title: Experience with flexible stapling techniques in laparoscopic and conventional surgery.
abstract: BACKGROUND
  Currently, advanced minimal-access surgery cannot be realized without the application of modern stapling devices. The introduction of stapling devices with a flexible shaft and computer-assisted steering abilities was followed by the technical basis to provide just these features. This study aimed to assess the clinical application of stapling devices connected to a flexible shaft supported by a computer-assisted drive for maneuvering the system and to study its feasibility, learning curve problems, and clinical safety criteria regarding morbidity of the patients.
  
  
  METHODS
  The experience with laparoscopic and open gastrointestinal and colorectal surgery was evaluated. Patients with esophageal, gastric, and colorectal diseases were selected. The stapling system consisted of a power console connected to a flexible shaft and a remote control unit. On the tip of the flexible shaft stapler, loading units could be attached and operated by the remote control. A circular loading unit, size 29 mm, was used for esophageal, gastric, and rectal anastomoses. The linear stapler (length, 55/75 mm) was applied for the gastric tube after esophageal resection, for the jejunal pouch after total gastrectomy, and for division and closure of small bowel. It also was used during laparoscopic sleeve gastrectomy or laparoscopic fundoplication with COLLIS-gastroplasty. All data from the procedures were prospectively assessed and documented. A literature analysis was performed to compare morbidity data and leak rates with those of the current study.
  
  
  RESULTS
  During an 8-year period, 394 patients (253 men and 141 women) were included in this study, and laparoscopic technique was performed in 52% of the cases. The mean age of the patients was 63 years (range, 16-93 years), and 33% of the patients had an American Society of Anesthesia classification of 3 or 4. A total of 1,258 firings were performed. The procedures included 54 esophageal resections, 90 gastric operations, and 197 colorectal resections. In the early experience, computer failures occurred for 2.9% of 173 patients (5 of 144 cartridge firings, 3.5%). Later, the problems and leak rate dropped from the initial 6.6% (11/173) to 3.2% (7/221). The complication and morbidity rates were similar to those in the literature. The flexible system had the advantage of enabling stapler application in special indications such as performance of intraabdominal laparoscopic COLLIS-Plasty by bending the system along the subphrenic area.
  
  
  CONCLUSIONS
  Application of the described stapling system was thought to be advantageous, especially for minimal-access surgery and special indications that required a flexible shaft. This advantage allows for introduction of innovative techniques in gastrointestinal and colorectal surgery.
authors.affiliation: Department of Surgery, AGAPLESION-Markus-Krankenhaus, Wilhelm-Epstein-Straße 4, 60431, Frankfurt am Main, Germany. Karl-Hermann.Fuchs@fdk.info
authors.forename: Karl-Hermann
authors.initials: KH
authors.lastname: Fuchs
authors.forename: Wolfram
authors.initials: W
authors.lastname: Breithaupt
authors.forename: Thomas
authors.initials: T
authors.lastname: Schulz
authors.forename: Alexander
authors.initials: A
authors.lastname: Reinisch
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015179:Colorectal Neoplasms / Q000601:surgery; D004867:Equipment Design; D004935:Esophageal Diseases / Q000601:surgery; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D005767:Gastrointestinal Diseases / Q000601:surgery*; D015391:Gastroplasty / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D008875:Middle Aged; D017792:Surgical Stapling / Q000379:methods*