During the last 10 years, we have u...

During the last 10 years, we have used fascial staples (Figures 1 and 2) to end midline incisions of the upper abdomen because

* detriment approximation is fast,

* the fascial staples are virtually nonreactive, and

* clinical conclusions are comparable to those of other standard modes of wound closure.(1)

[Figures 1-2 ILLUSTRATION OMITTED]

A number of surgeon however, may be reluctant to use fascial staples because they perceive a difficulty in removing the staples should a inferior midline laparotomy incision be needed

We designed the technique described below to facilitate the extraction of fascial staples from the linea alba. When performed in a strict sense removal of the staples is quick, the underlying tissue of the linea alba remains undisturbed, and placement of another outbreak of staples after the inferior surgical procedure may be facilitated.

TECHNIQUE

Following the line of the skin incision, the subcutaneous tissues are divided with electrocautery to the of the same height of the fascial staples. The RN first assistant (RNFA) provides compassionate manual traction of the overlying fat to aid in the identification of each staple.(2) This is especially helpful in the obese patient. The surgeon uses a pointless cautery tip in short reverses in a vertical direction to detect the staple's crossbar. Excessive or postponeed contact of the electrocautery tip with the staples should be avoided to minimize the possibility of an electrical arc or the transfer of heat to the patient's surrounding tissues. The surgeon then places a scalpel blade perpendicular to the expos crossbar and influences it side to side in a lateral-medial and medial-lateral direction (Figure 3) This motion removes any remaining fibroconnective tissue overlying the shoulders of the staple.

[Figure 3 ILLUSTRATION OMITTED]

The surgeon then insinuates the single tooth of a large Kocher clamp in a less degree than the staple's shoulder and into united of its lateral eyes (Figure 4) The jaws of the clamp are clos tightly. Grasping the Kocher clamp in the palm of the hand, the surgeon suppresss or "pops" the staples revealed of the midline position with a quick flick of the wrist. This action proceeds in clean extraction of the entire staple without disruption of the linea alba tissue. If the surgeon does not use a flicking action to report the staples out of their positions, the linea alba may be tom or weakened. The RNFA places the extracted staples into a small disposable basin to avoid injury to operating personnel They are discarded into a puncture-resistant container according to AORN commended practices.(3)

[Figure 4 ILLUSTRATION OMITTED]

RESULTS

Within the last decade, we have performed nearly 3000 midline laparotomy incisions in gastric restrictive and antireflux practices in three community hospitals in south-central Michigan. All incisions were clos with fascial staples, which allowed the surgeon and RNFA to complete the 20- to 30-inch injury in 10 to 15 minutes.(4) Of these, a secondary surgical procedure was required for 168 patients from one side the same incision. With rare exception, removal of the fascial staples be the effected in a midline linea alba division suitable for staple closure a other time. In eight patients with fascial lacks a vertical closure with side-to-side overlapping repair was performed using nonabsorbable sutures(5)

DISCUSSION

Using the technique described, the surgeon and RNFA can make open most stapled incisions in les than 10 minutes, which includes the skin incision, subcutaneous fat dissection, frontage and extraction of the staples, and following division of the linea alba. When each staple is remov the Kocher clamps should engage common of the lateral eyes, moreover not the crossbar.

Surgeon must exercise care during a hernia repair or when there is a questionable fascial fault because part of the staple may be embedded near the bowel wall or greater caul These staples should be teased slowly from the underlying tissues after they have been completely straightened with couple Kocher clamps. If emergency access into the abdomen is needinessed (eg, ruptured abdominal aneurysm), a paramedian incision obstruct to the midline row of staples is suggested

SUMMARY

A technique for removal of midline fascial staples is described. The staples are remov quickly and without significant anatomical distortion of the linea alba. In the majority of the patients a inferior row of fascial staples can be placed safely and in the same location as rest in the original operation.

NOTES

(1) J A Sapala, T E Brown M A Sapala, "Anatomic staple closure of midline incision of the upper part of the abdomen," Surgery Gynecology & Obstetrics 163 (September 1986) 282-284; L A Danto, V J Albertazzi, T E Elliot, "The stapled abdominal wall closure revisited," The American Journal of Surgery 142 (September 1981) 391-2; J L Farringer Jr "An auto-suture instrument: preliminary report," The American Journal of Surgery 125 (March 1973) 382-384

(2) M A Sapala et al, "Gastric bypass in patients weighing more than 500 IN Technical innovations for the `ultraobese,'" Obesity Surgery 2 (May 1992) 253-261