Stapled Anastomosis for Side-to-Side Cavo-Cavostomy in Orthotopic Liver Transplantation.

In liver transplantation, a side-to-side anastomosis is one of the commonly performed techniques of the inferior vena cava reconstruction. The authors report a case of an application of an endoscopic vascular linear stapler for a side-to-side caval anastomosis during deceased-donor liver transplantation. The back table procedure was performed in a standard fashion for a side-to-side anastomosis. The linear vascular stapler was introduced during the temporary clamping of the recipient's inferior vena cava and the anastomosis was created without problems. Suturing of the resulting defect completed the anastomosis. The use of the stapler resulted in a shortening of the anastomosis time. The staple line after the reperfusion of the graft was completely sealed. The patient's postoperative course was uncomplicated and post-operative ultrasound and computed tomography confirmed the patency of the anastomosis. This case demonstrates a novel approach to a side-to-side caval reconstruction during liver transplantation that enables a shortening of the implantation time and may improve the quality of anastomoses.

Evaluation of pulmonary artery bleeding during thoracoscopic pulmonary resection for lung cancer.

BACKGROUND: Bleeding from the pulmonary artery (PA) can be fatal in video-assisted thoracoscopic surgery (VATS) for lung cancer. We evaluated intraoperative PA injury and assessed precautions for thoracoscopic anatomic pulmonary resection. METHODS: We retrospectively analyzed a total of 1098 patients who underwent radical surgery for lung cancer utilizing complete VATS from January 2010 to December 2021. RESULTS: A total of 16 patients (1.5%) had PA injury during VATS, while hemostasis was performed by conversion to thoracotomy in eight patients (50.0%). Although there was a significantly greater operation time and blood loss for patients in the PA injury group (318.4 vs. 264.9 min, p = 0.001; 550.3 vs. 60.5 g, p ≤ 0.001, respectively), there was no significant different for the chest tube insertion duration and length of postoperative hospital stay (4.9 vs. 7.8 days, p = 0.157; 10.6 vs. 9.9 days, p = 0.136, respectively). There was a significant difference observed for the surgical procedure related to the left upper lobectomy in the PA injury group (43.8 vs. 18.8%, p = 0.012), with the primary causative PA determined to be the left anterior segmental PA (A3 ) (31.3%). CONCLUSIONS: VATS is both feasible and safe for lung cancer treatment provided the surgeon performs appropriate hemostasis, although fatal vascular injury could potentially occur during VATS. Surgeons need to be aware of the pitfalls regarding PA dissection management.

Hepatic and portal vein transection by vascular stapler in open living donor hepatectomy - A retrospective cohort study.

Background: In an effort to increase donor safety in living donor liver transplantation, the utilization of vascular staplers for the division of the right portal and hepatic veins in patients undergoing right lobe liver donation for living donor liver transplantation (LDLT) was implemented. In here we report our experience with vascular staplers in patients undergoing LDLT and evaluate the subsequent feasibility and safety for donors. Material and methods: 17 cases of living donor liver transplant were retrospectively analyzed. The right portal vein was transected directly at the bifurcation of the main portal vein, the right hepatic vein was resected directly at the wall of the inferior vena cava using a vascular stapler device. Results: We registered a complication rate of 41.2% (7 donors). According to the Clavien-Dindo classification, grade II and grade III complications were each observed in 5.9% and grade IIIb complications in 29.4%, whereas catastrophic bleeding, complications with residual disability or the necessity of re-laparatomy did not occur. Upon 6 weeks, all donors were able to return to their previous occupation in fully recovered condition. Conclusions: The utilization of vascular staplers in donors during open LDLT presents an encouraging alternative to manual over-sewing of vascular stumps. Apart from its timesaving aspect, the technique reduces the potential risk of life-threatening clamp slippage with subsequent uncontrolled blood loss.

Rationality and necessity of vascular stapler application during liver resection (Review).

Liver resection (LR) is the primary treatment method for patients with hepatocellular carcinoma (HCC). Improving surgical safety and reducing surgical morbidity and mortality is important for patients receiving LR. Various devices have been developed to facilitate vascular transection to reduce intraoperative blood loss, which is considered to be a predictor of poor surgical outcomes in patients undergoing LR. Vascular staplers have been widely applied for the division of major vascular and biliary structures in the process of LR; however, when and how to use these tools remains controversial. This review aims to report the rationality and necessity of using vascular staplers in vessel transection during liver surgery. Due to the risk of intraoperative and postoperative hemorrhage and biliary fistula, the process of transection of the portal pedicle and hepatic vein is a crucial step during LR. Stapling represents a vascular dissection technique that is widely used in laparoscopic LR and has then been popularized in open LR. Advocates argue that stapler transection methods provide several advantages, including diminished blood loss, fewer transfusion requirements and shorter operative times. However, other studies have failed to demonstrate those benefits when using these tools compared with the simple clamp-crushing technique. Using the stapler vascular transection method resulted in smaller surgical margins and similar surgical outcomes compared with those of the clamp-crushing vascular transection method. However, the intraoperative use of vascular staplers may significantly increase the financial burden of liver resection for patients with HCC, while not improving short- and long-term outcomes. Therefore, it has been suggested that vascular staplers should not be routinely used in LR. The current review discussed the above points and recommended that the stapling transection of the portal pedicle and hepatic vein should be applied during laparoscopic LR in a rational manner. However, the suturing ligation method should be routinely used in open LR.

Surgical treatment for common hepatic aneurysm. Original one-step technique.

INTRODUCTION: Hepatic artery aneurysms are rare, and their treatment represents a challenge for the surgeons. MATERIALS AND METHODS: A new technique is presented for common hepatic artery (CHA) aneurysm: it requires minimal vascular surgical dissection and only one linear vascular stapler is applied at the bottom of aneurysm. Aneurysm exclusion is easily obtained, which allowed retrograde thrombosis. Liver blood supply is ensured to the right and left hepatic artery, through the gastroduodenal artery, and can be previously monitored, with temporary clamping of the section area, by visual control, enzyme evaluation and intraoperative ultrasound examination. We reported an open surgical treatment, with simultaneous removal of hepatic and adrenal metastases, secondary to colon cancer. RESULTS: The duration of vascular surgery was 30 min and did not involve complications. Postoperative controls confirmed the efficacy of the procedure. DISCUSSION: This original technique can be added to the various open and endovascular techniques so far described for the treatment of a CHA aneurysm. It is advisable as open surgery, mostly in case of associated pathologies. CONCLUSIONS: The authors believe that this "one shot" technique by vascular staple of the distal part of CHA is minimally invasive and effective to obtain the exclusion of the aneurysm.

Evaluation of a Powered Vascular Stapler in Video-Assisted Thoracic Surgery Lobectomy.

BACKGROUND: A narrow-profile powered vascular stapler (PVS) was developed to provide superior access and precise staple placement in thoracic procedures. The objective of this study was to determine if the PVS would yield an equivalent rate of hemostatic interventions compared with standard of care (SOC) staplers in video-assisted thoracoscopic surgery lobectomy. MATERIALS AND METHODS: A randomized, controlled, multicenter study was conducted comparing PVS with SOC staplers in lobectomies performed for non-small cell lung cancer. The primary performance endpoint was the incidence of intraoperative hemostatic interventions, and the primary safety endpoint was the frequency of postoperative bleeding-related interventions. RESULTS: A total of 98 subjects participated in the SOC group and 103 in the PVS group. Rates of intraoperative hemostatic interventions were 5.3% and 8.3% for the SOC and PVS groups, respectively. These rates were not statistically different (P = 0.137), although the upper bound of the 95% confidence interval for the difference in intervention rates between PVC and SOC exceeded a predefined 3% criterion for equivalence. Simple compressions were performed more frequently in the PVS subjects, which accounted for the higher intervention rate in this group. Postoperative interventions for bleeding were required in one SOC subject (1.0%) and one subject from the PVS group (0.9%). Procedure-related adverse events occurred in 21 (21.9%) SOC subjects and 23 (21.9%) PVS subjects, with no adverse events related to use of the study devices. CONCLUSIONS: The PVS exhibited similar overall safety and effectiveness to SOC staplers in video-assisted thoracoscopic surgery lobectomy.

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.

Anterior approach for right hepatectomy using the 5-steps stapling technique: A preliminary study.

INTRODUCTION: Right hepatectomy via the anterior approach without prior liver mobilization is an accepted technique and the liver hanging maneuver facilitates this procedure. Hepatic parenchymal transection remains a critical part of this operation during which excessive blood loss can occur. Control of blood loss is important in hepatectomy as excessive bleeding and blood transfusion are associated with increased postoperative morbidity/mortality rates and compromised long-term oncological outcomes in these patients. METHODS: A 5-steps stapling technique was developed to decrease blood loss during right hepatectomy using the anterior approach with the liver hanging maneuver. All consecutive patients who underwent elective right hepatectomy in our center using this technique from January 2014 to June 2015 were retrospectively studied. This study aimed to describe this technique and report the preliminary outcomes. RESULTS: Eleven patients with hepatitis B-related hepatocellular carcinoma (HCC) with cirrhosis underwent the 5-steps stapling technique for right hepatectomy using the anterior approach with the liver hanging maneuver. The mean blood loss, liver parenchymal transection time and operation time were 227.3 ± 91.4 ml (SD), 40.0 ± 7.8 min, and 261.8 ± 48.5 min, respectively. No patients developed postoperative bleeding or bile leak. There was no 90-day mortality. CONCLUSION: The preliminary results of this 5-steps stapling technique for right hepatectomy using the liver hanging maneuver are encouraging as the technique resulted in little intraoperative blood loss and short operation time, and it caused no major complications and mortality.

Pre-resectional inflow vascular control: extrafascial dissection of Glissonean pedicle in liver resections.

BACKGROUND/AIMS: We are evaluated technique of anatomic major and minor hepatic resections using suprahilar-extrafascial dissection of Glissonean pedicle with vascular stapling device for transection of hepatic vessels intending to minimize operative time, and blood loss. METHODOLOGY: We prospectively analyzed the clinical records of 170 patients who underwent hepatic resection by suprahilar-extrafascial pedicle isolation and stapling technique in our clinic for emergency surgery in Belgrade. Patients who underwent hilar extrahepatic intrafascial dissection were excluded from the study. RESULTS: We performed 102 minor liver resections and 68 major hepatectomies. The minor liver resections were associated with significantly shorter surgery duration (95.1±31.1 vs. 186.6±56.5) and transection time (35.9±14.5 vs. 65.3±17.2) than major hepatectomies (P<0.001 for all). The mean blood loss was 255.6±129.9 mL in minor resection and 385.7±200.1 mL in major resection (P=0.003). The mean blood transfusion requirement was 300.8±99.5 mL for the patients with minor hepatectomy and 450.9±89.6 mL for those with major liver resection (P=0.067). There was no significant difference in morbidity and mortality between the groups (P=0.989; P=0.920). Major as well as minor liver resection were a superior oncologic operation with no significant difference in the 3-year overall survival rates. CONCLUSIONS: Extrafascial dissection of Glissonean pedicle with vascular stapling represents both an effective and safe surgical technique of anatomical liver resection. Presented approach allows early and easy ischemic delineation of appropriate anatomical liver territory to be removed (hemiliver, section, segment) with selective inflow vascular control. Also, it is not time consuming and it is very useful in re-resection, as well as oncologically reasonable.

Liver transection using vascular stapler: a review.

The clinical experience using a novel technique of liver resection with vascular staplers for dissection of hepatic parenchyma, was documented most recently in a prospective manner. These data have clearly demonstrated for the first time that stapler hepatectomy is a safe and fast dissection technique in major liver surgery (e.g. hepatectomy) which is feasible in a routine clinical setting.