Bariatric Times

Spotlight on Technology April 2015

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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Dr. Portenier, how many bariatric and metabolic surgical procedures do you perform per year? Dr. Portenier: At Duke Center for Metabolic and Weight Loss Surgery, Durham Clinic, we perform approximately 1,000 bariatric and metabolic surgical cases per year. The breakdown is as follows: 60 percent Roux-en-Y gastric bypass (RYGB), 15 percent revisions, and 25 percent laparoscopic sleeve gastrectomy (SG). How long have you been using the Covidien Group instrumentation, specifically the iDrive™ Ultra Powered Stapling System and other Tri-Staple™ Technology products, in metabolic and bariatric surgical procedures? Dr. Portenier: I have been using Covidien group's staplers from the beginning. Prior to the release of the iDrive™ Ultra powered, stapling system, I used their manual staplers. I started using the iDrive™ Ultra powered stapling system as soon as it was available in 2012. What were the key factors that drove your decision to switch from a manual to a powered stapler, then specifically, iDrive™ Ultra system? Dr. Portenier: One reason we embraced switching from a manual to powered stapler is that it was the next evolution in surgical technology and we wanted to be a part of it. Over time, the multiple advantages of switching have become clear. I find that the staple formation and firing are better, especially in thick tissue, due to the intelligence behind the firing process. These are factors that surgeons care about because they impact complication rates. At Duke we have a very low complication rate. Now, we are putting the stapler in tougher s ituations and finding that the iDrive™ Ultra system can handle them. For example, because of iDrive™ Ultra's Adaptive Firing™ Technology, we are able to use the iDrive™ Ultra system in a thick stomach, while maintaining the integrity of staple formation and the staple line. 1 –3 What is Adaptive Firing™ Technology and how does it work? Dr. Portenier: Adaptive Firing™ Technology allows the firing speed to adapt to variable tissue qualities, including different thicknesses and densities. The microprocessor controlling the firing speed offers a slower firing speed in thicker tissue, and may actually pause in tissue that is excessively thick. This feature may allow tissue relaxation to occur, improving tissue compliance and facilitating the firing process. How does Adaptive Firing™ Technology help in your procedures? Dr. Portenier: Adaptive Firing™ Technology is the most important element of the iDrive™ Ultra system and represents the beginning of intelligent staple firing. It measures torque forces and recognizes significant changes in tissue thickness and variability. If it encounters challenging tissue at the normal firing speed, it will slow down or stop the firing sequence in order to maintain proper staple formation, cut line quality, and consistency. This forces you to stop, reassess the situation, and decide how to proceed. For instance, the stapler may not fire because it senses resistance, which may indicate thicker tissue that requires a larger staple load or a tissue edema that needs to be milked out in order for a better staple line to form. With manual staplers, we rely on our senses to feel for tissue thickness, but in reality, we cannot sense it enough. In my opinion, the iDrive™ Ultra powered stapling system takes the guesswork out of the stapling process for us, especially in challenging tissue (e.g., on the distal part of the stomach/antrum in a male patient). When using a manual stapler, the surgeon may choose a purple reload. If you use the purple reload on the iDrive™ Ultra handle in the same case, it may not let you fire because the resistance indicates the need f or a larger black reload, thus guiding you to use the proper reloads for the task at hand. What other advancements does the iDrive™ Ultra Powered Stapling System offer compared to other surgical instrumentation? Dr. Portenier: One advancement I have observed is that the iDrive™ Ultra System allows stapling to be a one-handed process. I am involved in training fellows and have seen that individuals with smaller hands often need both hands to hold and fire manual staplers; thus requiring them to let go of another instrument. With the iDrive™ Ultra system, they are able to use one hand with all of the controls at their fingertips. This takes hand fatigue out of the equation allows for an easier, smoother stapling process. 4 Next, manual staplers have limitations. You can't control the load as precisely. iDrive™ Ultra system offers the full spectrum and range of articulation. It also has control in opening and closing of the jaws, which is important when keeping the size of common enterotomies small. Keeping the common enterotomy as small as possible may occasionally even save you from needing to use an additional staple load to close a common enterotomy that doesn't align well. Being able to control the stapler helps in all areas of a procedure. How does Adaptive Firing™ Technology compliment Tri-Staple™ Technology? Dr. Portenier: When staple lines fail, it tends to be the tissue that tears away from the staple line itself. I feel that gradual changes in staple height mean that it is less likely for the tissue to tear. Adaptive Firing™ Technology adds a level of security that you are firing the proper staple height in the proper manner. It measures torque and adjusts firing speed when needed. This ensures that you stay within the acceptable firing speed range for the tissue being fired upon. Also, the Endo GIA™ reload with Tri-Staple™ technology features gradual differences in staple heights and a stepped cartridge face, which reduces stress on the tissue, making it less likely that the tissue will tear. 5 P O T L I G H T o n T E C H N O L O G Y S S UPPLEMENT TO BARIATRIC TIMES VOLUME 12, NUMBER 4 • APRIL 2015 • SUPPLEMENT B A B u l l e t i n H i g h l i g h t i n g B a r i a t r i c a n d M e t a b o l i c S u r g i c a l P r o d u c t s iDrive™ Ultra Powered Stapling System and Tri-Staple™ Technology in Metabolic and Bariatric Surgical Procedures: An Interview with Dana M. Portenier, MD Dana M. Portenier, MD Dr. Portenier is with the Duke C enter for Metabolic and Weight L oss Surgery, Durham Clinic, Durham, North Carolina. QR code here

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