Are Laparoscopic Staplers Effective for Ligation of Large Intraabdominal Arteries? O. Hartung, 1 * V. Gariboldi, 1 V. Garitey, 2 R. Rieu, 2 C. Brunet 3 and Y. S. Alimi 1 1 Department of Vascular Surgery, Ho ˆpital Nord, 2 Laboratoire de Biome ´canique Cardiovasculaire—Me ´caBio, Ecole Supe ´rieure de Me ´canique de Marseille, and 3 Laboratoire de Biome ´canique applique ´e, Faculte ´ de Me ´decine Nord, Universite ´ de la Me ´diterrane ´e, Marseille, France Objectives. To evaluate ligation of aortoiliac arteries with laparoscopic staplers in order to develop specifically designed staplers. Methods. Cadaveric study. Seven human cadaver aortas were stapled using EndoGIA60 w staplers. Efficiency was evaluated macroscopically and on a hydrodynamic bench. Clinical study. Twelve patients had ligation of 14 large abdominal arteries (aorta: nine, iliac artery: four, hepatic artery: one) using a laparoscopic stapler. Stapling efficiency was judged on peroperative clinical and postoperative CT scan criteria. Results. Cadaveric study. Stapling was performed perfectly on four moderately calcified aortas, without leakage with a pulsatile pressure of . 250 mmHg. For three aortas with severe calcification, stapling was not efficient and major leakage occurred. Clinical study. Stapling appeared clinically efficient on all arteries but one aorta: this severely calcified aorta was ligated conventionally. The staplers are not easy to use due to their shape and their lack of articulation. After a mean follow-up of 31.3 months, all the other stapled arteries were effectively ligated. Conclusion. The commercially available staplers can be used securely on moderately calcified arteries but stapling of severely calcified arteries should be avoided. These devices should be redesigned to facilitate their use in vascular surgery. Key Words: Aorta; Ligation; Surgical staplers; Laparoscopic surgery. As laparoscopy and other mini invasive vascular surgical techniques develop, the need for specific instrumentation grows. Staplers have been used for 20 years in general, thoracic and other types of surgery. We have used a laparoscopic approach for aortic surgery since 1998 1–3 and the ligation of large arteries appeared difficult to perform, using classical tech- niques. The goal of this study was to evaluate to what extent staplers can occlude the human aorta and iliac arteries, to facilitate the development of staplers designed for vascular surgery. Methods Ex situ human cadaver aorta studies The experimentation took place in the department of Anatomy, Faculte ´ de Me ´decine Nord, Universite ´ de la Me ´diterrane ´e, Marseille, France. Seven infrarenal aortas with both iliac vessels were removed from human cadavers, five men and two women, mean age 83 years (74–90). For each donor, height and weight were noted as well as the extent of the aortic calcifications (Table 1). Calcifications were judged as severe when there were found to be concentric. Measurements were performed with an electronic caliper rule on each vessel: internal diameter and thickness of the aorta. The side branches and one common iliac artery were ligated. After removing the cutting blade, a Multifire Powered EndoGIA 60 w stapler (Tyco Healthcare, Norwalk, Connecticut, USA) (Fig. 1(A)) was used to occlude the infrarenal aorta, by placing transversally six rows of 4.8 mm staples (Fig. 1(B)). The efficiency of the stapler was evaluated visually for occlusion of the aorta and transfixion of both aortic walls by the staples. To facilitate establishing the connection between the infrarenal aorta and the hydrodynamic bench, an 8 mm polyester graft was interposed between one common iliac artery on one side (end- to-end anastomosis using a 3 – 0 polypropylene suture) Eur J Vasc Endovasc Surg 28, 281–286 (2004) doi: 10.1016/j.ejvs.2004.05.017, available online at http://www.sciencedirect.com on *Corresponding author. O. Hartung, Service de Chirurgie Vasculaire, CHU Nord, Chemin des Bourrely, 13915 Marseille Cedex 20, France. 1078–5884/030281 + 06 $35.00/0 q 2004 Elsevier Ltd. All rights reserved.