Laparoscopic Stapling & vessel ligation
Just as in open stapling there are two options, Tyco Healthcare or Ethicon Endosurgery. Try them both and use that you are happy with/find ergonomic. Don’t leave it up to the procurement manager to order the cheapest.
The ENDO GIA Universal (Tyco) is versatile and can accommodate a wide range of staple configurations. There are three lengths 30, 45 and 60mm. Cartridges can be straight or articulating and are used for dividing vascular pedicles, bowel or performing intra-corporal anastomosis. Make sure that the scrub nurse knows how to replace a cartridge. They can be difficult to put together.
Our preference however, for advanced colorectal and upper GI surgery is the Ethicon Endosurgery ATW45 (2.5mm staples or vascular cartridge - £ 689.43 for 3) plus either TR45B or TR45G cartridges for bowel division (£ 819.14 for 12)). If the vessels can be clipped and you are dividing thick rectum go for the ATG45 (4.1mm staples) @ £ 1253.00 for 3.
We initially used Tyco's ENDO GIA but after a few major problems (staple lines coming undone, scrub nurses finding it difficult to reload, the mechanism jamming and breaking) changed over to Ethicon. There was also a commercial reason - Tyco cartridges are very expensive (the mechanism lies within the cartridge and not within the gun as in Ethicon). They also come in packs of 12. Thus it does not take a long time to find an accumulation of unused cartridges on the shelf, particularly if you are persuaded to buy cartridges in three lengths for both vascular and bowel. Tyco will not take back any stock of 12 that has been broken into. We have not regretted moving over to Haem-o-Lock clips and ATG45.
BLA would suggest that wherever possible, fully dissect the vessel and clip it before dividing with your energy source. Vessel dissection is a good teaching model. Whilst the energy source will allow you to divide vessels up to 7mm – it sometimes fails. Remember you are not operating on a pig!
Our current preference for ligation of major vessels (Ileocolic, middle colic, inferior mesenteric) is to use non absorbable 10mm polymer ligation clips – Hem-o-lock rather than metal clips (vessels 5-13mm). They do not fall off.
5mm clips are useful in laparoscopic cholecystectomy and adrenalectomy and are just about ok for mesenteric vessels in thin people (3-10mm vessels). 12mm clips are useful in splenectomy and nephrectomy including donor nephrectomy.
These clips are really useful and cheap; £320 per box or £22.50 per cartridge of 6 (£25.00 for the largest clips). Unfortunately you will need to purchase a minimum of two clip appliers - we would suggest the 10mm. These are purchased direct from teleflex medical and cost £ 770 each. They do come with a lifetime guarantee.
Contact details; Teleflex Medical, Stirling Rd., Cressex Business Park, High Wycombe.
tel., 01494 532761, Fax 01494 524650 or E-mail email@example.com
It is also worth having a supply of endo-loops available.