Stapling and Reconstruction

With the introduction of the laparoscopic nephrectomy in 1991 by Clayman and colleagues, advancements in minimally invasive surgical equipment have expanded the application of laparoscopic techniques to several urologic reconstructive-type procedures. Laparoscopic stapling and clipping devices have been developed to provide more efficient alternatives to hand suturing to achieve hemostasis, tissue dissection, and tissue approximation. In spite of the availability of these devices and robotic platforms, it is also important for laparoscopic surgeons to develop intracorporeal suturing and knot tying skills in cases of device malfunction or unavailability. This chapter reviews the various clips, staplers, adjunct hemostatic agents, and suturing techniques required to perform non–robotic-assisted reconstructive laparoscopic urologic procedures.

Clips

Equipment

Occlusive clips are ideal for smaller vessels and provide a rapid, effective alternative for hemostasis. These clips are typically made of titanium and vary in size from 5 to 12 mm. Absorbable clips are available as well, and studies show no difference in adhesion formation between metallic and absorbable clips.

An occlusive clip starts out in a V shape, and as it is applied, the tips close first from distal to proximal ( Fig. 4-1 ). This ensures that the entire structure to be ligated is contained within the clip. Hem-o-lok, nonabsorbable polymer, ligating clips (Weck Closure Systems, Research Triangle Park, N.C.) are also available in four sizes (M, ML, L, XL), using 5- or 10-mm trocars ( Fig. 4-2 ). These clips perform the same function as sutures by penetrating and locking through multiple layers of tissue. The engaging clip latching mechanism allows the surgeon to feel the clip lock close. Hem-o-lok clips are contraindicated in the control of the renal artery during donor nephrectomies owing to the risk of clip dislodgement.

Occlusive clip appliers can be classified into the following categories: multiple or single load, and disposable or multiple use. Disposable clip appliers typically cost more than single-load reusable models, but the multiple-load feature makes their use much more efficient than withdrawing the instrument for each new clip to be placed. The majority of laparoscopic clip appliers used today are of the single-use and multiple-load variety, carrying 15 to 30 clips per unit ( Table 4-1 ).

TABLE 4-1

Disposable, Multiple-Load Single-Use Laparoscopic Clip Appliers

	Ligamax 5	10-mm Ligaclip	12-mm Ligaclip	Endo Clip	Endo Clip II	Endo Clip III	Acuclip Right-Angle
Manufacturer	Ethicon Endo-Surgery	Ethicon Endo-Surgery	Ethicon Endo-Surgery	Covidien	Covidien	Covidien	Covidien
Trocar size (mm)	5	10	12	5, 10	10	5	10
Number of clips	15	20	20	12-20	20	16	20
Sizes of clip	Medium/large	Medium/large	Large	Medium, Medium/large, Large	Medium/large	Medium/large	Medium/large
Clip loading	Automatic	Automatic	Automatic	Separate lever	Automatic	Automatic	Automatic

Ethicon Endo-Surgery, Cincinnati, Ohio; Covidien, Minneapolis, Minn.

The diameter of the shaft generally depends on the size of the clips. In general, shafts of 5 mm are available for small clips, 10 mm for medium to large clips, and 12 mm for large clips. The Ligamax (Ethicon Endo-Surgery, Cincinnati, Ohio) is a 5-mm shaft, single-use clip applier that is able to apply medium to large titanium clips. This is possible because its hinged jaws are retracted within the shaft until the handles are squeezed, and then the jaws advance and expand with a clip automatically loaded.

Present on all appliers are 360-degree rotating shafts that allow the tips to be placed around the target tissue at an ideal angle. Automatic loading clips are also available in many models, which immediately reload another clip into firing position. In addition, newer models may have a visual indicator showing the number of clips left.

Instrument Use

The vessel or other structure to be clipped should be dissected until the entire structure can be contained within the clip, without a significant amount of overlying tissue, to ensure maximum closure of the clip on the vessel. It is important to make sure the dissected window is large enough to accommodate the placement of several clips, with room to divide the structure with endoscopic scissors. Clips are typically used for small to medium-sized vessels, with one or two clips on either side before the vessel is divided.

Once the clip applier’s jaws are completely around the structure, the handle is firmly squeezed until the clip is placed ( Fig. 4-3 ). Then the clip applier is withdrawn at the same angle used for the approach to avoid accidentally displacing the clip. Additional clips are placed as necessary, and then the tissue is divided. A right-angle clip applier may be necessary to achieve the appropriate angle and may necessitate the use of a 10-mm trocar.

Linear Staplers

Equipment

Laparoscopic linear staplers are essential tools for the rapid division of tissue and vessels. The device deploys multiple, closely spaced, parallel rows of titanium staples. Most models require manually squeezing the handle three or four times to complete deployment of the staples and activating the knife to divide the tissue. There are newer models that have a battery-powered automatic device that allows for easier deployment and greater stapler stabilization with one hand.

Linear staplers can be broadly classified into cutting and noncutting staplers. Cutting staplers deploy loads with six intercalated rows of staples. With deployment of the stapler, staples are forced out of the load, through the tissue, and against an opposing anvil, closing back on itself ( Fig. 4-4 ). After the staples are fired, a knife follows and divides the tissue, leaving three rows of staples on each side. The staple line extends past the range of the cutting knife to avoid incising nonstapled tissue ( Fig. 4-4 ). Noncutting staplers, which fire three or four parallel rows of staples, are useful for closing enterotomies and repairing bladder injuries.