Abstract
Background Esophagojejunostomy (EJS) in laparoscopic total gastrectomy is a technically challenging and high-risk procedure. Current EJS techniques possess limitations, and an optimal solution remains uncertain. Therefore, we designed and developed a novel laparoscopic titanium purse-string forceps for purse-string suture placement at the distal esophagus. Our study involves laparoscopic total gastrectomy experiments in pigs, comparing EJS outcomes using laparoscopic titanium purse-string forceps with the established OrVil™ technique. Furthermore, we evaluated the feasibility and safety of the laparoscopic titanium purse-string forceps. In total, 20 experimental pigs were randomly assigned to an experimental (n = 10) and a control group (n = 10). The experimental group underwent EJS using the laparoscopic titanium purse-string forceps, whereas the control group underwent EJS using the OrVil™ technique. Preoperative, intraoperative, and postoperative data were collected for subsequent statistical analysis. All 20 pigs underwent the surgical procedure without mortality. Statistically significant differences were observed between the two groups in anvil head placement and fixation time, with the laparoscopic titanium purse-string forceps group exhibiting a shorter duration. Furthermore, the laparoscopic titanium purse-string forceps group demonstrated lower surgical consumable costs compared to the OrVil™ technique group. Conversely, the OrVil™ technique group exhibited an advantage in esophageal rupture repair time. No statistically significant differences were observed between the groups regarding postoperative weight change or other surgery-related data. The laparoscopic titanium purse-string forceps can be used safely and effectively to perform EJS during laparoscopic total gastrectomy. Compared to the OrVil™ technique, these forceps allow for faster and more secure placement and fixation of the anvil head, enhance surgical operability, and offer a more cost-effective alternative.
Subject terms: Gastric cancer, Oesophageal cancer
Introduction
Gastric cancer is the fifth most common malignancy worldwide and is primarily treated with surgery1,2. Over the past two decades, laparoscopic total gastrectomy (LTG) has emerged as a leading surgical approach for gastric cancer. Technological advancements, improved instrumentation, and increased surgeon experience have progressively validated the feasibility, safety, and efficacy of LTG. However, a critical challenge in LTG remains the safe and efficient execution of esophagojejunostomy (EJS), a key reconstructive step in the procedure3,4. In recent years, surgeons have predominantly used anastomotic techniques for EJS, broadly categorized into those derived from linear staplers and those derived from circular staplers5–8. Each technique has its advantages and limitations, and an ideal solution for EJS remains uncertain8–11.
So as to provide a new solution for completing EJS using circular staplers, as well as offering clinicians a new surgical technique. We used a novel laparoscopic titanium purse-string forceps (Chinese National Invention Patent Number: CN202211397125.3), developed by our team. This instrument, capable of safe insertion through a 12 mm trocar, facilitates safe and efficient esophageal transection and purse-stringing under laparoscopic visualization. To evaluate the safety, feasibility, efficacy, and affordability of this instrument, we performed LTG in live experimental pigs, intraoperatively comparing EJS performed with the laparoscopic titanium purse-string forceps and circular anastomosis with a control group undergoing EJS using the OrVil™ technique12.
Study subjects and surgical methods
The Ethics Committee of the Animal Experimentation Centre of Silver Snake (Shanghai) Medical Technology Co. approved the study protocol. In total, 20 Topek white pigs, weighing 30–40 kg (sex unspecified), were randomly assigned to two groups: the experimental group (n = 10), where EJS was performed using the laparoscopic titanium purse-string forceps, and the control group (n = 10), where EJS was performed using the OrVil™ technique. All pigs were purchased and maintained according to standard procedures by Silver Snake (Shanghai) Medical Tech Ltd., Shanghai, China (Permission Number. SCXK (Gan) 2023-0002). Preoperative bowel preparation, surgical site preparation, and anesthesia (Zoletil® 50 0.1 ml/kg was injected intramuscularly for anesthesia induction, anesthesia was maintained with isoflurane) were performed in accordance with the Animal Anaesthesia Operating Procedure SOP-008. During surgery, the laparoscopic titanium purse-string forceps or the OrVil™ technique were used to complete EJS as part of the LTG procedure in the respective groups. Vital signs and other relevant indicators were monitored throughout the surgical procedure. We confirm that all methods are reported in accordance with ARRIVE Guidelines (Animal Research: Reporting of In Vivo Experiments). All methods are performed in accordance with the relevant guidelines and regulations.
Surgical methods
The surgical procedures used the following equipment: a German STORZ laparoscopic surgical system, including a supporting cold light source and pneumoperitoneum equipment; laparoscopic surgical instruments (Kangji, Tonglu, Zhejiang Province); an OrVil™ device (DST Series EEA OrVil device, Medtronic, USA); and the novel laparoscopic titanium purse-string forceps. The titanium purse-string forceps is a single-piece design, forged from titanium alloy (Ti–6AI–4V, TC4). Its distal end functions as the purse-stringing mechanism, with two-needle entry points on the proximal aspect. The handle is equipped with two rotating operation axes: the front axis controls the opening and closing of the jaws, while the rear axis adjusts the angle of the head and clamp body. The jaws can open to a maximum angle of approximately 68° and can bend laterally by approximately 14° (Fig. 1).
Fig. 1.
Laparoscopic titanium purse-string forceps. (A) General view of laparoscopic titanium purse-string forceps; (B) Laparoscopic titanium purse-string forceps tip; (C) Laparoscopic titanium purse-string forceps handle; (D) Laparoscopic titanium purse-string forceps entry points; (E) Maximum angle of laparoscopic titanium purse-string forceps jaws opening approximately 68°; (F) Maximum angle of laparoscopic titanium purse-string forceps jaws lateral bending, approximately 14°.
Surgical procedure
All experimental pigs were placed in a recumbent position with their limbs restrained. Following intravenous anesthesia, standard disinfection and draping procedures were performed. The five-hole method was used to determine the placement of abdominal puncture sites (Fig. 2). A small incision was made 2 cm to the right of the gonads, through which a 10 mm trocar was inserted to serve as the observation port. Additional small incisions were created in the left mid and lower abdomen, where 5 mm and 12 mm trocars were placed to establish the primary operating channels for the surgeon. Similarly, small incisions were made in the right mid and lower abdomen, where 5 mm and 12 mm trocars were inserted to serve as the assistant’s operating channels. All the animal experiments were conducted by Xi Li (chief surgeon), Dong Zhang (assistant surgeon) and Zhipeng Cao (assistant surgeon).
Fig. 2.
Surgical hole position diagrams of experimental pigs. (A) Preoperative hole position markings; (B) Intraoperative hole position diagram.
Abdominal exploration was initially performed to assess the presence of organ injury, evaluate abdominal adhesions, determine the relative positioning of abdominal organs, and identify any primary abdominal disease. If no abnormalities were detected, a complete gastrectomy was performed following the standard total gastrectomy procedure (details omitted).
Experimental group (laparoscopic titanium purse-string forceps group)
Following total gastric dissection, the duodenum was transected using a laparoscopic linear cutting stapler (Endo GIA™ Ultra, Medtronic). A laparoscopic titanium purse-string forceps was introduced into the abdominal cavity through a 10 mm trocar on the assistant’s side. The forceps tip was angulated using the adjustment knob until perpendicular to the longitudinal axis of the abdominal esophagus, and the esophagus was then clamped (Fig. 3A).
A 2 − 0 polypropylene purse-string suture was introduced into the abdominal cavity through a 5 mm trocar. Both ends of the suture were threaded through the needle channel at the tip of the forceps, emerging from the head of the instrument. Subsequently, the purse-string suture was tightened, leaving a thread length of 6–8 cm. Finally, the needles were removed from the body (Fig. 3B).
The esophagus was incised along the lower edge of the purse-string forceps for approximately three-quarters of its circumference, leaving the remaining one-quarter intact. This preserved segment allowed for traction of the esophagus, preventing retraction and facilitating the guided insertion of the anvil into the transected esophageal end (Fig. 3C).
The purse-string forceps were removed, followed by the extraction of the 12 mm trocar. The anvil was introduced into the abdominal cavity through the resulting abdominal wall incision (Fig. 3D).
Using a laparoscopic anvil grasper, the anvil was clamped and guided along the esophageal opening into the transected end of the esophagus. The purse-string suture was then tightened and secured with a knot. Finally, an ultrasonic scalpel was used to completely transect the esophagus, completing the anvil placement (Fig. 3E,F).
The pneumoperitoneum was deflated, and a 5 cm midline epigastric incision was made. A Lap Disc was inserted through this incision to facilitate the removal of the stomach specimen. Next, the digestive tract was reconstructed using the Roux-en-Y method. The jejunum was exteriorized through a mid-abdominal incision approximately 40 cm distal to the pylorus. The mesentery of the jejunal segment was dissected, and the proposed transection site was marked. Subsequently, the jejunum was transected at the marked site using a laparoscopic linear cutting stapler (Endo GIA™ Ultra).
To create an anastomosis sealing sleeve, sterile gloves were used. The distal jejunum was opened and, following disinfection, the circular anastomotic body was carefully inserted 5 cm into the jejunal stump. Next, it was secured with silk sutures to prevent slippage during the anastomosis procedure (Fig. 3G).
The body of the circular anastomosis device and the distal jejunum were gradually inserted into the abdominal cavity. Next, the abdominal incision was closed using sterile gloves, reinforced with gauze, and the pneumoperitoneum was re-established.
The puncture rod of the circular anastomosis device was slowly retracted and connected to the central rod of the anvil, ensuring that the jejunum remained free of torsion and tension before completing the connection. Subsequently, the puncture rod was gradually rotated back to close the circular anastomosis, followed by 15 s of post-anastomotic compression to complete the EJS (Fig. 3H). The anastomosis was carefully rotated backward, slightly opening the anvil component. The fixation suture at the jejunal stump was then cut, and the anastomosis was exteriorized to assess its integrity. Finally, the jejunal stump was closed using a laparoscopic linear cutting stapler. The details of the jejuno-jejunal side-to-side anastomosis are not described here.
Fig. 3.
Surgical procedure of the laparoscopic purse-string forceps group. (A) The forceps tip clamps esophagus. (B) The ends of the suture were threaded through the needle channel at the tip of the forceps. (C) The esophagus was incised partly. (D) The anvil was introduced into the abdominal cavity. (E) The anvil is guided into the transected end of the esophagus. (F) The anvil placement is completed. (G) The circular anastomotic body was carefully inserted the jejunal stump. (H) The anvil is attached to the circular anastomotic body.
Control group (OrVil™ group)
Following complete dissection of the stomach, the esophagus was transected 2–3 cm above the gastroesophageal junction using a laparoscopic linear cutting stapler (Endo GIA™ Ultra). A small incision, approximately 0.5 cm in length, was then made in the center of the transected esophageal end using an ultrasonic scalpel (Harmonic Ace, Ethicon, USA) (Fig. 4A,B).
A specialist anesthetist carefully inserted a nasogastric tube equipped with the OrVil™ device (Fig. 4F) through the mouth into the esophagus. The tube was guided through the small incision at the transected esophageal end, allowing it to enter the abdominal cavity. Under laparoscopic guidance, the surgeon assisted by gently pulling the nasogastric tube out through the esophageal incision. The tube was gradually retracted until the central rod of the anvil was fully exposed, ensuring that the anvil head was securely positioned at the esophageal transection site (Fig. 4C).
The fixation wire between the anvil and the nasogastric tube was cut, allowing the nasogastric tube to be separated from the anvil and gently removed from the abdominal cavity. To prevent the anvil from retracting into the mediastinum along with the esophagus, the assistant held it in place using an anvil grasper. This step completed the anvil placement (Fig. 4D).
The subsequent steps for EJS (Fig. 4E) and jejunojejunostomy were performed in accordance with steps 6–9 of the experimental group (laparoscopic titanium purse-string forceps group) and are not reiterated here.
Fig. 4.
Surgical procedure of the OrVil™ technique group. (A) Laparoscopic linear cutting stapler transect esophagus. (B) A Small incision is made in the transected esophageal end. (C) The anvil is fully exposed. (D) The anvil placement is completed. (E) Esophageal-jejunal anastomosis. (F) The OrVil™ device.
Postoperative treatment
Postoperative monitoring included regular assessment of vital signs, including temperature, respiration, blood pressure, and heart rate. For pain management, a 4% analgesic injection (0.2 mL/kg) was administered. Intravenous rehydration was the primary supportive treatment for the first 3 days postoperatively. Each pig received approximately 1000 mL of daily rehydration fluid, which included 10 mL of 10% potassium chloride injection, 10 mL of 25% magnesium sulfate injection, and ceftriaxone sodium (10 mg/kg). Arterial blood gas analysis was performed on postoperative day 3, to assess blood electrolyte levels. Any abnormal values were addressed with 5% dextrose injection and appropriate electrolyte supplementation. A semi-liquid diet was initiated on postoperative day 3. Bowel function recovery was assessed based on stool output. If deemed normal, a soft diet was introduced on postoperative day 7. On postoperative day 8, all pigs were euthanized by the designated animal care personnel in accordance with the Guidelines for Euthanasia of Animals (American Veterinary Medical Association). The specific method was intravenous injection of potassium chloride under deep anesthesia, and death was confirmed by auscultation of breath sounds and heartbeat.
Observations
Primary outcome measures included total operation time (t total), esophageal dissection time (t1), anvil placement and fixation time (t2), total anvil operation time (t3), intraoperative blood loss, preoperative hemoglobin (Hb) level, postoperative Hb level, and postoperative complications. Secondary outcomes included preoperative weight, weight on postoperative day 7, and cost of surgical supplies.
It should be noted that at Laparoscopic titanium purse-string forceps group: t1: Time from the forceps introduce into the abdominal cavity to remove the forceps from the abdominal cavity, t2: Time from the anvil is introduced into the abdominal cavity to transect the esophagus completely, and at OrVil™ group: t1: Time from the laparoscopic linear cutting stapler introduce into the abdominal cavity to complete the transected esophageal incision, t2: Time from OrVil™ device tube into the mouth to remove the nasogastric tube from the abdominal cavity, and t3: t1 + t2.
Data processing
Surgical metrological data were acquired through video documentation of all experimental procedures. Data entry was performed using Microsoft Excel (Standard Edition, 2021; Microsoft Corp., Redmond, WA, USA). Statistical graphics were generated using GraphPad Prism version 10.0.3 (GraphPad Software Inc., Boston, MA, USA). Statistical analyses were performed using SPSS version 27.0.1.0 (IBM Corp., Armonk, NY, USA). Normally distributed data are presented as mean ± standard deviation. Intergroup comparisons for normally distributed data were performed using an independent samples t-test. Non-normally distributed data are presented as the median and interquartile range (Q1, Q4). Non-parametric tests were used for intergroup comparisons of non-normally distributed data. P-values < 0.05 were considered statistically significant. Asterisks (*) denote p < 0.05, indicating a statistically significant difference between groups.
Results
All surgical procedures in the experimental pigs were completed without intraoperative complications, including the need for additional incisions, resuscitations, or mortality. Body weight, intraoperative data, postoperative data, and the cost of surgical consumables were pooled for analysis across both groups.
Postoperative body weights were reduced in both groups, with a greater reduction observed in the laparoscopic titanium purse-string forceps group compared to the OrVil™ technique group. However, this difference was not statistically significant (Table 1). In the statistical analyses of t total and t3, the laparoscopic titanium purse-string forceps group demonstrated a shorter duration; however, the difference was not statistically significant. Notably, t1 was significantly shorter in the OrVil™ technique group compared to the laparoscopic titanium purse-string forceps group, whereas t2 was significantly shorter in the laparoscopic titanium purse-string forceps group than in the OrVil™ technique group (Table 2).
Table 1.
Statistics of changes in body weight of pigs before and after surgery.
| Laparoscopic titanium purse-string forceps group | OrVil™ group | p value | |
|---|---|---|---|
| Preoperative weight and | 33.4 ± 2.2 | 34.9 ± 3.3 | 0.25 |
| Postoperative weight at day 7 (kg) | 30.1 ± 2.6 | 32.2 ± 3.2 | 0.12 |
In total 20 experimental pigs (laparoscopic titanium purse-string forceps group, n = 10; OrVil™ group, n = 10). Values are expressed as 
. Asterisks (*) denote p < 0.05, indicates statistically significant differences.
Table 2.
Time to operation statistics.
| Laparoscopic titanium purse-string forceps group | OrVil™ group | p value | |
|---|---|---|---|
| Total operation time (t total, min) | 187.2 ± 12.7 | 197.7 ± 10.6 | 0.06 |
| Esophageal dissection treatment time (t1, min) | 9.1 ± 1.6 | 7.4 ± 1.3 | 0.02* |
| Anvil placement and fixation time (t2, min) | 10.5 ± 1.5 | 12.7 ± 1.9 | 0.01* |
| Total anvil operation time (t3, min) | 19.6 ± 3.1 | 20.1 ± 2.9 | 0.70 |
In total 20 experimental pigs (laparoscopic titanium purse-string forceps group, n = 10; OrVil™ group, n = 10). Values are expressed as 
±S. Asterisks (*) denote p < 0.05, indicates statistically significant differences.
No statistically significant differences were observed between the two groups in preoperative or postoperative Hb levels, intraoperative blood loss, or postoperative complication rates (Tables 3 and 4). Regarding the cost of surgical consumables, expenditures were lower in the laparoscopic titanium purse-string forceps group compared to the OrVil™ technique group (Table 5).
Table 3.
Intraoperative bleeding statistics.
| Laparoscopic titanium purse-string forceps group | OrVil™ group | p value | |
|---|---|---|---|
| intraoperative blood loss (ml) | 81.0 ± 21.8 | 73.0 ± 30.9 | 0.51 |
| preoperative Hb leve (g/L) | 137.7 ± 7.9 | 143.4 ± 10.4 | 0.19 |
| postoperative Hb level (g/L) | 131.0 ± 10.2 | 138.4 ± 10.7 | 0.13 |
In total 20 experimental pigs (laparoscopic titanium purse-string forceps group, n = 10; OrVil™ group, n = 10). Values are expressed as 
±S. Asterisks (*) denote p < 0.05, indicates statistically significant differences.
Table 4.
Statistics of postoperative complications.
| Laparoscopic titanium purse-string forceps group | OrVil™ group | |
|---|---|---|
| Anastomotic stenosis (number of cases) | 0 | 1 |
| Abdominal blood loss (number of cases) | 1 | 0 |
| Incidence (%) | 10% | 10% |
In total 20 experimental pigs (laparoscopic titanium purse-string forceps group, n = 10; OrVil™ group, n = 10).
Table 5.
Statistics on the cost of surgical consumables.
| Unit Price (RMB) | Total price (RMB) | |
|---|---|---|
| Laparoscopic titanium purse-string forceps group | 22,000 | 22,000 |
| OrVil™ group | 6000 | 60,000 |
In total 20 experimental pigs (laparoscopic titanium purse-string forceps group, n = 10; OrVil™ group, n = 10).
Discussion
The evolution from traditional open surgery to minimally invasive surgery has significantly impacted the treatment of gastric cancer. LTG has largely replaced traditional open total gastrectomy13,14. Numerous studies have demonstrated the feasibility, safety, and efficacy of LTG15–18. Researchers worldwide are investigating optimal surgical procedures for LTG, with a particular focus on achieving safe and efficient EJS under laparoscopy.
Based on our clinical experience, we analyzed various anastomotic techniques for EJS and concluded that reconstruction using a circular stapler creates a round lumen, which more closely resembles normal physiological structure and offers advantages over linear staplers. Therefore, we selected the circular stapler for performing EJS. However, creating the esophageal purse-string suture during LTG with a circular stapler can be challenging and risky due to the limited subdiaphragmatic space19,20. To address this challenge, we introduced open purse-string forceps for laparoscopic use. Leveraging the advantages of open purse-string forceps, including ease of use, broad applicability, established foundation in surgical practice, and potential for widespread adoption and further development, we designed and developed a laparoscopic titanium purse-string forceps. This novel instrument allows for the replication of open surgical techniques during LTG procedures.
To evaluate the feasibility and safety of using laparoscopic titanium purse-string forceps for LTG, we conducted a comparative study with the OrVil™ technique, a well-established method for circular staple placement. This technique is widely performed worldwide, due to its short learning curve, ease of mastery, and broad applicability. However, the OrVil™ technique requires the involvement of the surgical team and technical support staff, typically anesthesiologists; this reliance can lead to inconsistencies in the placement of the anvil holder, affecting procedural efficiency and increasing surgical risk. Second, the technique necessitates specific esophageal conditions, and improper case selection or placement may result in complications, such as esophageal injury, staple holder dislodgement, and procedural failure; these limitations emphasize the need for alternative techniques, to optimize surgical outcomes in LTG.
Our study yielded several significant findings. Notably, the OrVil™ technique group demonstrated a shorter t1 compared to the laparoscopic titanium purse-string forceps group (9.1 ± 1.6 min vs. 7.4 ± 1.3 min; p = 0.02). The OrVil™ technique group demonstrated an advantage in requiring fewer steps to complete esophageal dissection and esophageal opening compared to the laparoscopic titanium purse-string forceps group. However, t2 was significantly shorter in the laparoscopic titanium purse-string forceps group compared to the OrVil™ technique group (10.5 ± 1.5 min vs. 12.7 ± 1.9 min, p = 0.01), suggesting that the use of the alloy loader in the laparoscopic titanium purse-string forceps technique facilitates a more efficient and comfortable procedure. Despite this advantage, no statistically significant differences were observed between the two groups for t3. This indicates that, although the titanium purse-string forceps technique offers certain procedural conveniences, it does not shorten the overall anastomosis operation time. From another perspective, this suggests that the laparoscopic titanium purse-string forceps technique is not inferior to the OrVil™ technique in terms of operative performance.
Notably, two postoperative complications were observed across all experimental pigs, with one case in the laparoscopic titanium purse-string forceps group and one in the OrVil™ technique group, resulting in an incidence rate of 10% in both groups. In the laparoscopic titanium purse-string forceps group, the first experimental pig developed postoperative abdominal hemorrhage, presenting with tachycardia and ultrasound findings suggestive of intra-abdominal effusion, but no hematochezia or melena was seen. Ultrasound-guided puncture confirmed a noncoagulable intra-abdominal effusion. The pig was promptly treated with symptomatic conservative management, including fluid resuscitation and hemostatic therapy. Bleeding ceased after 3 days of treatment, and the pig subsequently recovered without further complications. The cause of the analysis was re-bleeding of the mesenteric vessels coagulated by ultrasound. In the OrVil™ technique group, the third experimental pig exhibited anorexia and vomiting on postoperative day two. Gastroscopy revealed anastomotic edema and stenosis, which improved significantly following 5 days of symptomatic treatment, including fasting, acid suppression, rehydration, and intravenous nutrition. The remaining 18 animals recovered uneventfully without complications. Previous studies have shown that the incidence of Esophagojejunostomy stenosis is high in laparoscopic total gastrectomy with OrVil™ technology, moreover use of 21 mm circular stapler is an important risk factor21. In our study, there was no anastomotic stenosis in the laparoscopic titanium purse-string forceps group. Perhaps, we can speculate that laparoscopic titanium purse-string forceps may be helpful in reducing the occurrence of Esophagojejunostomy stenosis.
In addition, we included a comparative analysis of the medical economics associated with the OrVil™ device. Despite its long-standing presence in the Chinese medical market, the Medtronic OrVil™ kit used in our study remains costly, with a market price of up to RMB (Renminbi) 6000. The total expenditure on the OrVil™ device in our study amounted to RMB 60,000. In contrast, the laparoscopic titanium purse-string forceps device costs RMB 22,000 in our technical sample, with additional expenses limited to the cost of repeated decontamination. This represents a significant cost advantage over the OrVil™ device, emphasizing the economic feasibility of the laparoscopic titanium purse-string forceps technique.
We identified several advantages of using laparoscopic titanium purse-string forceps. First, the laparoscopic titanium purse-string forceps operate on the same principles as traditional open surgical purse-string forceps, making them easy to use without requiring additional training. Second, the procedure does not necessitate extra technical support staff; it can be completed with the cooperation of the surgical team alone. Third, titanium alloy surgical instruments are sterilizable and reusable, with single laparoscopic titanium purse-string forceps being sufficient to conduct experiments on 10 pigs, offering a cost-effective solution for medical applications.
In addition, the design of the laparoscopic titanium purse-string forceps offers several advantages. Its bendable clamp head allows for maneuverability during complex intra-abdominal procedures. The operator can adjust the clamp head angle via a control knob up to 14°, allowing for a more flexible grip on the lower end of the esophagus. Furthermore, the forceps’ construction from titanium alloy results in a lightweight and compact instrument. Although exhibiting similar mechanical properties to the commonly used martensitic alloy steel, titanium alloy offers superior high-temperature and corrosion resistance. Notably, titanium alloy is 43% lighter than martensitic alloy steel for the same volume, enhancing handling and reducing fatigue. Finally, the instrument facilitates easy needle penetration. The needle direction aligns nearly parallel with the connecting axis, and the “Z”-shaped folding line design of the clamp head-axis junction fully exposes the needle insertion point, simplifying and improving the precision of needle placement.
Despite these advantages, our initial experience with this novel purse-string forceps has revealed several limitations. The needle insertion direction is from left to right, requiring right-handed operators to thread the needle using a backhand technique. As a result, controlling the needle insertion direction may be challenging during initial use, and proficiency can only be achieved after a period of practice.
Conclusion
We evaluated the feasibility, safety, and efficacy of a novel laparoscopic titanium purse-string forceps by comparing its performance with the established OrVil™ technique for completing laparoscopic total gastrectomy in a swine model. Laparoscopic titanium purse-string forceps have the advantage of a shorter anvil placement and fixation time. Overall, the performance of laparoscopic titanium purse-string forceps was not inferior to the OrVil™ technique. In addition, the laparoscopic titanium purse-string forceps presents a more economical alternative. Although these findings were limited to an animal model, further clinical studies are required to validate their efficacy in human applications.
Acknowledgements
We are very grateful for the help of the Shanghai Medical Instruments (Group) Ltd., Corp. Surgical Instruments Factory and the Animal Experimentation Centre of Silver Snake (Shanghai) Medical Technology Co Ltd.
Author contributions
CW Ke, X Li and MZ Zha designed the study; X Li, D Zhang and ZP Cao performed the animials experiments; D Zhang and ZP Cao analyzed the data. D Zhang wrote the manuscript; CW Ke and X Li revised the manuscript. All authors read and approved the final submission of the manuscript.
Funding
This study was supported by the Biomedical Science and Technology Support Special Project of the Science and Technology Innovation Action Plan 2021 of Shanghai Municipality (Grant ID: 21S31904100) and the Science and Technology Commission of Minhang District 2022 (Grant ID: 2022MHZ067).
Data availability
The data used and/or analyzed during the current study are available from the corresponding authors upon reasonable request.
Declarations
Competing interests
The authors declare no competing interests.
Ethics approval and consent to participate
The experiment was approved by the Ethics Committee of the Animal Experimentation Centre of Silver Snake (Shanghai) Medical Technology Co.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Dong Zhang, Zhipeng Cao, Xi Li and Chongwei Ke contributed equally to this work.
Contributor Information
Xi Li, Email: h_karma@163.com.
Chongwei Ke, Email: dr_kecw@163.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used and/or analyzed during the current study are available from the corresponding authors upon reasonable request.