V8-12: Malfunction of linear cutting stapler in kidney surgery

Video

Introductions and Objectives
Numerous techniques exist for hilar control during laparoscopic and robotic nephrectomy. These include locking polymer clips, titanium clips, and individual or en bloc staple ligation. Staplers are most commonly employed for renal vein division and control. Stapling has proven safe, reproducible, rapid, and secure. Nevertheless, various types of stapler malfunction have been reported in the MAUDE (Manufacturer and User Device Experience) database with a failure incidence of 0.003%. Urologists must be acutely aware of these rare but potentially devastating scenarios. This video summarizes and illustrates various malfunction scenarios, and their proper management.

Methods
This video is a multicenter cases collection including 6 videos which exemplify linear cutting stapler failure on both the artery, and vein. Both inciting factors, and techniques for the surgeon to extricate themselves from these terrifying scenarios are depicted. The authors collected their experiences to offer recommendations, technical maneuvers and tips, both to prevent and solve these problems.

Results
There are two mechanism of action, depending on the brand and stapling mechanism. Some simultaneously staple and cut, others make a complete staple line, followed by cutting. We only present malfunction that occur with the second mechanism. Failures depicted include complete vein or artery transection, cutting failure with incomplete staple line, failure to release from tissue, staple line over a previous clip, as well as an unspecified stapler malfunction.

Conclusions
Staplers are frequently used in urologic surgery, however the incidence of malfunction is quite low, so low that a resident may never see a staple malfunction during training. This educational video was therefore made to demonstrate the spectrum of potential types of device malfunctions. We hope that our recommendations serve as a teaching tool to minimize the risk of stapler misuse, and to deal with these dangerous complications.

Funding: None