A simple method to save on costs in pulmonary emphysema operations

The hazard of prolonged air leaks causing protracted postoperative hospital stay increases the already high costs of lung volume reduction operations for severe emphysema. To solve the problem, Cooper [1] proposed to reinforce the staple line with bovine pericardial strips. Subsequently, an inert material, such as expanded polytetrafluoroethylene (Gore-Tex; WL Gore & Associates, Inc, Flagstaff, AZ), was introduced, displaying the same advantages of bovine pericardium but apparently of more practical use [2]. Lung volume reduction operations can be performed either through sternotomy or videothoracoscopy. The use of videothoracoscopy is increasing as the reduced trauma seems particularly desirable in such compromised patients, although automatic staplers further increase costs. Each unilateral lung volume reduction procedure usually requires 8 to 12 loading units, and the number of cartridges doubles with bilateral procedures. Also because of our experience with more than 1,700 thoracoscopic procedures, we opted for videothoracoscopy within our department. It was immediately apparent that polytetrafluoroethylene sleeves specifically designed for automatic endoscopic staplers further increased the expenses, as each loading unit of polytetrafluoroethylene reinforcing sleeves costs about $66 US. Considering the number of reinforcing strips required (8 to 12 for unilateral lung volume reduction operation, 16 to 24 for bilateral lung volume reduction operation) the expense is relevant. Following the instructions of the manufacturer, the polytetrafluoroethylene sleeve (SEAMGUARD Staple Line Reinforcement Material; W.L.Gore & Associates) is positioned on a 45-mm Endopath stapler (Ethicon Endosurgery Inc, Cincinnati, OH), and after firing, the exceeding part of the sleeve is grasped distally to the jaws, removed and discarded. We developed our own technique to reuse these parts of the sleeve to reinforce three more staple lines. The two remaining parts of Seamguard are sectioned with straight scissors along the folding lines of the residual sheets of Gore-Tex, thus producing three wide and three narrowe strips (Fig 1). One of the larger strips is now laid on the cutting surface of the stapler’s cartridge jaw and tied to it with two Vicryl 4-0 precut threads (Ethicon) (Fig 2). The narrower strip is fixed to the stapler’s anvil in the same way. It is important to check that the two knotted threads are positioned within the limits of the cut line and the knots are kept externally with long edges. The Gore-Tex sheet exceeding the cutting zone of the stapler must be sectioned (see dotted line in Fig 2) to prevent the polytetrafluoroethylene lamina flaps from folding back while the stapler is applied onto the parenchyma. Sometimes the distal thread is pushed forward by the stapler blade without being sectioned. Grasping one of the two longer edges of the thread and sectioning it with endoscopic scissors overcomes the problem (Fig 3). The same steps are repeated until the entire parenchyma line is stapled, reusing every part of each new Seamguard sleeveOur hospital pays $66 for each set of Seamguard. At an average of 8 to 12 (for unilateral operation) and 16 to 24 units (for bilateral operations) is required, the expense can reach $528 to $792 or $1,056 to $1,584, respectively. With our technique the cost for reinforcing the staple lines is reduced to one fourth (ie, $132 to $198 [for unilateral procedures] to $264 to $396 [for bilateral procedures]). Because the cost of the stapler and its reloading units cannot be reduced, the marked reduction of expenses for reinforcing the staple line with Seamguard allows us to cope with the economic aspect of this operation. The slightly longer time required for fashioning and tying the stripes is overcome by its economic advantage; furthermore, the cutting and tying time decreases progressively as experience increases.