Use of staplers and adverse events in thoracic surgery

Thoracoscopic Massive Bleeding After Firing Mediastinal Trunk of the Pulmonary Artery With Calcified Lymph Node

The thoracoscopic management of hilar calcified lymph nodes is a technical challenge as the dense adhesions with the bronchus and vessels prevented a safe dissection. Herein, we reported the unexpected bleeding after firing the mediastinal trunk of the pulmonary artery with calcified lymph nodes during the completion of thoracoscopic right upper lobectomy for the management of lung cancer. The bleeding was successfully fixed by an emergent thoracotomy. We used a standard white vascular cartridge that probably was unable to staple a thick tissue, such as the vessel with calcified lymph node. Thus, the best strategy remained to cut the pulmonary artery where the lymph nodes were not attached, and the plasty of the pulmonary artery should be considered if the lymph nodes could not be dissected from the vessels. If the surgeons were not confident to manage this situation under thoracoscopy, conversion to thoracotomy should never be forgotten. Open surgery could facilitate the dissection of calcified lymph nodes and safely fix unexpected bleeding due to vascular lesions.

Leakage pressures of partial and total lung lobectomies performed with thoracoabdominal staplers in cadaveric dogs

OBJECTIVE

To compare leakage pressures of stapled partial and total lung lobectomies using thoracoabdominal (TA) staplers in canine cadaveric specimens.

STUDY DESIGN

Ex vivo experimental study.

SAMPLE POPULATION

A total of 29 lung lobes from six canine cadavers.

METHODS

Lower respiratory tracts were harvested from canine cadavers >15 kg. Lung lobes were randomized to groups: total lobectomy with a TA30-V3 (TL-30), partial lobectomy with two TA30-V3 cartridges in a wedge configuration (PL-30), and partial lobectomy with a TA60-3.5 mm (PL-60). The leakage pressure (pressure at which air bubbles were first seen from submerged tissue) was assessed, and groups were compared.

RESULTS

All nine PL-30 and all nine PL-60 sites leaked at median pressures of 10 cm H2O (range 10-15) and 18 cm H2O (range 10-20), respectively. Only 1/11 TL-30 site leaked during testing at a pressure of 22 cm H2O. PL-30 and PL-60 sites were more likely to leak at 20 (OR: 437; 95% CI: 7.9-24 171; p = .003) and 30 (OR: 133; 95% CI: 4.8-3674.2; p = .003) cm H2O compared to TL-30 sites, and the leakage pressure was greater for TL-30 as compared to PL-30 (marginal effect: -46.14; 95% CI: -55.9 to -36.38; p < .001) and PL-60 (marginal effect: -41.2; 95% CI: -51.73 to -30.67; p < .001) sites. PL-60 leakage pressures were greater than those of PL-30 (marginal effect: 4.94; 95% CI: 1.43-8.44; p = .006).

CONCLUSION

In canine cadaveric lung, total lobectomies with a TA30-V3 were less likely to leak at physiological pressures than partial lobectomies with either TA30-V3 or TA60-3.5 mm staplers.

CLINICAL SIGNIFICANCE

These results suggest a greater potential risk for air leakage at physiologically relevant pressures following partial as compared to total lobectomies with the TA stapling devices and techniques used commonly in veterinary surgery.

Comparative study between using a stapler and hand sewing in bullectomy

Introduction

Spontaneous pneumothorax is a life-threatening thoracic condition that could be either primary spontaneous pneumothorax (PSP) in the absence of an underlying lung disease or secondary spontaneous pneumothorax (SSP) in the presence of an underlying lung disease. In the case of recurrent, contralateral spontaneous pneumothorax or persistent air leak with a chest drain, surgery with bullectomy associated with pleurectomy or pleurodesis is the gold standard management.

Aim

To compare two different techniques for bullectomy, either by using staplers or by hand sewing.

Material and methods

Retrospective review of all patients with spontaneous pneumothorax who underwent bullectomy and pleurectomy by thoracotomy. Group A (30 patients) had repair by using staplers and group B (30 patients) had repair using the hand sewing technique.

Results

The mean operative cost was 4400 ±433.4 Egyptian pounds (EGP) versus EGP 2733.3 ±253.7 in group A and group B respectively (p = 0.001). Mean post-operative cost was 1000 ±100 EGP in group A compared to EGP 2060 ±154.4 in group B (p = 0.0001). Duration of air leak was 1.8 ±1.095 and 9.1 ±3.2 days in group A and group B, respectively (p = 0.0001). Re-exploration occurred in 1 patient in group A (3.3%) and 2 patients in group B (6.6%) (p = 0.5).

Conclusions

The operative cost was significantly higher in the stapler group compared to the hand sewing technique group. However, the duration of post-operative air leak, post-operative hospital stay and post-operative cost were significantly lower in the stapler group. There was no significant difference between the 2 groups in the re-exploration rate after surgery.

Stapler-induced vascular injury during uniportal VATS lobectomy: lessons learned from a rare complication case

BACKGROUND

Due to advances in video-assisted thoracic surgery (VATS), the majority of lung resections can be performed safely via VATS with low morbidity and mortality. However, pulmonary artery (PA) bleeding often requires emergency conversion to thoracotomy, potentially leading to a life-threatening situation. We report a case of pulmonary artery injury caused by an unexpected stapler-tissue interaction during uniportal VATS lobectomy, highlighting the importance of recognizing and managing such rare complications to improve patient outcomes.

CASE PRESENTATION

A 63-year-old man underwent uniportal VATS left upper lobectomy for a suspected primary lung cancer. During the procedure, unexpected bleeding occurred from the third branch of the pulmonary artery (A3) after withdrawal of an unfired stapler. The protruding staple of the A3 stump was inadvertently hooked and stretched by the groove of the staple anvil. Although the bleeding was controlled by compression with the lung, the injured A3 stump required repair. Due to the extensive intimal injury near the central part of the left main pulmonary artery and the potential risk of fatal postoperative complications, we converted to open thoracotomy for definitive vascular repair by suturing. The patient had no postoperative complications and was discharged on postoperative day 8.

CONCLUSIONS

This case report provides valuable lessons regarding the rare stapler-related vascular injury during uniportal VATS lobectomy. It is important to note that even during non-vascular dissection, unexpected stapler-tissue interactions can lead to bleeding. To prevent the vessel stump entanglement with stapler components, maintaining separation between the stapler and staple stumps is crucial. In uniportal VATS, manipulation during stapler insertion is one of the most challenging phases for instrument interference, requiring increased caution to prevent complications such as the vascular injury described in this case. Thorough preoperative planning, specific intraoperative precautions, and adapted safety protocols that address the limitations of uniportal VATS are essential for effective management of potential complications. Although techniques for thoracoscopic vascular control exist, they are not always feasible and conversion to open thoracotomy should be considered when necessary to ensure patient safety.

A real-world study evaluating the safety and utility of a two-row stapler reload on pulmonary vasculature

Background

Endoscopic staplers are common surgical devices used for the ligation and division of vasculature in thoracic procedures. When a stapler ligates and divides pulmonary vasculature, potentially catastrophic intraoperative bleeding at the staple-line may occur. The aim of this study was to confirm the safety and discuss the utility of a two-row stapler reload, by assessing the incidence of clinically necessary intraoperative hemostatic intervention when applied to pulmonary vasculature in real-world applications.

Methods

This study was designed as a prospective non-comparative registry study conducted in seven centers across the United States, to confirm the safety and performance of Signia™ Small Diameter Reloads (SDR) when used for indicated thoracic surgical procedures. The primary endpoint was the incidence of hemostatic intervention related to the ligation and division of pulmonary arteries and veins. A five-point Likert scale scored hemostasis of each SDR staple-line. Secondary endpoints included the incidence of device-related only adverse events (AEs), device deficiencies, and procedure-related hospital readmission up to and including 30 days post operation.

Results

SDR was fired 302 times across pulmonary vasculature in 120 subjects. Three firings required clinically necessary hemostatic intervention for an intervention rate of 0.99% (3 of 302 firings). Moreover, 97.5% (117 of 120 subjects) had intact SDR staple-lines regardless of surgical access or stapler handle preference. Only 4 (3.3%) thoracoscopic and robotic procedures converted to open, but none were due to SDR staple-lines. There was no statistically significant difference between the Likert score of transected arteries compared to veins (P=0.61). There were no device deficiencies or device-only related AEs reported.

Conclusions

In this study, the two-row stapler reloads demonstrated favorable safety and efficacy profiles when fired across hilar vessels in the thoracic space with a 99% hemostatic rate, independent of surgical access and stapler handle preference.

Design and preliminary validation of a high-fidelity vascular simulator for robot-assisted manipulation

The number of robot-assisted minimally invasive surgeries is increasing annually, together with the need for dedicated and effective training. Surgeons need to learn how to address the novel control modalities of surgical instruments and the loss of haptic feedback, which is a common feature of most surgical robots. High-fidelity physical simulation has proved to be a valid training tool, and it might help in fulfilling these learning needs. In this regard, a high-fidelity sensorized simulator of vascular structures was designed, fabricated and preliminarily validated. The main objective of the simulator is to train novices in robotic surgery to correctly perform vascular resection procedures without applying excessive strain to tissues. The vessel simulator was integrated with soft strain sensors to quantify and objectively assess manipulation skills and to provide real-time feedback to the trainee during a training session. Additionally, a portable and user-friendly training task board was produced to replicate anatomical constraints. The simulator was characterized in terms of its mechanical properties, demonstrating its realism with respect to human tissues. Its face, content and construct validity, together with its usability, were assessed by implementing a training scenario with 13 clinicians, and the results were generally positive.

Examination of resistance of various methods of pulmonary vessel occlusion to hydrostatic pressure

Objective

The aim of this study was to compare pressure resistance of the most common methods of vessel occlusion during thoracic surgical procedures: ligations, clips, and vascular endostaplers.

Methods

Pulmonary vessels were obtained during routine thoracic surgeries. A ball-tipped cannula was inserted through an opening in the side wall and secured with a linen ligature from slipping out. Subsequently, saline was infused into the vessel. We recorded the pressure on which a leakage occurred.

Results

A total of 65 vessels, divided between 3 groups, were enrolled in the study. In the endostaplers group, median bursting pressures were 262.5 mmHg and 300 mmHg for arteries and veins, respectively. In the case of clips, it was over 750 mmHg in both types of the vessels. The same results were observed in the ligation group. Minimal bursting pressures in endostapler occlusion were 187.5 mmHg and 225 mmHg in arteries and veins, respectively. In the case of clips, it was 600 mmHg for arteries and 675 mmHg for veins. A total of 525 mmHg (arteries) and 750 mmHg (veins) were the minimal leaking values observed in vessels occluded with ligations. Comparative analysis showed statistically significant differences in endostapler-clips and endostapler-ligations pairs (p < 0.001). There were no differences between clips and ligations.

Conclusions

The examined methods are capable of occluding pulmonary vessels under physiological conditions. Furthermore, ligations and clips are resistant to pressures highly exceeding physiological values.

Outcomes following combined median sternotomy and ventral midline laparotomy for bicavitary penetrating wooden foreign bodies

Combined abdominal and thoracic pathology caused by extra-gastrointestinal migration of an ingested wooden foreign body (WFB) is an uncommon but serious injury. Presenting clinical signs are typically nonspecific and, in the absence of observed WFB ingestion, diagnosis is challenging. Treatment requires concurrent abdominal and thoracic surgical exploration to remove the WFB and address injuries caused by its migration. This case series describes perioperative characteristics and outcomes in 4 dogs following combined median sternotomy and ventral midline laparotomy (CMSVML) for bicavitary penetrating WFBs. Key clinical message: Treatment of bicavitary penetrating WFBs with CMSVML provided postoperative outcomes similar to those in previous reports; however, high-grade complications and prolonged hospitalization were commonly encountered.

Cold coagulation in thoracoscopic treatment of primary pneumothorax: a comparison with apicectomy

OBJECTIVES

Primary spontaneous pneumothorax is a common disease, whose surgical treatment is still enigmatic in terms of timing and technique. Herein, we reported our experience with the parenchymal-sparing technique via cold coagulation (CC), in comparison to stapler apicectomy (SA).

METHODS

We retrospectively collected data of all patients with apical blebs or <2 cm bullae treated with minimally invasive surgery for recurrent or persistent spontaneous pneumothorax, from 2010 to 2020. Two different surgical techniques were used: SA and the parenchymal-sparing CC of the apex. Perioperative and long-term results were analysed and compared.

RESULTS

Out of 177 patients enrolled, 77 patients (CC group) underwent cold-coagulation of the apex while 100 patients (SA group) were treated with SA. Two groups were comparable in terms of age, surgical indication, intraoperative findings and affected side. CC group had a mean operative time of 43.2 min (standard deviation ± 19.5), shorter than SA group with 49.3 min (standard deviation ± 20.1, P-value: 0.050). Complication rate was significantly different between 2 groups, 5 (7%) and 16 (16%), for the CC and SA groups, respectively (P: 0.048), even if not in terms of prolonged postoperative air leak (P: 0.16). During the follow-up, 13 homolateral recurrences were reported: 2 (3%) in group CC and 11 (11%) in group SA; with a significant difference (P: 0.044). All reinterventions (postoperative prolonged air leak and recurrences) required an SA.

CONCLUSIONS

Parenchymal-sparing technique through CC of apical blebs and bullae is an effective treatment for primary spontaneous pneumothorax and guarantees a good immediate lung sealing, despite stapling still represents the choice treatment in complex cases.

The technique of stump closure has no impact on post-pneumonectomy bronchopleural fistula in the non-small cell lung cancer-a cross-sectional study

Background

Pneumonectomy is a high-risk radical resection procedure, with bronchopleural fistula (BPF) being its most challenging and severe complication. This study aimed to assess the surgical risk factors and the impact of the bronchial stump closure technique on the incidence of the BPF.

Methods

This is a single-center, cross-sectional study of the medical records of 455 post-pneumonectomy patients operated due to non-small cell lung cancer (NSCLC) in 2006-2017. We analyzed the following variables and their influence on the occurrence of the BPF: operation side, surgical techniques (i.e., manual suture or the stapler), stump buttressing, the extension of pneumonectomy, comorbidities, and postoperative complications.

Results

BPF occurred in 7.47% of post-pneumonectomy patients. BPF was more prevalent in right-sided pneumonectomy versus left-sided (10.98% vs. 5.32%; P=0.026). The use of a stapler or manual suture was not associated with the incidence of the BPF (7.96% vs.7.09%, P=0.72). There were no significant differences in the occurrence of BPF among bronchial stump buttressing with the parietal pleura (P=0.80), intercostal muscle flap (IMF) (P=0.46), and pericardial fat pad (P=0.88). When comparing data from 2006-2012 with those from 2013-2017, we found a steady decrease in the number of performed stump reinforcements, but this was not associated with a higher risk of BPF.

Conclusions

The method used for stump closure, additional tissue buttressing of the bronchial stump and year of the surgery had no significant impact on the occurrence of BPF. Only right-sided pneumonectomy was associated with higher BPF occurrence.