Potential surgical challenge: Hooking the staple stump.

Involvement of the staple stump using the lower clamp cover of the stapler.

Knowledge of the potential risk of staple stumps becoming entangled in the lower clamp cover of the stapler could be helpful for decreasing difficulties during stapling.

See Commentaries on pages 78 and 80.

A 61-year-old man was referred to our hospital with an abnormal shadow on a radiograph of the chest. Computed tomography of the chest revealed a 20-mm nodule in the middle lobe of the right lung, which was suspected as primary lung cancer. This study was conducted in accordance with the Declaration of Helsinki and approved by the research review board of Kansai Medical University Hospital (approval no. 2015630, approval date: December 16, 2019). Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Thoracoscopic right middle lobectomy was performed for diagnosis using an Endo GIA Universal Stapler (Medtronic, Minneapolis, Minn). After minor fissures, A4 and A5 were autosutured, we stapled the right middle lobe bronchus, and tried to open the jaws by pulling the black return knob. The moving lower clamp cover hooked the edge of the staple stump of A4 and stressed the main right pulmonary artery (Figure 1). We immediately stopped pulling the black return knob and released the hooking staple stump using endoscopic forceps without damaging the pulmonary artery (Video 1).

Figure 1

The moving lower clamp cover hooked the edge of the staple stump of A4, stressing the main right pulmonary artery.

The reported rate of adverse events related to vascular stapling during the video-assisted thoracoscopic surgery is 2.2% to 4.1%., The main causes of vessel injury (90%) are technical and visual insufficiency. We used a manual-type stapler, which allowed us to stop stapling. If we used the electric-type, it quite likely would have led to vascular injury. Since stapling devices other than Covidien and robotic-type staplers lack parts, such as a lower clamp cover, it is highly unlikely that stapling difficulties will occur. to prevent mishaps such as the present case, surgeons should keep the lower clamp cover and staple stump away from each other while stapling.