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Vessel sealing devices effectively produce hemostatic seals with minimal thermal damage, but the strength of seals decreases as vessel diameter increases. Because vessels sealed at an angle to the vessel require a greater functional seal diameter than those sealed perpendicularly to the vessel, it was hypothesized that perpendicular seals would have comparably higher burst pressures. Ex vivo, porcine carotid arteries of nominal diameters of 5, 6, and 7 mm were sealed perpendicularly to and at a 45°angle to the longitudinal axis of the vessels, and burst pressures of the sealed vessels were measured. Overall burst pressures were 51% greater for perpendicular seals than for angled seals (P < .001). Mean burst pressures for the 5-mm angled and 7-mm perpendicular groups, which have similar seal lengths, were not significantly different (P = .959). Analysis using the functional diameter as a covariate indicated that the seal length is the primary variable in determining burst pressure, and not some other inherent characteristic of angled versus perpendicular sealing. These results suggest that at least for vessels q5 mm in diameter, surgeons should approach vessels perpendicularly and not at an angle, for the highest possible seal strength. The development of articulated sealing and cutting devices would provide greater seal strength, in addition to improved maneuverability, especially in laparoscopic surgery, where angles of approach may be limited by the fixed location of surface cannulas.

A comprehensive review of operative outcomes of robotic surgical procedures performed with the da Vinci robotic system using either endoscopic linear staplers (ELS) or robotic staplers is not available in the published literature. We conducted a literature search to identify publications of robotic surgical procedures in all specialties performed with either ELS or robotic staplers. Twenty-nine manuscripts and six abstracts with relevant information on operative outcomes published from January 2011 to September 2017 were identified. Given the relatively recent market release of robotic staplers in 2014, comparative perioperative clinical outcomes data on the performance of ELS vs. robotic staplers in robotic surgery is very sparse in the published literature. Only three comparative studies of surgeries with the da Vinci robotic system plus ELS vs. da Vinci plus robotic staplers were identified; two in robotic colorectal surgery and the other in robotic gastric bypass surgery. These comparative studies illustrate some nuances in device design and usability, which may impact outcomes and cost, and therefore may be important to consider when selecting the appropriate stapling technologies/technique for different robotic surgeries. Comparative perioperative data on the use of ELS vs. robotic staplers in robotic surgery is scarce (three studies), and current literature identifies both types of devices as safe and effective. Given the longer clinical history of ELS and its relatively more robust evidence base, there may be trade-offs to consider before switching to robotic staplers in certain robotic procedures. However, this literature review may serve as an initial reference for future research.

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