The History of Surgical Staplers: A Combination of Hungarian, Russian, and American Innovation

Since their development in 1908, surgical staplers have been used as a method of “mechanical suturing” in efforts to divide hollow viscera and create anastomoses in an efficient and sterile manner. The concept for the surgical stapler was first developed by Humér Hultl, a Hungarian professor and surgeon, and designed by Victor Fischer, a Hungarian businessman and designer of surgical instruments. The design was highly acclaimed; however, it was bulky, cumbersome, and expensive to manufacture. In 1920, Aladár Petz, a student of Hultl, incorporated two innovations to the Fischer-Hultl stapler to create a more lightweight model, which was named the Petz clamp. In 1934, Friedrich of Ulm designed what would be the predecessor to the modern-day linear stapler. In the 1950s, Russian and American staplers began to emerge. Throughout the 1960s, a variety of stapling instruments were developed in the United States, manufactured by the United States Surgical Corporation. In the 1970s, Johnson & Johnson Ethicon brand joined the market. The United States Surgical Corporation was later bought by Tyco Healthcare and became Covidien in 2007. Through the collaboration of Felicien Steichen, Mark Ravitch, and Leon Hirsch, surgical staplers were further modified to incorporate interchangeable cartridges with various designs. With the advent of minimally invasive surgery began production of laparoscopic surgical staplers. Since its inception, the surgical stapler has provided a means to efficiently create safe and effective visceral and vascular anastomoses. The surgical stapler design continues to evolve while still maintaining the basic principles that were implemented in the original design.

Postmortem Evaluation of Left Flank Laparoscopic Access in an Adult Female Giraffe (Giraffa camelopardalis)

There are still few reports of laparoscopy in megavertebrates. The giraffe (Giraffa camelopardalis) is the tallest land mammal, and the largest ruminant species. An 18-year-old multiparous female hybrid giraffe, weighing 650 kg, was euthanized for chronic health problems, and left flank laparoscopy was performed less than 30 minutes after death. Safe primary access was achieved under visualisation using an optical bladed trocar (Visiport Plus, Tyco healthcare UK Ltd) without prior abdominal insufflation. A left paralumbar fossa approach allowed access to the spleen, rumen, left kidney, and intestines, but did not allow access to the reproductive tract which in nongravid females is intrapelvic in nature.

174 TRANSCERVICAL EMBRYO COLLECTION IN THE DOMESTIC BITCH

Embryo collection in the bitch is usually performed via surgical collection or uterine excision. Our objective was to collect embryos nonsurgically, or with minimal surgical invasion. Estrus was monitored using vaginal cytology and progesterone analysis during 1 natural cycle and 13 cycles induced by the submucosal insertion of a 2.1-mg deslorelin implant into the vestibulum of Walker-type hounds (n = 10, 30 kg). Bitches (n = 14 cycles) were transcervically inseminated twice in 12 cycles, (3.3 and 5.2 days post-LH) and once on 2 cycles (Day 6 post-LH) with fresh semen. Uterine flushes (n = 14) using an equine medium (ViGro, Bioniche Animal Health USA Inc., Athens, GA, USA) were done 13 to 15 days after the LH peak. Nonsurgical, nonanesthetized flushes were attempted in 9 cycles. In one cycle an 8-Fr, 55-cm Foley catheter with a 1-mL cuff (SurgiVet, Waukesha, WI, USA) stiffened with a metal stylette was inserted through the cervix using a 22-Fr sheath (63027KL, Karl Storz Veterinary Endoscopy, Goleta, CA, USA) and a 3.5-mm cystoscope, (63325BA, Karl Storz Veterinary Endoscopy) and flushed with 1.5 mL of medium infused and recovered by aspiration. In a one bitch, an 8-Fr polypropylene catheter (Sovereign, Tyco Healthcare, Mansfield, MA, USA) was transcervically passed after failing to pass an 8-Fr Foley catheter, but a flush was not done. In 5 cycles, the 22-Fr sheath could not be passed into the cranial vagina, so a 9.5-Fr, 43-cm cystoscope (27012L, Karl Storz Veterinary Endoscopy) was used to transcervically pass a 5-Fr, non-cuffed catheter (17500/0005, Minitube of America, Verona, WI, USA). Only non-cuffed catheters could be passed through the 9.5-Fr cystoscope, so no flushes were attempted. In 2 cycles, the cervix could not be visualized. Surgical flushes under anesthesia were attempted in 5 cycles. One was by transcervical catheterization using an 8-Fr catheter identical to the nonsurgical attempts, but adding surgical exteriorization of the uterine horns and retrograde flushing with 20 mL of medium. In 4 bitches the uterus was exteriorized by ventral midline laparotomy; one had a pyometra at surgery, and in three, 14-gauge i.v. catheters (Angiocath, BD, Sandy, UT, USA) were placed in the tip and body of each horn, and the uterus was retrograde flushed with 20 mL of medium. No embryos were recovered by the nonsurgical and/or transcervical flushes. Passing the 22-Fr sheathed cystoscope that accommodated a cuffed catheter into the cranial vagina, passing a cuffed catheter, or visualizing the cervix was unsuccessful in 7 of 9 cycles. Uterine distension appeared to cause discomfort during nonsurgical flushes. Three of 5 bitches that had a 5-Fr, non-cuffed catheter were subsequently pregnant. One blastocyst was recovered after surgical flushing with the i.v. catheters in the uterus. Nonsurgical embryo recovery in the bitch was most likely unsuccessful, compared to ours and previous work, due to inabilities to pass a cystoscope into the cranial vagina, to pass a catheter through the cervix, to visualize the cervix, or to create uterine distension using a small volume of medium. Pregnancies were maintained after successful transcervical catheterization of mated bitches.

Airway Management with Endotracheal Tube versus Combitube® during Parabolic Flights

Background Training of National Aeronautics and Space Administration space shuttle astronauts revealed difficult airway management with endotracheal tubes (ETTs) under microgravity conditions. The authors performed a randomized comparative study of ETT and Combitube (ETC; Tyco Healthcare, Pleasanton, CA). The aim of the study was to evaluate ease, time of insertion, and success rates during normogravity and parabolic flights using mannequins. Methods After normogravity experiments, four flyers performed intubation on a mannequin during the flights. Sixty-two intubation attempts were performed using the ETC (normogravity, 29; microgravity, 33), and 58 intubation attempts were performed using the ETT (each 29 attempts, both conditions). Time to completion of the intubation procedure, success rate, and ease of insertion were recorded. Results The ETC performed equally well between normogravity (median, 18 s; range, 17-25 s) and microgravity (median, 18.5 s; range, 17-28 s), whereas the ETT performed significantly slower under microgravity (median, 20 s; range, 17-27 s) as compared with normogravity (median, 18 s; range, 16-22 s; P = 0.019). One hundred nine of 120 (90%) were successful. The ETT and ETC were comparable with respect to successful intubations, under normogravity or microgravity, respectively. Conclusions Both the ETC and ETT perform comparably well. Slight differences could be found with respect to time of insertion in favor of the ETC. Because this is the first experiment using the ETC on the KC-135, it is shown that there is enough time to perform the insertion procedure. Because the ETC airway requires less training and is easier to insert than an ETT, it is recommended for further study as an alternative airway to what is currently on the shuttle.

Comparison of Mucosal Pressures Induced by Cuffs of Different Airway Devices

Background High pressures exerted by balloons and cuffs of conventional endotracheal tubes, the Combitube (Tyco Healthcare Nellcor Mallinckrodt, Pleasanton, CA), the EasyTube (Teleflex Ruesch, Kernen, Germany), the Laryngeal Mask Airway (LMA North America, San Diego, CA), the Intubating Laryngeal Mask Airway (Fastrach; LMA North America), the ProSeal (LMA North America), and the Laryngeal Tube (LT; VBM Medizintechnik, Sulz, Germany) may traumatize the pharyngeal mucosa. The aim of this study was to compare pressures exerted on the pharyngeal, tracheal, and esophageal mucosa by different devices designed for securing the patient's airways. Methods Nineteen fresh cadavers were included. To measure mucosal pressures, microchip sensors were fixed on the anterior, lateral, and posterior surfaces of the proximal balloon and the distal cuff of the investigated devices. Depending on the respective airway device, the cuff volume was increased in 10-ml increments at the proximal balloon starting from 0 to a maximum of 100 ml, and in 2-ml increments at the distal cuff starting from 0 up to 12 ml. Results Tracheal mucosal pressures were significantly higher using the Combitube compared with the endotracheal tube and the EasyTube. Maximal esophageal pressures were significantly higher using the EasyTube compared with the Combitube. Using cuff volumes according to the manufacturers' guidelines, we found the highest pharyngeal pressures with the Intubating Laryngeal Mask Airway versus all other devices. At maximal volumes, the Laryngeal Mask Airway, the Intubating Laryngeal Mask Airway, and the ProSeal induced significantly higher pharyngeal pressures compared with all other devices. Using a pharyngeal cuff volume of 40 ml, the Intubating Laryngeal Mask Airway followed by the Laryngeal Mask Airway exerted significantly higher pressures compared with the other devices. Conclusions Although some devices exhibit a somewhat higher mucosal pressure when compared with others, the authors believe that the observed differences of the cuff pressures do not suggest a clinically relevant danger, because the investigated devices, except the endotracheal tubes, are not intended for prolonged use.