“Non-Triangle Plane” Surgical Technique of Video-Assisted Thoracic Surgery Atypical Segmentectomy for Stage IA Non-Small-Cell Lung Cancer: Early Experience

Objectives: To evaluate the safety and feasibility of a novel surgical technique (“non-triangle plane” technique) of two-port (mini-utility) video-assisted thoracic surgery (VATS) atypical segmentectomy (S3+S1+2c) with tunneling stapler for small-sized non-small-cell lung cancers (NSCLCs) located in left S3 close to the intersegmental plane between S3 and S1+2c.Materials and Methods: This retrospective descriptive study included 16 patients who, between April 2016 and December 2019, underwent a single two-port (mini-utility) VATS atypical segmentectomy (S3+S1+2c) with tunneling stapler technique for small-sized NSCLCs with a ground-glass opacity (GGO) rate of more than 50% by a constant surgical team in two hospitals. Perioperative data and survival data were collected and retrospectively analyzed. Postoperative follow-up was performed every 6 months.Results: Six patients were with adenocarcinoma in situ, and ten were with minimally invasive adenocarcinoma. The mean surgical margin was 14.06 ± 3.02 mm. The mean operation time was 53.88 ± 9.76 min. The mean duration of chest tube drainage was 4 ± 1.21 days, and the median length of postoperative hospital stay was 4 days. There was no perioperative morbidity and mortality. The median follow-up was 47.5 months (17–61 months). No recurrences occurred, and all patients were still alive at the last registered follow-up (May 31, 2021).Conclusion: Two-port (mini-utility) VATS atypical segmentectomy (S3+S1+2c) with tunneling stapler technique is a safe and feasible option for the treatment of small-sized NSCLCs located in left S3 close to the intersegmental plane between S3 and S1+2c.

Linear versus Circular Stapler for Gastrojejunal Anastomosis in Laparoscopic Roux-En-Y Gastric Bypass: An Analysis of 211 Cases

Purpose. Although laparoscopic Roux-en-Y gastric bypass (LRYGB) is a frequently performed bariatric procedure, there is still no consensus on its technical implementation. Methods. 211 patients treated with LRYGB in a single institution between March 2011 and October 2016 were analyzed retrospectively. A subgroup analysis for the linear (LSA) versus circular stapler technique (CSA) for gastrojejunal anastomosis (GJA) was performed to evaluate complications and outcomes. Results. 128 (60.6%) patients received GJA with CSA and 83 (39.4%) with LSA. Average weight loss one year after surgery, respectively, BMI after one year of follow-up (kg/m2), showed no significant difference. Median surgery time was significantly shorter in the LSA group. If the procedure was performed with CSA, significantly more wound infections occurred. Conclusions. Both the circular and the linear stapler techniques for gastrojejunal anastomosis in laparoscopic Roux-en-Y gastric bypass are safe methods with comparable outcomes. A disadvantage of CSA is the significantly higher rate of wound infections, a circumstance which requires increased attention.

Strategies to improve the accuracy of lung stapling in uniportal and multiportal thoracoscopic sublobar lung resections

The challenges in video-assisted thoracic surgery for sublobar lung resection include difficulty in tumour localization by palpation and difficulty in determining appropriate resection lines. Virtual-assisted lung mapping (VAL-MAP), a bronchoscopic preoperative multispot lung dye-marking technique, allows for both tumour localization and determination of resection lines. To facilitate stapler-based resection, the AMAGAMI or ‘incomplete grasping’ stapler technique is useful to adjust the alignment of the stapler and resection lines. However, when the lung tissue to be stapled is thick, there is unavoidable uncertainty in the staple line inside the lung. We experimentally demonstrated that up to 1 cm of slippage of lung parenchyma occurs at stapling when the stapled lung tissue is >1 cm thick. VAL-MAP 2.0 is a new generation of VAL-MAP combining multispot dye markings with intrabronchial microcoil placement, allowing for 3-dimensional lung mapping and intraoperative navigation using fluoroscopy. The uncertainty of stapling in the lung parenchyma can be partly overcome by VAL-MAP 2.0.

Stapled Surgery for Hemorrhoidal Prolapse: From the Beginning to the Modern Times

Introduction: Hemorrhoidal disease is the most common proctologic condition in adults. Among the different surgical procedures, one of the greatest innovations is represented by the stapled hemorrhoidopexy. The history of this technique started with a single stapler use passing thorough a double stapler technique to resect the adequate amount of prolapse, finally arriving to the use of high volume devices. Methods: Nevertheless each device has its own specific feature, the stapler is basically made up with one or more circular lines of titanium staples whose height may be variable. The procedure is based on different steps: Introduction of the CAD, evaluation of the prolapse, fashioning purse string or parachute suture, introduction of the stapler head beyond the suture, pull the wires through the window, close the stapler and keep pulled the wires of the suture held together with a forcep, fire using two hands, open the stapler and remove it and check the staple line and then check the specimen. One of the latest innovations in stapled surgery the Tissue Selective Therapy. It is a minimally invasive procedure in which there is a partial circular stapled hemorrhoidopexy focused on the prolapsing piles with bridges of normal mucosa left. Results: Several studies have reported that SH is a safe and effective procedure to treat the hemorrhoidal prolapse. It is a quicker procedure with a shorter hospital stay and earlier return to work if compared with the conventional treatment. This is due to a less postoperative pain, postoperative bleeding, wound complications and constipation. Furthermore, the first generation devices had worse outcomes if compared with those of the new generation stapler that showed lower postoperative complication rate with better anatomical and symptomatic results. Conclusions: Stapled procedure for the treatment of symptomatic hemorrhoidal prolapse represents one of the most important innovations in proctology of the last century bringing with it the new revolutionary concept of the rectal intussusception as a determining factor involved in the natural history of the disease. Stapled hemorrhoidopexy marked an era in which the surgeon may to offer to the patients a safe, effective treatment with less pain and fast recovery.

A Shorter Circular Stapler Height at the Gastrojejunostomy during a Roux-En-Y Gastric Bypass Results in Less Strictures and Bleeding Complications

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is prone to a number of complications, most notably at the gastrojejunostomy (GJ) staple line. The circular stapler technique is a common method used to create the GJ anastomosis. Although recent studies have shown a decreased rate of anastomotic strictures with shorter stapler heights, the optimal circular stapler height to use remains controversial. We therefore completed a retrospective cohort study within the Alberta Provincial Bariatric Program (APBP) to compare outcomes between the 3.5 mm and 4.8 mm stapler heights. We identified 215 patients who had a LRYGB done between the years 2015 and 2017. 143 patients had the GJ constructed with a 3.5 mm circular stapler height, with the remaining 72 patients having the GJ fashioned with a 4.8 mm stapler height. The rate of anastomotic stricturing was lower in the 3.5 mm stapler group compared to the other cohort (3.5 versus 13.9%, resp., p=0.008). Likewise, the overall rate of bleeding complications was lower in the 3.5 mm stapler group compared to the 4.8 mm group (6.3 versus 15.3%, resp., p=0.04). The rate of anastomotic stricturing and postoperative bleeding is lower with the use of a 3.5 mm circular stapler compared to a 4.8 mm circular stapler when forming the GJ.