chiyoda-ku, Tokyo 102-8798, Japan e-mail: [email protected] E. Mizutani e-mail: [email protected]
We devised a new method. First, the introducer is shortened to a length of approximately 3 cm, which is longer than the width of the vessels. Both angles of the edges of the shortened introducer were cut off to be the same shape as the original introducer. Then, we attached the introducer to a curved tip (Fig. 1). Second, we passed a right angle dissector through the back of the pulmonary vessels. The dissector then caught the edge of a Penrose drain, which was cut off diagonally. The width of the Penrose drain was 6 mm in the normal state and 9 mm at the time of compression. Last, the introducer is inserted into the Penrose drain pulled out through an access port, and we pulled the Penrose drain near the vessels then pushed the stapler with the introducer into the proper position (Figs. 2, 3).
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Gen Thorac Cardiovasc Surg
upper lobes, three right lower lobes, seven left upper lobes and nine left lower lobes. This method was applied to most vessels that had been previously cut with straight staplers, and only five straight staplers were used for vessels. The curved staplers were used in thirty-seven cases for pulmonary veins and in forty-six cases for pulmonary arteries. The angle of insertion of the curved tip staplers was fundamentally the same as that of the straight staplers. The insertion of staplers was smooth in all cases.
Comment Fig. 1 The introducer is shortened to a length of approximately 3 cm
Fig. 2 A shortened introducer attaches to a curved tip. The introducer is inserted into a Penrose drain, which was passed through the back of vessels and pulled out through an access port
Fig. 3 Intraoperative view shows that a stapler with a curved tip, a shortened introducer and a Penrose drain is smoothly guided
Between July 2012 and June 2013, we used eighty-three curved tips in thirty-two cases of thoracoscopic surgery for lobectomy. We performed lobectomy on thirteen right
123
Staplers with curved tips are better than conventional straight staplers in the approach to treat pulmonary vessels. The optional introducer does not have to be removed before suturing, and is very useful. However, the following two weak points were observed in cases in which we used accessory introducers. First, because the introducer is long, it is often difficult to lead it to a target point and requires a long time to insert when performing vascular exclusion and it can therefore induce additional strain. Second, the edges of introducers are often caught on the surrounding tissue. In addition, it has been heard that, in other institutions, curved tip staplers are usually used without introducers because optional introducers are difficult to use. A curved-tip stapler, even which employed without an introducer, can be used to approach vessels more easily than a straight stapler; however, there is a risk of causing damage to the back of vessels with the tip unless adequate space is maintained below the vessels. In particular, sufficient care is required in thoracoscopic surgery due to the lack of complete solid vision. Safer and easier inductive methods using a curved tip were necessary. The stapler was usually induced after first securing a pulmonary vessel with a silk thread. When the perivascular sheath or surrounding tissue was considered to be at risk of being caught by the stapler, the vessel was secured with a Penrose drain instead of a silk thread [5]. However, when we used a Penrose drain, it was necessary to exclude the drain from the stapler before suturing, and scrupulous care was required in cases with fragile vessels. The width of the Penrose drain was almost the same as the width of the endostapler; therefore, the presence of adequate space below the vessels can be assessed. Furthermore, the following two advantages are associated with the use of elastic shortened introducers. First, the placement of an elastic introducer between a soft Penrose drain and a hard curved tip allows for a smooth introduction. Second, Penrose drains sometimes detach from staplers when pulling on them. Accessory introducers lock onto a curved tip and cannot be easily detached. The shortened introducer is inserted into the Penrose drain and the Penrose drain is
Gen Thorac Cardiovasc Surg
pulled near the vessels, after which the stapler can be smoothly pushed with the introducer. Therefore, we devised a new method with shortened introducers and Penrose drains. This method was very useful, and combined the advantages of a Penrose drain and an introducer. These included the fact that the staplers do not catch surrounding tissue when the Penrose drain is used. Second, Penrose drains are soft, and they induce minimal strain for vessels. The shortened introducer allowed the curved tips of the staplers to be guided smoothly into the target location. Using introducers, there is a little damage to the surrounding tissue caused by the curved tips. The staplers were smoothly guided into place in all cases. In this method, the Penrose drain is not removed before suturing, and the time of tension is shortened. We have been using this method in most of procedures involving staplers for pulmonary vessels.
Conflict of interest All authors have no financial or other interest in the manufacture or distribution of the device.
References 1. Sugarbaker DJ, Mentzer SJ. Improved technique for hilar vascular stapling. Ann Thorac Surg. 1992;53:165–6. 2. Yamashita S, Tokuishi K, Moroga T, Abe S, Yamamoto K, Miyahara S, et al. Totally thoracoscopic surgery and troubleshooting for bleeding in non-small cell lung cancer. Ann Thorac Surg. 2013;95:994–9. 3. Flores RM, Ihekweazu U, Dycoco J, Rizk NP, Rusch VW, Bains MS, et al. Video-assisted thoracoscopic surgery (VATS) lobectomy: catastrophic intraoperative complications. J Thorac Cardiovasc Surg. 2011;142:1412–7. 4. Todd LD, William RM. Anvil extension technology in thoracic surgery. Ann Thorac Surg. 2012;93:1280–4. 5. Lin MW, Lee JM, Lee YC. Penrose drain tube as a guide for endostaplers during lobectomy via video-assisted thoracoscopic surgery. Thorac Cardiovasc Surg. 2010;58:184–9.
123
HOW TO DO IT
Safe stapling technique for pulmonary vessels with the shortened introducers and curved tips in thoracoscopic surgery Eiki Mizutani • Kazuki Nakahara Shigeki Miyanaga • Ayako Seike
•
Received: 18 September 2013 / Accepted: 5 December 2013 Ó The Japanese Association for Thoracic Surgery 2013 TM
TM
Abstract Endo GIA curved tips with Tri-Stapler is more useful for the approach for pulmonary vessels than conventional straight staplers. Unless adequate space is maintained below the vessels, there is a risk of causing damage to the back of vessels with the curved tip without optional introducers. The recommended method involves passing silk thread through the back of the pulmonary vessels and ligating the thread to the introducer. However, the long introducer often applies tension to pulmonary vessels and can be caught in the tissues surrounding vessels. Therefore, we devised a new method. First, the introducer is shortened to a length of approximately 3 cm and attached to a curved tip. Second, a Penrose drain is passed through the back of the vessels. Last, the introducer is inserted into the drain and the stapler is guided. The vessels can be cut without removing the introducers and Penrose drains from staplers. Keywords
straight staplers have been used, and the approach for the TM vessels sometimes is risky. Endo GIA curved tips and TM introducers with Tri-Stapler (Covidien, Norwalk, CT) have recently been developed as a safer approach for the vessels [4]. The recommended method for employing the TM Endo GIA curved tip and an optional flexible introducer TM with the Tri-Stapler involves passing silk thread through the back of the pulmonary vessels and ligating the thread to the introducer of the curved tip. The weak point of this method is that it is often difficult to lead the long introducer to a target point, which applies tension to vulnerable pulmonary vessels and can result in the instrument becoming caught in the tissue surrounding the vessels, especially in thoracoscopic surgery due to the lack of complete solid vision. We herein report the usefulness and advantages of curved tips and shortened introducers for performing surgery on pulmonary vessels.
Curved tip Stapler Thoracoscopic surgery Materials and methods
Introduction The widespread use of video-assisted thoracic surgery (VATS) is supported by staplers, and pulmonary vessels are now often treated with staplers [1]. These fragile vessels have to be treated carefully, because repairing them is often difficult, and errors can be fatal [2, 3]. So far, only E. Mizutani K. Nakahara (&) S. Miyanaga A. Seike Department of Thoracic Surgery, Tokyo Teishin Hospital, 2-14-23 Fujimi, Chiyoda-ku, Tokyo 102-8798, Japan e-mail: [email protected] E. Mizutani e-mail: [email protected]
We devised a new method. First, the introducer is shortened to a length of approximately 3 cm, which is longer than the width of the vessels. Both angles of the edges of the shortened introducer were cut off to be the same shape as the original introducer. Then, we attached the introducer to a curved tip (Fig. 1). Second, we passed a right angle dissector through the back of the pulmonary vessels. The dissector then caught the edge of a Penrose drain, which was cut off diagonally. The width of the Penrose drain was 6 mm in the normal state and 9 mm at the time of compression. Last, the introducer is inserted into the Penrose drain pulled out through an access port, and we pulled the Penrose drain near the vessels then pushed the stapler with the introducer into the proper position (Figs. 2, 3).
123
Gen Thorac Cardiovasc Surg
upper lobes, three right lower lobes, seven left upper lobes and nine left lower lobes. This method was applied to most vessels that had been previously cut with straight staplers, and only five straight staplers were used for vessels. The curved staplers were used in thirty-seven cases for pulmonary veins and in forty-six cases for pulmonary arteries. The angle of insertion of the curved tip staplers was fundamentally the same as that of the straight staplers. The insertion of staplers was smooth in all cases.
Comment Fig. 1 The introducer is shortened to a length of approximately 3 cm
Fig. 2 A shortened introducer attaches to a curved tip. The introducer is inserted into a Penrose drain, which was passed through the back of vessels and pulled out through an access port
Fig. 3 Intraoperative view shows that a stapler with a curved tip, a shortened introducer and a Penrose drain is smoothly guided
Between July 2012 and June 2013, we used eighty-three curved tips in thirty-two cases of thoracoscopic surgery for lobectomy. We performed lobectomy on thirteen right
123
Staplers with curved tips are better than conventional straight staplers in the approach to treat pulmonary vessels. The optional introducer does not have to be removed before suturing, and is very useful. However, the following two weak points were observed in cases in which we used accessory introducers. First, because the introducer is long, it is often difficult to lead it to a target point and requires a long time to insert when performing vascular exclusion and it can therefore induce additional strain. Second, the edges of introducers are often caught on the surrounding tissue. In addition, it has been heard that, in other institutions, curved tip staplers are usually used without introducers because optional introducers are difficult to use. A curved-tip stapler, even which employed without an introducer, can be used to approach vessels more easily than a straight stapler; however, there is a risk of causing damage to the back of vessels with the tip unless adequate space is maintained below the vessels. In particular, sufficient care is required in thoracoscopic surgery due to the lack of complete solid vision. Safer and easier inductive methods using a curved tip were necessary. The stapler was usually induced after first securing a pulmonary vessel with a silk thread. When the perivascular sheath or surrounding tissue was considered to be at risk of being caught by the stapler, the vessel was secured with a Penrose drain instead of a silk thread [5]. However, when we used a Penrose drain, it was necessary to exclude the drain from the stapler before suturing, and scrupulous care was required in cases with fragile vessels. The width of the Penrose drain was almost the same as the width of the endostapler; therefore, the presence of adequate space below the vessels can be assessed. Furthermore, the following two advantages are associated with the use of elastic shortened introducers. First, the placement of an elastic introducer between a soft Penrose drain and a hard curved tip allows for a smooth introduction. Second, Penrose drains sometimes detach from staplers when pulling on them. Accessory introducers lock onto a curved tip and cannot be easily detached. The shortened introducer is inserted into the Penrose drain and the Penrose drain is
Gen Thorac Cardiovasc Surg
pulled near the vessels, after which the stapler can be smoothly pushed with the introducer. Therefore, we devised a new method with shortened introducers and Penrose drains. This method was very useful, and combined the advantages of a Penrose drain and an introducer. These included the fact that the staplers do not catch surrounding tissue when the Penrose drain is used. Second, Penrose drains are soft, and they induce minimal strain for vessels. The shortened introducer allowed the curved tips of the staplers to be guided smoothly into the target location. Using introducers, there is a little damage to the surrounding tissue caused by the curved tips. The staplers were smoothly guided into place in all cases. In this method, the Penrose drain is not removed before suturing, and the time of tension is shortened. We have been using this method in most of procedures involving staplers for pulmonary vessels.
Conflict of interest All authors have no financial or other interest in the manufacture or distribution of the device.
References 1. Sugarbaker DJ, Mentzer SJ. Improved technique for hilar vascular stapling. Ann Thorac Surg. 1992;53:165–6. 2. Yamashita S, Tokuishi K, Moroga T, Abe S, Yamamoto K, Miyahara S, et al. Totally thoracoscopic surgery and troubleshooting for bleeding in non-small cell lung cancer. Ann Thorac Surg. 2013;95:994–9. 3. Flores RM, Ihekweazu U, Dycoco J, Rizk NP, Rusch VW, Bains MS, et al. Video-assisted thoracoscopic surgery (VATS) lobectomy: catastrophic intraoperative complications. J Thorac Cardiovasc Surg. 2011;142:1412–7. 4. Todd LD, William RM. Anvil extension technology in thoracic surgery. Ann Thorac Surg. 2012;93:1280–4. 5. Lin MW, Lee JM, Lee YC. Penrose drain tube as a guide for endostaplers during lobectomy via video-assisted thoracoscopic surgery. Thorac Cardiovasc Surg. 2010;58:184–9.
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