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MMCTS
(November 10, 2008). doi:10.1510/mmcts.2008.003145 Copyright © 2008 European Association for Cardio-thoracic Surgery
Procedure Computer assisted surgical staplingDepartment of Surgery, Division of Cardiothoracic Surgery, Oregon Health and Science University, L353, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA * Corresponding author: Corresponding author. Tel.: +1-503-4947820; fax: +1-503-4947829. sukumarm{at}ohsu.edu
Computer assisted surgical stapling is the application of new technology to conventional staplers. The components of the system, their use in open thoracic surgery and a review of the literature to date are presented.
Key Words: Computer assisted • New technology • Surgical stapler
Surgical stapling devices have been used in thoracic surgery for over 20 years and have proven as reliable as suturing for the bronchus, pulmonary artery, pulmonary vein or lung parenchyma [1]. They have allowed for the widespread application of thoracoscopy to complex procedures within the chest. Until recently these staplers were hand-fired requiring the hand of the surgeon or assistant to generate the force required to create a staple line while transecting the tissue. Advances in technology have allowed for the staple line to be created by the graduated and uniform application of force generated via a computer. The role of this technology in the arena of thoracic surgery is still to be determined and whether it will positively impact on the way that operations are being performed is unknown. We describe the system, its working, our limited experience with it and a review of the current literature.
SurgASSIST is the name that has been given to this new surgical stapling platform by the manufacturers Power Medical Interventions (W. Langhorne, PA, USA). The components include:
The types of DLUs currently available are:
The types of DLUs soon to be available are the linear cutters with a white (vascular) 2.5 mm staple height. Each DLU contains an electronic device that is programmed to activate a specific program in the microprocessor in the console. When fired, the scalpel in the DLU cuts tissue distally first and proceeds proximally preventing tissue being displaced as is seen with conventional linear cutting staplers.
The power console is a mobile unit that can be moved from OR to OR and plugs into an electrical power outlet. Both the flex shaft and the remote control unit connect to the power console. The flex shaft can be sterilized using gas/steam techniques and the end to which the DLU or power extender connects is brought up onto the operation field. The remote control unit (RCU) can be controlled by a circulating nurse or using a sterile plastic cover for the unit, the surgeon. The DLU can be directly fixed to the flex shaft or to the power extender and this connection is simple with the DLU ‘clicking’ into place. There is also feedback from the power console that indicates whether the DLU is properly loaded. In open thoracic surgery the incision and access to the chest are performed as is customary and the stapler introduced into the chest through the thoracotomy. The tissue to be stapled is dissected either sharply or with cautery before the stapler is applied. The DLU is then placed across the tissue to be stapled (Photo 6).
When using the right angled stapler it is sometimes necessary to position the DLU first and then connect it to the flex shaft. Once the DLU is positioned it is closed using the RCU. The computer in the PC then determines whether the DLU is appropriate for the tissue to be transected and it issues a ‘ready to fire’ message on the liquid crystal display on the PC (Photo 7). If the PC senses that the tissue is too thick or there is too great a resistance, an ‘out of firing/stapling range’ message is displayed and the DLU will not fire. An auditory prompt can also be heard for all of the steps involved with the firing of the DLU. This allows the surgeon to concentrate on the surgical field during the firing. The DLU is fired by deploying the ‘fire’ button on the RCU. The staples are laid down and the tissue transected with the DLU opening once the firing is complete (see Photo 7B). Drainage and closure of the chest are performed as in any thoracotomy.
Pros
Cons
Our preliminary experience at the Oregon Health Sciences University and Portland VA Medical Center involved 30 firings of the stapler while performing open thoracic surgery. The stapler was used on the pulmonary vessels, the bronchus and the lung parenchyma with hemo- and pneumo-stasis that was comparable to conventional staplers. No misfiring of the stapler or malfunction of the system occurred during this time. No injuries to the stapled tissue or lung were encountered. The staple lines did not require extra reinforcement with sutures or Bioglue for bleeding or airleaks. There was no obvious prolongation of airleak or additional time for chest tube drainage and no patient was discharged with a chest tube for airleak.
The computer assisted stapling system has been in use for the last four years [2]. It has been used primarily in general and gynecological surgery [1, 2, 3, 4, 5, 6]. The application in thoracic surgery has been recent and there are no large series documenting its use or benefit over conventional staplers [1]. A recent series from France reports on the use of the system in 38 patients where the stapler was fired 26 times during open surgery and 12 times during VATS with no misfiring or malfunction [1]. For the use in VATS they experienced difficulty with the inability of the stapler to open widely and the excess flexibility of the flex shaft. These issues have been now addressed by the inclusion of the power extender and wider opening DLUs. Further experience with the stapler is from the University of Chicago where a hundred open thoracic procedures were performed using the SurgASSIST system. One incomplete firing on a pulmonary vein and one bronchial dehiscence were reported in 502 firings of the stapler. They found the flex shaft was too flexible and did not provide any advantage over conventional staplers and that the right angle cutting stapler was too bulky or large to be used during thoracoscopy and required a thoracotomy [8]. More widespread experience with this system in thoracic surgery will likely determine the role for this new technology, which is currently in evolution [7]. Whether this technology facilitates minimally invasive or robotic thoracic surgery is another unanswered question. Experience with laparoscopy suggests that with continued improvements, the design of the system will evolve allowing easier performance of stapling during thoracoscopy [2]. At the current time it is clear that there are some disadvantages with the system which are outlined earlier in the article. Suggestions for improvement and the currently improved instrument are outlined below. The flexible shaft is currently difficult to manipulate both with open and thoracoscopic application. An instrument that combined features of both the flexible shaft and the power extender would improve considerably on the versatility of the system. A rigid shaft with a short remote-controlled flexible end allowing the DLU to reach the site of use easily and be placed around or across the tissue to be stapled would seem to make the most sense. Slimming the profile of the right angle cutter to allow easier placement across vessels would be an improvement; making thoracoscopic lobectomy a technically simpler operation due to the ease of placing the stapler across the vessels. The most recent addition and technological improvement to the SurgASSIST platform is the i60 Intelligent 60 mm endoscopic linear cutter. This is a completely hand-held device which mimics the appearance of a conventional hand-held EndoGIA stapler but uses computer mediated power to open, close and fire the DLU. A further advantage is its ability to articulate to 60 degrees (Photo 8 and images at – MMCTSLink 174). It has only recently been released for use in the clinical setting and to date there are no reports on its use or evaluation against conventional staplers.
The system is currently FDA-approved and as more thoracic surgical experience is gained and design advancements are made it will find its place in the armamentarium of the thoracic surgeon.
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