HOW I DO IT Application of a Penrose Drain Guide for Vascular Stapling During Hepatic Surgery: How I Do It Caitlin W. Hicks & Michael A. Choti Received: 2 September 2013 /Accepted: 9 October 2013 /Published online: 2 November 2013 # 2013 The Society for Surgery of the Alimentary Tract Abstract The use of stapling devices to manage vascular pedicles during hepatic surgery has been a significant advance in the field. However, insertion and application of the stapler in vascular dissection planes can be associated with injury to adjacent structures. We describe a five-step technique using a silicone Penrose drain to aid in the positioning of an endovascular stapling device to obtain vascular control during hepatectomy. The use is described here for hepatic vein management during right hepatectomy. The technique can be also used for other applications when transecting major vessels during major liver surgery. The use of this silicone Penrose-guided endovascular stapler technique is a simple, cost-effective maneuver that can be used to improve control and prevent vascular injury during the division of major vascular structures when performing hepatic surgery. Keywords Hepatectomy . Endovascular stapler . Hepatic vein . Surgical technique . Silicone drain . Penrose drain Introduction The use of endovascular staplers to aid in hepatic resection is well described both for vascular and parenchymal transection. 1, 2 In order to achieve control of hepatic inflow and outflow prior to transection, a stapler can be used both to divide the portal pedicle as well as for the transection of the appropriate hepatic veins. Staplers can also be used to divide structures within the parenchyma. To facilitate this process, a dissection plane is typically created around the vessel, and a loop is used to encircle the structure prior to transection, which allows for assurance of identification and the application of a small amount of traction. The stapling device is then inserted into the dissection plane and around the vessel. However, care must be taken to avoid injury of surrounding structures when attempting to guide the device through the critical perivascular dissection plane. In particular, traction injury or tear of the inferior vena cava can occur with the placement of the stapler during the transection of a hepatic vein. The aim of the current report is to describe the application of a new technique for safer insertion of the endovascular stapler through a narrow dissection plane. Here, we describe the extrahepatic transection of the right hepatic vein during right hepatectomy using a silicone Penrose drain guidance of the endovascular stapler. This is a simple, cost-effective, five- step technique that can be used to improve the safe placement of a stapling device for the transection of vessels during hepatic surgery. Technique When using this method during a right hepatectomy, the planning, exploration, and mobilization steps of the procedure remain the same as those for a standard liver resection. An important step for achieving extrahepatic vascular control is to divide the right hepatic vein using a stapling device. For the technique that we describe, a rigid linear endovascular stapler is used (Multifire Endo GI 30 Stapler, Covidien Surgical, Mansfield MA) with the assistance of a silicone Penrose drain (Bentec Medical, Woodland, CA) for guidance in a five-step approach. First, the vein is identified, and a right-angle dissector is used to define the dissection plane behind the vessel. When M. A. Choti (*) Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390‐9031, USA e-mail: michael.choti@utsouthwestern.edu C. W. Hicks Department of Surgery, The Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 665, Baltimore, MD 21287, USA J Gastrointest Surg (2014) 18:411–413 DOI 10.1007/s11605-013-2392-1