Preventing a pitfall: no-knife staplers that require caution during handling

For safer division of the pulmonary vessels at video-assisted thoracoscopic surgery (VATS), a no-knife stapler (NAW ENDOPATH Flex45 No Knife Endoscopic Linear Stapler, Ethicon Endo-Surgery) is of help. We have used it during 177 sessions in 156 patients and noted two incidences where several of the staples were malformed but did not cause a bleeding event. A close investigation revealed that the cause was excessive rotation of the articulation lever. Thus, to avoid staple malformation, the articulation lever should not be rotated beyond its limit of mobility.