Geoffrey Bloomfield, MD. UM Upper Chesapeake Health
Objective: This 10 patient case series demonstrates experience with a 5mm diameter stapling device for cystic duct ligation and stump closure during a cholecystectomy where there is dilated cystic duct. Laparoscopic cholecystectomy is a routine procedure in which upsizing for a dilated cystic duct could cause increased pain at the subxiphoid port and negative impact on cosmesis. The development of a 5mm diameter stapling device has made it possible to complete laparoscopic cholecystectomy with a dilated cystic duct with a maximum port size of 5mm. Benefits of using only 5mm ports have been reported to minimize post-operative pain, lower incidence of port-site hernia, faster return to activities and improved cosmesis.
Procedure: A 10mm camera was placed in the umbilical port and three 5mm working ports were placed in the abdomen (anterior axillary line, midclavicular line, subxiphoid area to the right of midline). Dissection of the structures revealed a dilated cystic duct, average width of 4mm (Figure 1). The JustRight™ 5mm stapler by Bolder Surgical was placed in the subxiphoid port so the stapler could be fired perpendicular to the mobilized cystic duct. The jaw length was suited to manage the size of the dilated duct and the tissue compressed to the appropriate thickness before firing. The images illustrate the JustRight™ 5mm Stapler being clamped across the cystic duct and the divided duct with optimal hemostasis at the staple line.
Device Description: The JustRight™ 5mm stapler places 4 rows of standard B-shaped staples and cuts down the middle. The staple line is 25mm long. The device operation is similar to other 12mm staplers on the market and the device has demonstrated equivalence to the strength and leak pressures of the EndoGIA staple line. Results:The 5mm port technique was used on all 10 adult patients who presented with cholecystitis with dilated cystic duct. All had a normal post-op course with no complications. The average patient age was 45 years old with an average BMI of 32. Average procedure time was 41 minutes with a post-op pain score of 5 (scale 0-10, 10 being worst). Dr. Bloomfield observes patients in his practice with upsized ports at the subxiphoid position to use more opioids for pain. The 5mm JustRight™ Stapler allows the incision to remain small and minimizes the need for significant pain management. The average number of days of narcotic use for this series was 2 days. Patients reported an average of 5 days to return to normal activity. Patients scored extremely satisfied with this procedure in an overall satisfaction poll.
Conclusions: The JustRight™ 5mm Stapler is a safe and secure way to manage a dilated cystic duct in a laparoscopic cholecystectomy. The cystic duct is a delicate structure near other critical ducts and vasculature necessitating an appropriately sized device for transection. Large stapling devices are more appropriate for structures like the large intestine where visualization and precision are not as critical. In conclusion, using the 5mm stapler is a viable alternative to clips for adequate hemostasis of the dilated cystic duct stump in cholecystectomy.
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This abstract was accepted for Poster presentation at the 2020 SAGES Virtual Meeting in the topic. Its program number was: ETP607 and its Abstract ID was: 106302