Pitfalls related to the use of endostaplers during video-assisted thoracic surgery

The use of staplers during thoracoscopic pulmonary resections has entailed several incidents. This study aimed to evaluate the rate of adverse events related to the use of an endostapler during video-assisted thoracic surgery (VATS).

All thoracoscopic procedures involving the use of an endostapler were prospectively studied. The study was based on the analysis of data prospectively entered into a database and the review of videotapes recorded during the procedure. The video clip of each incident was included into the database. The following events were recorded: oozing or hemorrhage on the staple line, partial or total disruption of the staple line, and any other technical issue.

A total of 434 firings were made during 130 thoracoscopic operations. The operations involved 77 wedge resections of lung nodules, 11 pulmonary biopsies, 34 bullectomies, and 8 thoracoscopic lobectomies. Although firing was uneventful for most patients, a minor or major problem was encountered during 34 firings (7.6%). Two technical malfunctions of the device occurred, both of them noticed by the scrub nurse before introduction of the stapler into the trocar. The other pitfalls were oozing (13 cases) and active hemorrhages (5 cases) on the staple line and disruption of the staple line, either partial (13 cases) or total (1 case). Conversion to thoracotomy was never necessary. Whereas no specific action was imposed by the pitfall in 12 cases, the incident led to a repair in 22 cases. None of the incidents had a clinical consequence in the postoperative course. The video tapes were reviewed to check whether the accident was unpredictable or due the surgeon's misuse or misjudgment. In 14 cases, no cause was found. In 5 cases, the lung parenchyma probably was too thick for the staples chosen, whereas no technical error was found in the remaining 15 cases.

Although some adverse events are attributable to surgical errors, many are linked to the device. This underscores the need for improving staplers and evaluating new technologies.