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Ann Thorac Surg 2005;80:1902
© 2005 The Society of Thoracic Surgeons
Department of Surgery, Union Memorial Hospital, Suite 610, JPB 3333 N Calvert St, Baltimore, MD21218-2895
(Email: richard.heitmiller{at}medstar.net).
Doctors Gossot and Nana [1] describe the use of a computer-controlled stapler for lung surgery to address the problems associated with current stapling methods (including staple line hemorrhage, oozing, and disruption) that the authors state are "frequent." I believe that with proper dissection of the vessel or airway and judicious selection of the type and thickness of the stapler, current mechanical staplers are safe, and clinically significant complications associated with their use are infrequent. On the other hand, the authors describe a system that could signal a new direction of minimally-invasive technologies.
Enormous strides have been made in minimally invasive methods. However, surgeons are still limited by their ability to see in three dimensions, by their lack of tactile feedback and by the limitations of their instruments. One developmental approach to these problems is to use computed based robotic systems in order to improve the surgeon‘s capabilities by generating three-dimensional imagery and simulated instrument tactile feedback. Another developmental approach is to improve the capabilities of the instrumentation itself. The stapling system described by Gossot and Nana is an example of the latter. The authors describe The SurgAssist system (Power Medical Interventions, New Hope, PA) that comprises a computer console and a remote control unit that directs a flexible stapling shaft and cartridge (referred to as the Digital Loading Unit [DLU]). The advantages of this system are that the flexible stapler can be directed toward the target, and then the stapler "senses" the target tissue to ensure proper closure and stapling.
In this early clinical experience with video-assisted thoracic surgery (VATS), the SurgAssist system did not seem to be as effective in practice as it had been in theory. In 3 of 8 VATS patients, conversion to open staplers was needed because the flexible stapler could not be positioned properly for use. In addition, there was one lung parenchymal tear requiring suturing thought secondary to the length of the flexible articulating stapler and its limited jaw opening. Clearly, technologic refinements are needed to enhance system use in VATS patients.
Many of the technologies initially developed for laparoscopic or thoracoscopic surgery, become integrated into open surgical methodology with immediate positive results. That fact is well demonstrated in this study. The authors used the SurgAssist in 26 open thoracotomies with no instrument-related complications or need to convert to conventional staplers.
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