Perioperative outcomes of transvaginal specimen extraction laparoscopic total gastrectomy and conventional laparoscopicassisted total gastrectomy

BACKGROUND Natural orifice specimen extraction surgery(NOSES)has emerged as a promising alternative compared to conventional laparoscopic-assisted total gastrectomy(LATG)for treating gastric cancer(GC).However,evidence regarding the efficacy and safety of NOSES for GC surgery is limited.This study aimed to compare the safety and feasibility,in addition to postoperative complications of NOSES and LATG.METHODS Dual circular staplers were used in Roux-en-Y digestive tract reconstruction for transvaginal specimen extraction LATG,and its outcomes were compared with LATG in a cohort of 51 GC patients with tumor size≤5 cm.The study was conducted from May 2018 to September 2020,and patients were categorized into the NOSES group(n=22)and LATG group(n=29).Perioperative parameters were compared and analyzed,including patient and tumor characteristics,postoperative outcomes,and anastomosis-related complications,postoperative hospital stay,the length of abdominal incision,difference in tumor type,postoperative complications,and postoperative survival.RESULTS Postoperative exhaust time,operation duration,mean postoperative hospital stay,length of abdominal incision,number of specific staplers used,and Brief Illness Perception Questionnaire score were significant in both groups(P<0.01).In the NOSES group,the postoperative time to first flatus,mean postoperative hospital stay,and length of abdominal incision were significantly shorter than those in the LATG group.Patients in the NOSES group had faster postoperative recovery,and achieved abdominal minimally invasive incision that met aesthetic requirements.There were no significant differences in gender,age,tumor type,postoperative complications,and postoperative survival between the two groups.CONCLUSION The application of dual circular staplers in Roux-en-Y digestive tract reconstruction combined with NOSES gastrectomy is safe and convenient.This approach offers better short-term outcomes compared to LATG,while long-term survival rates are comparable to those of conventional laparoscopic surgery.

Magnetic resonance imaging-based deep learning model to predict multiple firings in double-stapled colorectal anastomosis

BACKGROUND Multiple linear stapler firings during double stapling technique(DST)after laparoscopic low anterior resection(LAR)are associated with an increased risk of anastomotic leakage(AL).However,it is difficult to predict preoperatively the need for multiple linear stapler cartridges during DST anastomosis.AIM To develop a deep learning model to predict multiple firings during DST anastomosis based on pelvic magnetic resonance imaging(MRI).METHODS We collected 9476 MR images from 328 mid-low rectal cancer patients undergoing LAR with DST anastomosis,which were randomly divided into a training set(n=260)and testing set(n=68).Binary logistic regression was adopted to create a clinical model using six factors.The sequence of fast spin-echo T2-weighted MRI of the entire pelvis was segmented and analyzed.Pure-image and clinical-image integrated deep learning models were constructed using the mask region-based convolutional neural network segmentation tool and three-dimensional convolutional networks.Sensitivity,specificity,accuracy,positive predictive value(PPV),and area under the receiver operating characteristic curve(AUC)was calculated for each model.RESULTS The prevalence of≥3 linear stapler cartridges was 17.7%(58/328).The prevalence of AL was statistically significantly higher in patients with≥3 cartridges compared to those with≤2 cartridges(25.0%vs 11.8%,P=0.018).Preoperative carcinoembryonic antigen level>5 ng/mL(OR=2.11,95%CI 1.08-4.12,P=0.028)and tumor size≥5 cm(OR=3.57,95%CI 1.61-7.89,P=0.002)were recognized as independent risk factors for use of≥3 linear stapler cartridges.Diagnostic performance was better with the integrated model(accuracy=94.1%,PPV=87.5%,and AUC=0.88)compared with the clinical model(accuracy=86.7%,PPV=38.9%,and AUC=0.72)and the image model(accuracy=91.2%,PPV=83.3%,and AUC=0.81).CONCLUSION MRI-based deep learning model can predict the use of≥3 linear stapler cartridges during DST anastomosis in laparoscopic LAR surgery.This model might help determine the best anastomosis strategy by avoiding DST when there is a high probability of the need for≥3 linear stapler cartridges.

Optimal choice of stapler and digestive tract reconstruction method after distal gastrectomy for gastric cancer:A prospective case–control study

BACKGROUND Gastric cancer is the most common cause of cancer-related deaths,and is classified according to its location in the proximal,middle,or distal stomach.Surgical resection is the primary approach for treating gastric cancer.This prospective study aimed to determine the best reconstruction method after distal gastrectomy for gastric cancer.AIM To explore the efficacy of different staplers and digestive tract reconstruction(DTR)methods after radical gastrectomy and their influence on prognosis.METHODS Eighty-seven patients who underwent radical gastrectomy for distal gastric cancer at our institution between April 2017 and April 2020 were included in this study,with a follow-up period of 12-26 mo.The patients were assigned to four groups based on the stapler and DTR plan as follows:BillrothⅠ(B-I)reconstruction+linear stapler group(group A,22 cases),B-I reconstruction+circular stapler group(group B,22 cases),Billroth II(B-II)reconstruction+linear stapler group(group C,22 cases),and B-II reconstruction+circular stapler group(group D,21 cases).The pathological parameters,postoperative gastrointestinal function recovery,postoperative complications,and quality of life(QOL)were compared among the four groups.RESULTS No significant differences in the maximum diameter of the gastric tumors,total number of lymph nodes dissected,drainage tube removal time,QLQ(QOL questionnaire)-C30 and QLQ-STO22 scores at 1 year postoperatively,and incidence of complications were observed among the four groups(P>0.05).However,groups A and C(linear stapler)had significantly lower intraoperative blood loss and significantly shorter anastomosis time,operation time,first fluid diet intake time,first exhaust time,and length of postoperative hospital stay(P<0.05)than groups B and D(circular stapler).CONCLUSION Linear staplers offer several advantages for postoperative recovery.B-I and B-II reconstruction methods had similar effects on QOL.The optimal solution can be selected according to individual conditions and postoperative convenience.

Application of stapling devices in liver surgery: Current status and future prospects

The liver is a vascular-rich solid organ. Safe and effective dissection of the vessels and liver parenchyma, and control of intraoperative bleeding are the main concerns when performing liver resection. Several studies have confirmed that intraoperative blood loss and postoperative transfusion are predictors of postoperative morbidity and mortality in liver surgery. Various methods and instruments have been developed during hepatectomy. Stapling devices are crucial for safe and rapid anastomosis. They are used to divide hepatic veins and portal branches, and to transect liver parenchyma in open liver resection. In recent years, laparoscopic liver surgery has developed rapidly, and is now preferred by many surgeons. Stapling devices have also been gradually introduced in laparoscopic liver surgery, from dividing vascular and biliary structures to parenchymal transection. This may be because staplers make manipulation more simple, rapid and safe. Even in single incision laparoscopic surgery, which is recognized as a new minimally invasive technique, staplers are also utilized, especially in left lateral hepatectomy. For safe application of stapling devices in liver surgery, more related designs and modifications, such as application of a suitable laparoscopic articulating liver tissue crushing device, a staple line reinforcement technique with the absorbable polymer membrane or radiofrequency ablation assistance, are still needed. More randomized studies are needed to demonstrate the benefits and find broader indications for the use of stapling devices, to help expand their application in liver surgery.

金属覆膜支架联合鼻胆管治疗内镜逆行胰胆管造影术Ⅲ型Stapfer穿孔的研究(附6例报告)

目的总结金属覆膜支架联合鼻胆管治疗内镜逆行胰胆管造影术(ERCP)Ⅲ型Stapfer穿孔的疗效及安全性。方法对ERCPⅢ型Stapfer穿孔患者放置金属覆膜胆道支架,支架内再放置鼻胆引流管,术后2~4周行支架取出术。结果 6例患者均好转出院,无开腹手术患者,有效率100.00%,无支架相关并发症发生。1例住院期间出现腹腔感染症状,发生率为16.67%。结论金属覆膜支架联合鼻胆管治疗ERCPⅢ型Stapfer穿孔的方法是安全有效的,值得临床推广应用。

Hemorrhoidectomy- making sense of the surgical options

While debate continues as to which is the best surgical method for the treatment of hemorrhoids, none of the currently available surgical methods approach the ideal surgical option, which is one that is effective while being safe and painless. In reality, the less painful the procedure, the more likely it is to be associated with recurrence post-op. Where hemorrhoids surgery is concerned, there isn&#x02019;t a &#x0201c;one size fits all&#x0201d; option. Most of the randomized controlled trials performed to date include hemorrhoids of various grades and with a focus on only comparing surgical methods while failing to stratify the outcomes according to the grade of hemorrhoid. We believe that surgery needs to be tailored not only to the grade of the hemorrhoids, but also to the size, circumferential nature of the disease, and prevailing symptomatology.

Compression anastomosis clip for gastrointestinal anastomosis

AIM: To investigate the feasibility of compression anastomosis clip (CAC) for gastrointestinal anastomosis proximal to the ileocecal junction. METHODS: Sixty-six patients undergoing gastrointe-stinal anastomosis proximal to the ileocecal junction were randomized into two groups according to the anastomotic method, CAC or stapler. RESULTS: The postoperative recovery of patients in CAC and stapled anastomosis groups was similar. No postoperative complication related to the anastomotic method was found in either group. Both upper gastrointestinal contrast radiography at the early postoperative course and endoscopic examination after a 6-mo follow-up showed a better healing at the compression anastomosis. CONCLUSION: CAC can be used not only in colonic surgery but also in gastrointestinal anastomosis. Our result strongly suggests that CAC anastomosis is safe in various complication circumstances. However, it should be further conf irmed with a larger patient sample.

Simplifying Laparoscopic Surgery for Left Side Colon and Rectal Cancer Using Linear Stapler for Vascular Ligation: A Prospective Cohort Study

Introduction: Systematic lymphadenectomy and ligation of the feeding artery is extremely important when performing radical resection in colorectal cancer. However, vascular surgery via laparoscopy requires advanced skills and techniques;thus, this procedure needs to be simplified while maintaining quality of the surgery to make it a preferred technique for the surgeons. Methods: There were 49 patients who underwent laparoscopic sigmoidectomy or anterior resection till T2 level for sigmoid colon cancer and recto-sigmoid colon cancer. We analyzed short-term and long-term outcomes between stapling ligation and clipping ligation techniques used in these surgeries. Results: The mean volume of blood loss in the stapling ligation group was 12.8 ± 12.3 ml, which was significantly lower than 41.9 ± 71.2 ml of mean volume of blood loss in the clipping ligation group. There was no significant difference in the mean duration of surgery, the mean number of harvested lymph nodes, morbidity, recurrence, and 5-year relapse free survival rates between the 2 groups. Conclusions: This study demonstrates a surgical technique using staplers for vascular treatment of tumor-feeding arteries as a new technical improvement in laparoscopic colectomy for the treatment of early-stage colon cancer. We found that the described procedure was technically safe, simple, convenient, and oncologically valid.

New flexible endoscopic controlled stapler technique for the treatment of Zenker's diverticulum:A case series

AIMTo report about the combination and advantages of a stapler-assisted diverticulotomy performed by flexible endoscopy.METHODSFrom November 2014 till December 2015 17 patients (8 female, 9 male, average age 69.8 years) with a symptomatic Zenker diverticulum (mean size 3.5 cm) were treated by inserting a new 5 mm fully rotatable surgical stapler (MicroCutter30 Xchange, Cardica Inc.) next to an ultrathin flexible endoscope through an overtube. The Patients were under conscious sedation with the head reclined in left position, the stapler placed centrally and pushed forward to the bottom of the diverticulum. The septum was divided by the staple rows under flexible endoscopic control.RESULTSIn eleven patients (64.7%) the stapler successfully divided the septum completely. Mean procedure time was 21 min, medium size of the septum was 2.8 cm (range 1.5 cm to 4 cm). In four patients the septum was shorter than 3 cm, in seven longer than 3 cm. To divide the septum, averagely 1.3 stapler cartridges were used. Two minor bleedings occurred. Major adverse events like perforation or secondary haemorrhage did not occur. After an average time of two days patients were discharged from the hospital. In 6 patients (35.3%) the stapler failed due to a thick septum or insufficient reclination of the head. Follow up endoscopy was performed after an average of two months in 9 patients; 4 patients (44.4%) were free of symptoms, 5 patients (55.6%) stated an improvement. A relapse of symptoms did not occur.CONCLUSIONFlexible endoscopic Zenker diverticulotomy by using a surgical stapler is a new, safe and efficient treatment modality. A simultaneously tissue opening and occlusion prevents major complications.

Brachiocephalic artery stenting through the carotid artery: A case report and review of the literature

BACKGROUND As the population ages and people’s living standards gradually improve,the incidence of cerebrovascular disease in China is increasing annually,posing a serious threat to people’s health.The incidence of brachiocephalic artery stenosis in ischemic cerebrovascular disease is relatively low,accounting for 0.5% to 2% of patients,but its consequences are very serious.Herein,we report a case of brachiocephalic artery stenting through the carotid artery.CASE SUMMARY The patient was a 66-year-old man.He came to our hospital because of repeated dizziness and was diagnosed with ischemic cerebrovascular disease (stenosis at the beginning of the brachiocephalic artery).Cerebral angiography suggested that the stenosis of the brachiocephalic artery had almost occluded it.Contrast agent threaded a line through the stenosis,and there was reversed blood flow through the right vertebral artery to compensate for the subclavian steal syndrome in the right subclavian artery.To improve the symptoms,we placed an Express LD (8 mm × 37 mm) balloon expanding stent in the stenosis section.After the operation,the patient’s dizziness significantly improved.However,after 6 mo,the patient was re-admitted to the hospital due to dizziness.A computed tomography scan of the head revealed multiple cerebral infarctions in bilateral basal ganglia and the right lateral ventricle.An auxiliary examination including computerized tomography angiography of the vessels of the head and cerebral angiography both showed severe stenosis in the brachiocephalic artery stent.During the operation,the guidewire and catheter were matched to reach the opening of the brachiocephalic artery.Therefore,we decided to use a right carotid artery approach to complete the operation.We sutured the neck puncture point with a vascular stapler and then ended the operation.After the operation,the patient recovered well,his symptoms related to dizziness disappeared,and his right radial artery pulsation could be detected.CONCLUSION In patients with brachial artery stenosis,when the femoral artery approach is difficult,the carotid artery is an unconventional but safe and effective approach.At the same time,the use of vascular suturing devices to suture a carotid puncture point is also commendable.Although it is beyond the published scope of the application,when used cautiously,it can effectively avoid cerebral ischemia caused by prolonged artificial compression,and improper suturing can lead to stenosis of the puncture site and improper blood pressure,resulting in the formation of a hematoma.Finally,satisfactory hemostasis can be achieved.

Therapeutic effects of the TST36 stapler on rectocele combined with internal rectal prolapse

BACKGROUND The most common causes of outlet obstructive constipation(OOC)are rectocele and internal rectal prolapse.The surgical methods for OOC are diverse and difficult,and the postoperative complications and recurrence rate are high,which results in both physical and mental pain in patients.With the continuous deepening of the surgeon’s concept of minimally invasive surgery and continuous in-depth research on the mechanism of OOC,the treatment concepts and surgical methods are continuously improved.AIM To determine the efficacy of the TST36 stapler in the treatment of rectocele combined with internal rectal prolapse.METHODS From January 2017 to July 2019,49 female patients with rectocele and internal rectal prolapse who met the inclusion criteria were selected for treatment using the TST36 stapler.RESULTS Forty-five patients were cured,4 patients improved,and the cure rate was 92%.The postoperative obstructed defecation syndrome score,the defecation frequency score,time/straining intensity,and sensation of incomplete evacuation were significantly decreased compared with these parameters before treatment,and the differences were statistically significant(P<0.05).The postoperative anal canal resting pressure and maximum squeeze pressure in patients decreased compared with before treatment,and the differences were statistically significant(P<0.05).The initial and maximum defecation thresholds after surgery were significantly lower than those before treatment,and the differences were statistically significant(P<0.05).The postoperative ratings of rectocele,resting phase,and defecation phase in these patients were significantly decreased compared with those before treatment,and the differences were statistically significant(P<0.05).CONCLUSION The TST36 stapler is safe and effective in treating rectocele combined with internal rectal prolapse and is worth promoting in clinical work.

Evaluation of the clinical efficacy and safety of TST33 mega hemorrhoidectomy for severe prolapsed hemorrhoids

BACKGROUND The pathogenesis of hemorrhoids is mainly anal cushion prolapse.Although the traditional treatment has a certain curative effect,it is not ideal.The remission rate of postoperative symptoms is low.Even if temporary remission is achieved,patients with hemorrhoids easily relapse after 1-2 years.The new technique of using staplers to treat prolapsed hemorrhoids has good therapeutic effects in clinical practice.AIM To explore the effect of TST33 mega stapler prolapse and hemorrhoid mucosal resection in the treatment of patients with severe prolapsed hemorrhoids.METHODS A total of 204 patients with severe prolapse hemorrhoids who were admitted to the department of anorectal in our hospital from April 2018 to June 2020 were selected,and the patients were randomly divided into group A and group B with 102 cases in each group using a randomized controlled clinical research program.Patients in Group A were treated with a TST33 mega stapler and hemorrhoid mucosal resection to treat prolapse,and patients in Group B were treated according to the Procedure for Prolapse and Hemorrhoids;the operation time,intraoperative blood loss,hospital stay,the difference in operation time,intraoperative blood loss,hospitalization time,pain degree before and after operation,degree of anal edema,anal Wexner score,and surgical complications were compared between the two groups of patients.RESULTS The operation time,intraoperative blood loss and hospitalization time in Group A were significantly lower than those in Group B(P<0.05).The cure rate of Group A was 98.04%,compared with 95.10%cure rate of Group B,and the difference was not statistically significant(P>0.05).The visual analogue scale(VAS)at 12 h and 24 h postoperatively in Group A were significantly lower than those in Group B(P<0.05).The comparison of the VAS scores between Group A and Group B at 48 h,72 h and 96 h postoperatively revealed that the difference was not statistically significant(P>0.05).One day postoperatively,the degree of perianal edema in Group A was compared with that in Group B,and the difference was not statistically significant(P>0.05).Seven days postoperatively,the degree of perianal edema in Group A was significantly lower than that in Group B(P<0.05).The comparison of anal Wexner scores between the two groups preoperatively and at 1 mo,3 mo and 6 mo postoperatively showed that the difference was not statistically significant(P>0.05).The Wexner scores of the two groups at 1 mo,3 mo and 6 mo postoperatively were significantly lower than the scores preoperatively(P<0.05).The postoperative complication rate of Group A was 2.94%lower than that of Group B(11.76%),which was statistically significant(P<0.05).CONCLUSION TST33 mega anastomotic hemorrhoidectomy treatment for patients with severe prolapse hemorrhoids,leads to less postoperative pain,the rapid recovery of perianal edema and has fewer complications.

Laparoscopic appendectomy,stump closure and endoloops:A meta-analysis

BACKGROUND Acute appendicitis(AA)is one of the main indications for urgent surgery.Laparoscopic appendectomy(LA)has shown advantages in terms of clinical results and cost-effectiveness,even if there is still controversy about different devices to utilize,especially with regards to the endoloop(EL)vs endostapler(ES)when it comes to stump closure.AIM To compare safety and cost-effectiveness of EL vs ES.METHODS From a prospectively maintained database,data of 996 consecutive patients treated by LA with a 3 years-follow up in the department of Emergency General Surgery-St Orsola University Hospital,Bologna(Italy)were retrieved.A metaanalysis was performed in terms of surgical complications,in comparison to the international literature published from 1995 to 2021.RESULTS The meta-analysis showed no evidence regarding wound infections,abdominal abscesses,and total post-operative complications,in terms of superiority of a surgical technique for the stump closure in LA.CONCLUSION Even when AA is complicated,the routine use of EL is safe in most patients.

Robot-assisted trans-gastric drainage and debridement of walled-off pancreatic necrosis using the EndoWrist stapler for the da Vinci Xi:A case report

BACKGROUND Walled-off pancreatic necrosis (WOPN) is a late complication of acute pancreatitis. The management of a WOPN depends on its location and on patient's symptoms. Trans-gastric drainage and debridement of WOPN represents an important surgical treatment option for selected patients. The da Vinci surgical System has been developed to allow an easy, minimally invasive and fast surgery, also in challenging abdominal procedures. We present here a case of a WOPN treated with a robotic trans-gastric drainage using the da Vinci Xi. CASE SUMMARY A 63-year-old man with an episode of acute necrotizing pancreatitis was referred to our center. Six wk after the acute episode the patient developed a walled massive fluid collection, with an extensive pancreatic necrosis, causing obstruction of the gastrointestinal tract. The patient underwent a robotic transgastric drainage and debridement of the WOPN performed with the da Vinci Xi platform. Firstly, an anterior ideal gastrotomy was carried out, guided by intraoperative ultrasound (US)-scan using the TilePro? function. Then, through the gastrotomy, the best location for drainage on the posterior gastric wall was again US-guided identified. The anastomosis between the posterior gastric wall and the walled-off necrosis wall was carried out with the new EndoWrist stapler with vascular cartridge. Debridement and washing of the cavity through the anastomosis were performed. Finally, the anterior gastrotomy was closed and the cholecystectomy was performed. The postoperative course was uneventful and a post-operative computed tomography-scan showed the collapse of the fluid collection. CONCLUSION In selected cases of WOPN the da Vinci Surgical System can be safely used as a valid surgical treatment option.

EVALUATION OF STAPLING TECHNIQUE IN SURGICAL TREATMENT OF ESOPHAGEAL AND CARDIAC CANCER

Objective: To investigate an effective method to prevent anastomotic leakage and stenosis, evaluating the role of stapling technique in surgical treatment of esophageal and cardiac cancer. Methods: The stapling technique was used in end-to-side esophagogastromosis in surgical treatment of esophageal and cardiac cancer. Results: 128 patients were so treated. One patient died of superior mesenteric artery embolism, and the operative mortality was 0.78%. No anastomotic leakage or stenosis was found in this series. The other complications included postoperative thoracic cavity bleeding in 1 (0.78%), myocardial infarction in 2 (1.56%), stress ulcer of stomach in 1 (0.78%), and gastroparsis in 4 (3.12%). The overall morbidity rate was 4.7%. Conclusion: Using stapler to perform end-to-side esophagogastromosis has the advantages of being simple and safe, cutting short the operation time, and preventing leakage and stenosis. It is an ideal technique in the treatment of esophageal and cardiac cancer.

Expressions of Connexin and Par-3 in the Distal Margin of Rectal Cancer after Ultra-low Anterior Resection

This study examined the expression of connexin and protease-activated receptor 3 （par-3） in the distal resection margin of rectal cancer and the correlation of the expression of the two proteins with tumor relapse. A total of 40 patients with rectal cancer underwent ultra-low anterior resection with curved cutter stapler. The pathological specimens were divided into 3 groups in terms of sampling sites： tumor group, 2.0-cm group （in which the tissues were harvested 2.0 cm distal to the tumor tissues）, 3.0-cm group （in which the tissues were taken 3.0 cm away from the tumor tissues）. All the samples were pathologically observed and then measured for the expression of connexin and par-3 by employing immunohistochemistry and Western blotting. The operations in this series went uneventfully. No anastomotic stoma bleeding, stenosis and death occurred postoperatively. Histopathologically, in the tumor group, epithelial cells lost normal pattern of arrangement and polarity, and were loosely connected and even detached. In the 3.0-cm group, the epithelia had normal appearance, obvious cell polarity and essentially intact cell junction. Immunohistochemistry and Western blotting indicated that the 3.0-cm group had the strongest expression of connexin and par-3, and the expression in the 2.0-cm group and the tumor group was relatively weak. There existed significant difference in the expression of the two proteins among the three groups （P〈0.05 for all）. It was concluded that the down-regulated connexin and par-3 in the distal margin of rectal cancer tissues may indicate the progression of the disease and high likelihood of recurrence and metastasis. Although no tumor cells were found in the sections of the 2.0cm group, the decreased expression of connexin and par-3 may suggest the development of anaplasia and the increased odds of tumor relapse. Therefore, we are led to speculate that tumor resection only including 2.0 cm of unaffected rectum could not completely avoid the distant metastasis and local relapse.

State of the Art Hemorrhoidal Stapler Using a Modified Technique: A Step towards the Goals of Implement

Background: Procedure for prolapse and hemorrhoids (PPH) has emerged as an alternative surgical treatment of symptomatic hemorrhoids. The operative technique along with the device to be used is constantly evolving. Aim: The aim of the present study was to evaluate results of PPH using a modified technique and an innovative circular stapler. Material and Methods: A prospective, comparative study of patients undergoing PPH for symptomatic Grade II and Grade III internal hemorrhoids with either 32 mm or 34 mm stapler diameter (Circular Stapler for Hemorrhoids-CSH 32/34) during a 36 month period (1/1/2012-1/1/2015) was performed. A modified operative technique using two purse string sutures was employed. Patients were evaluated and compared in terms of postoperative complications, operation time, length of hospital stay and time to return to normal activities. Results: A total of 100 patients were included: 50 in the CSH 32 group and 50 in the CSH 34 group. Complication rates were equal for both stapler diameters (32 mm and 34 mm). Serious or life threatening complications were not encountered and need for reintervention was never met. Operation time, length of hospital stay and time to return to normal activities were similar in both groups. Conclusions: Our study suggests that there are no significant differences between the two available diameters of a new-fangled circular stapler, using a modified technique. It seems that progress of hemorrhoidal staplers has led to a step towards the goals of implement and from then on complications of surgical practice could be merely a matter of operative technique.

Treatment of a densely fused fissure during thoracoscopic right middle lobectomy

Aim: To report a case of fused fissure between the right upper and middle lobes that we treated using a surgical stapler rather than a Ligasure device for the benefit of creating a better division between the right upper and middle lobes and to effectively seal the lung parenchyma. Case: A 2-year-old girl with congenital cystic adenomatoid malformation of the right middle lobe (RML) was referred to our institution for further management after a series of infections. The vein of the RML, which drains into the superior pulmonary vein, was isolated and divided using endoclips. The bronchus was then exposed and divided using endo-clips. The arteries of the RML could be identified and ligated, allowing a line demarcating the major fissure to be identified and dissected. A stapler device was then used to seal the lung parenchyma and create a division between the right upper and middle lobes. She is currently well after follow-up of 16 months, with no episodes of respiratory distress or recurrence of symptoms. Conclusion: Our technique for dividing the pulmonary vein, then the bronchus, then the pulmonary artery and finally the fused fissure is safe and could be applied whenever fused fissures are encountered during thoracoscopic pulmonary lobectomy.

Applicability of Sigmoid Colon Graft for Vaginal Replacement (Colovaginoplasty) at Young Age

Objective: - To evaluate the applicability, feasibility, complications, short and long term results of vaginoplasty by using sigmoid colon graft with stapler assistance for resuming colonic continuity in children with absent vagina. Patients and Methods: - Records of 15 patients 8 of them had Androgen Insensitivity Syndrome, 4 had congenital vaginal atresia, and 3 had Congenital Adrenal Hyperplasia, underwent sigmoid graft vaginal reconstruction with the aid of circular stapler during the period from 2005 to 2010 were reviewed retrospectively. Results: A neovagina was constructed in those patients who aged from 3 to 9 years (mean 4 years), where sigmoid colon was used in all patients. Hospital stay ranged from 5 to 12 days (mean 7), operative time ranged from 60 to 120 min (mean 75 min). All patients were followed up 6 monthly in the first year and then yearly, complications occurred in 4 patients: introital stenosis in 2, and another 2 cases had minor wound infection. The need for neovaginal dilation was indicated in 5 out of 15 patients. There was no complications related to bowel anastomosis, No mortality in this group and the cosmetic results were excellent in all cases. Conclusion: Sigmoid colovaginoplasty appears to be applicable for remedy of vaginal atresia at any age. It is associated with a less complication rate, the long term results is satisfactory and it seems a better technique, especially in girls who doesn’t expect sexual activity shortly after surgery.

Safety and Efficacy of Circumcision Stapler in the Treatment for Children with Phimosis and Redundant Prepuce

Objective: To observe the clinical effect and safety of circumcision stapler in children with phimosis and redundant prepuce. Methods: From July 2013 to July 2017, 40 children were prospectively randomized and assigned to experiment group (circumcision stapler n = 20) or control group (conventional circumcision, n = 20). Outcomes were operation time, intraoperative blood loss and postoperative complications. Results: There was significant difference between the two groups for operation time (5.35 min vs 30.30 min, P < 0.05) and intraoperative blood loss (2.56 ml vs 10.40 ml, P < 0.05) respectively. Conclusion: Circumcision staplers are superior to conventional circumcision for the advantages of shorter operation time and fewer blood losses.