Use of Staplers in Pulmonary Surgery

Symposium on Surgical Stapling Techniques

Use of Staplers in Pulmonary Surgery

Timothy Takara, M.D.*

Lung stapling devices have been part of the thoracic surgeon's armamentarium for just over two decades. In that short time they have almost completely replaced manual suturing of the bronchial stump in many institutions all over the world. Why this wide popularity? One of the complications of resectional surgery of the lung that thoracic surgeons have always been keen to avoid is the complication of bronchial stump leakage or breakdown with the development of bronchopleural fistulas. The cartilaginous and springy bronchus, which is built to maintain its patency, resists collapse. Thus, after surgical closure, there is a strong natural tendency for the bronchial stump to reopen. Ways to minimize this tendency have always interested thoracic surgeons. 3 • 5 • 2° Few have taken the trouble, however, to study the problem seriously. Rienhoff of Johns Hopkins was among the first to take the problem to the experimental laboratory. 20 In the dog, Rienhoff found that after pneumonectomy (the acid test for bronchial closure) there were essentially three patterns of healing (Fig. 1). In the first, the closed end of the bronchus remained cone shaped as originally sutured; this occurred in less than a third of the bronchi. At the other extreme, all the sutures pulled out, and the bronchus resumed its full diameter to the cut end. Here it was bridged by a thin membrane of bronchial epithelium and subpleural areolar fibrous tissue, like a skin over a drum. This was seen in about 16 per cent of the cases. In the largest group, a combination of both patterns was seen, that is, incomplete bronchial coaptation, with the end partly narrowed and partly occluded by a tampon or plug of fibrous tissue, some sutures having cut through. Significantly, none of the dogs developed a bronchopleural fistula, even those in which the bronchus resumed its full diameter to the cut end. Rienhoff concluded that, regardless of the technique of closure, a high proportion of bronchi would reopen, in whole or in part, because of gradual erosion of sutures through the bronchial wall as the semirigid bronchus resumed its natural shape. Thus, neither the type of suture material nor *Chief of Staff, Veterans Administration Medical Center, Asheville; and Clinical Professor of Surgery, Duke University Medical Center, Durham, North Carolina Surgical Clinics of North America-Val. 64, No. 3, June 1984

461

462

TIMOTHY TAKARO

Figure 1. Three patterns of healing (diagrammed after Rienho!P"). Top, The bronchial stump has healed as it was originally sutured. Middle, Incomplete bronchial coaptation, with the end partially narrowed and partly occluded by a plug of fibrous tissue. Bottom, The sutures have pulled out, and the bronchus has resumed its full diameter to the cut end (its end is covered only by a thin membrane of bronchial epithelium and areolar fibrous tissue).

UsE OF STAPLERS IN PULMONARY SURGERY

463

the method of insertion of sutures could be depended on for complete or permanent bronchial closure. As the mediastinal pleura and peribronchial connective tissue participated in the healing of the bronchus, which took place only at the cut end and not at the suture line, the sutures could be regarded as a temporary measure to prevent air from blowing to and fro during respiration while the all-important cut end of the bronchus was healing. This line of thinking led Rienhoff to advocate placing the suture line as far proximal to the cut end of the bronchus as possible. His reasoning was that, as the sutures cut through (as expected), or if they became infected (as was more likely in those early years), the sutured areas would be far removed from the cut or healing end of the bronchus. Rienhoff believed that it was hazardous to use any form of suture on the cut end of the bronchus, as, it would constitute a foreign body, no matter what the material was and would interfere with healing. Some of Rienhoff s ideas were soon challenged by Sweet, 26 who reasoned that it was illogical to use mattress sutures that approximated the mucosal surfaces proximal to the cut end of the bronchus. Not only could no healing be expected at the level of the suture line, as Rienhoff had in fact, pointed out, but mattress sutures might well impair the circulation to the cut healing end of the bronchial stump. Instead, Sweet advocated interrupted through-and-through sutures over the cut end of the bronchus, which became a widely accepted technique. Because of dissatisfaction with the security of the bronchial closure following lung resection, especially for tuberculosis and especially before effective antimicrobial therapy became available, Smith et al. 25 investigated the possibility of closing the bronchial stump mechanically, using staples or preformed wire sutures. This study followed favorable reports by several workers about the efficacy of bronchial closure using bronchial and lung staplers developed in the Soviet Union after World War Il. 1· 2• 14• 18• 19• 21 The Scientific Research Institute for Experimental Apparatus and Instruments in Moscow was the site where these and many other stapling devices were developed. 27 The instrument originally designed for bronchial closure by the Soviets, the so-called UKB-25, placed a single row of staples oriented parallel to the long axis of the bronchus across the bronchial stump (Fig. 2). Amosov, however, found that the UKL-40, an instrument by which two staggered rows of staples could be inserted simultaneously with their orientation at right angles to the long axis of the bronchus, gave a more secure closure. 1 Others confirmed these findings. 4 · 6 • 3 • 13 This is the configuration that evolved in the development of American staplers, which were patterned after the Soviet model. Smith's experimental work confirmed Rienhoff s earlier work and also showed the superiority of stapled over handsewn bronchial closures, especially with the use of the UKL-40. 25 Further studies lent support to these concepts and helped explain the success and popularity of these instruments. Using a model of flexible sheets, Peterffy and Calabrese 17 showed that, because manual sutures tended to be placed at different distances from the cut edge of the bronchus and to be tied with variable degrees of force (that is, force was not constant),

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TIMOTHY TAKARO

Figure 2. Left, A single row of staples oriented parallel to the long axis of the bronchus has been placed across the left main bronchial stump by the UKB-25 instrument. Right, Two rows of staples, staggered with respect to each other and oriented at right angles to the long axis of the bronchus, have been placed across the left main bronchus by the UKL-40--the preferred pattern.

deformations of the cut edge resulted (Figs. 3A and B). The distribution of pressures on the contacting surfaces that had been sutured was also variable. The disproportions were considered to produce unfavorable conditions fur healing. However, the uniformly applied distances with staplers and uniform forces resulting in uniform pressures eliminated such deformations and disproportions, and perhaps promoted more uniform healing (Fig. 3C). The clinical studies of PeterflY and Calabrese supported these findings. 17 Comparing three methods of bronchial closure (two manual methods using silk and nylon sutures and the mechanical method using the stapling device), Scott and coworkers at the National Institutes of Health were able to demonstrate more favorable leakage pressures, reduced incidences of inflammatory reaction, and improved collagen production with stapled closure. 23 • 24 Our own clinical work at the Veterans Administration Hospital in Asheville, while not a controlled study, confirmed the impression that the incidence of bronchopleural fistulas was reduced with the use of bronchial staplers. 4 • 6 During the ensuing two decades, stapled closure of bronchi has enjoyed wide popularity, and, in many institutions, has essentially displaced suture closure of bronchi, except for bronchoplastic procedures, or where an unusually short stump is required, or where there is a need to visualize the interior of the bronchus. This popularity has been based not on controlled studies but on observational, usually retrospective, analyses of data. 6. 1. w. 13, 15, 16, 22. 2s, 29 In fact, there are no strictly controlled studies comparing rates of bronchopleural fistulas following suturing versus stapling of bronchi. A crucial test, however, is the rate of bronchopleural fistulas after pneumonectomy. Only a small number of reports compare the results of main

465

UsE OF STAPLERS IN PULMONARY SURGERY

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Figure 3. A and B, Hypothesized forces and pressures following manual suturing of the bronchial stump, which shows that they are not constant. C, Forces and pressures following mechanical suturing of the bronchial stump, which are constant. (From PeterflY, A., and Calabrese, E.: Mechanical and conventional manual sutures of the bronchial stump: A comparative study of 298 patients. Scand. J. Thorac. Cardiovasc. Surg., 13:87-91, 1979; with permission.)

bronchial closure with staplers and different hand-suturing techniques (Table 1). Thus, of 1976 collected cases of pneumonectomy procedures using manual techniques, there were 119 (6.0 per cent) bronchopleural fistulas reported, whereas in 647 cases following mechanical suturing, there were only 28 bronchopleural fistulas (4.3 per cent) (p = n.s.). In all four hospitals in which direct comparisons could be made between manual and mechanical suturing, stapled closures were always associated with a lower rate of bronchopleural fistulas than with manual suturing. The incidence of bronchopleural fistulas after lobectomy has also generally been more favorable after stapled bronchial closures. It should be noted, however, that there are some disadvantages associated with the use of bronchial stapling devices. They are expensive; they may not be readily available; the proximal bronchial lumens cannot be examined; and,

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TIMOTHY TAKARO

Table 1. Comparative Incidence of Bronchopleural Fistulas After Pneumonectomy STAPLED BRONCHI

SUTURED BRONCHI

AUTHOR

Kessler Dart6 Malave 16 Williams29 Schoefer 22 Hankins 10 Verain 28 ForresterWood7 Lawrence 15 13

TOTALS

YEAR

No. of Cases

No. of Fistulas

(Per Cent)

No. of Cases

No. of Fistulas

(Per Cent)

123 117

4 8

(3.2) (7.0)

1969 1970 1971 1976 1977 1978 1979 1980

218 1222 85 148 33 225

10 56 9 ll 5 25

(4.5) (4.6) (10.6) (7.4) (15.1) (11.1)

112

7

(6.3)

33 225

1 6

(3.3) (2.7)

1982

45

3

(6.6)

37

2

(3.9)

1976

119

(6.0)*

647

28

(4.3)*

*Mean.

until recent modifications, the application of excessive force to the jaws of the device could result in the crushing and devitalization of the bronchial stump. The advantages of speed of application, minimal dissection of the bronchus, and use of nonreactive, strong (stainless steel) suture material, however, are very real, and on balance outweigh the disadvantages. There are several other general uses of lung staplers that can be important. The devices permit resection of sublobar pulmonary lesions with a minimal amount of contiguous normal tissue, and without regard for segmental planes. The staplers effectively seal pulmonary parenchyma, markedly reducing air and blood leakage and the complications associated with them, as compared with classic segmental or subsegmental resections. It is possible to resect almost any area of the lung without significant damage to the surrounding pulmonary tissue, as long as it is approached from the periphery. When a large excision is necessary, two or three placements of the stapler or the use of a larger device may be needed. This type of "trans-segmental" resection was carried out 95 times in an earlier series with five significant complications. The one death was unrelated to the use of the stapler. 6 In seven instances, a residual space problem, which could be managed conservatively, was observed. No patient required a thoracoplasty. In addition, the devices can also be used to effect closure of largecaliber vascular structures in which suture-ligature might be hazardous, and suture-closure time consuming. The small-size staples lend themselves best to closure of the main pulmonary artery or extrapericardial or intrapericardia! veins and the atrial wall. They were used in this manner without complications in 35 patients in a previously reported series. 6 Gaskin and Bergmann8 reported this use of staplers for performing pneumonectomy, with "en masse" stapling of the hilar vessels in 41 consecutive pneumonectomies, with no complications attributable to the use of the staplers, and acceptable rates of mortality and morbidity. The staplers have also been used for the excision of blebs and bullae in patients with emphysematous blebs and spontaneous pneumothorax. 12

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467

There are now at least three sizes of stapling devices for bronchial, parenchymal, and vascular suturing, with three different lengths for the legs of the staples for each device: 4.8, 3.5, and 3.0 mm. In addition, loading has been greatly simplified. A device that incorporates both the staples and the anvil against which the staples are driven and by which they are appropriately deformed is inserted into the head of the instrument and snapped into place. It requires only that the handle be squeezed to effect closure of the staple line. This has worked very well for us, but still has not totally eliminated the occurrence of bronchopleural fistulas. / There is little doubt that staplers are useful in pulmonary surgery. They are not foolproof or totally free of problems and complications, and still require the exercise of good judgment, especially that gained from experience. But they have brought us closer to achieving a secure bronchial closure after pulmonary resection by contributing to the reduction of the incidence of bronchopleural fistula following lung resection. They have also simplified the resection of lung parenchyma, and the closure of largecaliber blood vessels in the hilum of the lung.

REFERENCES l. Amosov, N. M., and Berezosky, K. K.: Pulmonary resection with mechanical suture. J. Thorac. Cardiovasc. Surg., 41:325, 1961. 2. Androsov, P. 1.: New instruments for thoracic surgery. Dis. Chest, 44:550, 1963. 3. Bettman, R. B.: Experimental closure of large bronchi: A study of the factors concerned in the failure of bronchi to heal. Arch. Surg., 8:418, 1924. 4. Betts, R. H., and Takara, T.: Use of a lung stapler in pulmonary reserticm. Ann. Thorac. Surg., 1(No. 2):197-202, 1965. 5. Bjork, V. 0.: Suture material.and technique for bronchial closure and bronchial anastomosis. J. Thorac. Surg., 32:22, 1956. 6. Dart, C. H., Jr., Scott, S.M., and Takara, T.: Six-year clinical experience using automatic stapling devices for lung resections. J. Thorac. Cardiovasc. Surg., 80:406--409, 1980. 7. Forrester-Wood, C.-P.: Bronchopleural fistula following pneumonectomy for carcinoma of the bronchus. J. Thorac. Cardiovasc. Surg., 80:406--409, 1980. 8. Gaskin, R. J., and Bergmann, M.: Pneumonectomy by "en masse" stapling of hilar vessels. Ann. Thorac. Surg., 19:242-247, 1975. 9. Goldman, A : An evaluation of automatic ·suture with UKL-60 and UKL-40 devices by pulmonary resection. Dis. Chest, 46:9--36, 1964. 10. Hankins, J. R., Miller, J. E., Attar, S., et a!.: Bronchopleural fistula-Thirteen year experience with 77 cases. J. Thorac. Cardiovasc. Surg., 76:755-762, 1978. 11. Hood, R. M., Kirksey, T. D., Calhoun, J. H., eta!.: The use of automatic stapling devices in pulmonary resection. Ann. Thorac. Surg., 16:85, 1973. 12. Huu, N., Doutriaux, M., Barra, J. A., eta!.: Suture automatique et chirurgie pulmonaire. Poumon, 35:267-275, 1979. 13. Keszler, P.: The mechanical suture with UKL-40 and UKL-60 in pulmonary surgery. Dis. Chest, 56:383-388, 1969. 14. Laitinen, E., Merikallio, E., and Perasalo, 0.: Suture of the bronchial stump at pneumonectomy by Androsov's stapling device. Ann. Chir. Gynaecol., 50:423, 1961. 15. Lawrence, G. H., Ristroph, R., Wood, J. A., eta!.: Methods for avoiding a dire surgical complication: Bronchopleural fistula after pulmonary resection. Am. J. Surg., 144:136--140, 1982. 16. Malave, G., Foster, E. D., Wilson, J. A., eta!.: Bronchopleural fistula-Present-day study of an old problem. A review of 52 cases. Ann. Thorac. Surg., 11:1-10, 1971.

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17. Peterffy, A., and Calabrese, E.: Mechanical and conventional manual sutures of the bronchial stump--A comparative study of 298 patients. Scand. J. Thorac. Cardiovasc. Surg., 13:87-91, 1979. 18. Ravitch, M. M., Brown, I. W., and Daviglus, G. F.: Experimental and clinical use of the Soviet bronchus stapling instrument. Surgery, 46:97, 1959. 19. Ravitch, M. M., Steichen, F. M., Fishbein, R. H., eta!.: Clinical experience with the Soviet mechanical bronchus stapler (UKB-25). J. Thorac. Cardiovasc. Surg., 47:446, 1964. 20. Rienhoff, W. F., Jr., Gannon, J., Jr., and Sherman, I.: Closure of the bronchus following pneumonectomy. Ann. Surg., 116:481-531, 1942. 21. Rzepecki, W., Birecka, A., and Goralczyk, J.: Mechanical suture with metallic material in resection of pulmonary tissue (the UKL-60 apparatus). Am. Rev. Respir. Dis., 86:798, 1962. 22. Schaefer, G., and Demischew, M.: Closure of the bronchial stump: Suturing or stapling? Zentralbl. Chir., 102:661-663, 1977. 23. Scott, R.N., Faraci, R. P., Goodman, D. G., eta!.: The role of inflammation in bronchial stump healing. Ann. Surg., 181:381-385, 1975. 24. Scott, R. N., Faraci, R. P., Aubrey, H., et a!.: Bronchial stump closure techniques following pneumonectomy: A serial comparative study. Ann. Surg., 116:206--211, 1976. 25. Smith, D. E., Karish, A. F., Chapman, J. P., eta!.: Healing of the bronchial stump after pulmonary resection. J. Thorac. Cardiovasc. Surg., 46:548, 1963. 26. Sweet, R. H ..o Closure of the bronchial stump following lobectomy or pneumonectomy. Surgery, 18:82, 1945. 27. Takara, T.: Institute for experimental surgical instruments in Moscow. Science, 195:1942, 1963. 28. Verain, C., Cayot, M., Viard, H.: Etude comparative des modes de suture automatique et manuelle en chirurgie pulmonaire-a propos de 132 resections. Ann. Chir., 33:147-150, 1979. 29. Williams, N. S., and Lewis, C. T.: Bronchopleural fistula: A review of 86 cases. Br. J. Surg., 63:520-522, 1976. Veterans Administration Medical Center Asheville, North Carolina 28805