Pediatric surgery is unique in the specialty’s requirement for operating in small spaces, made even more challenging in laparoscopic approaches. 5 mm endoscopic staplers provide a much-required solution; although extensive use of 5 mm endoscopic staplers has been reported in the adult population, there are far less reports of centers using them in the pediatric population.

A non-systematic review of PubMed was performed to investigate the use of 5 mm in pediatric endoscopic procedures. Six studies were identified as of October 2023, with results available in children aged between 1 day and 17 years. Three reports describe the use of 5 mm endoscopic staplers in bowel anastomosis in patients ranging from 1 day to 204 months in age, and from 1.9 to 79.8 kg in weight [1,2,3]. Two reports describe the use of 5 mm endostaplers in laparoscopic anorectoplasty from 2 to 6 months in age [4, 5]. One report described the use of 5 mm endostaplers in thoracoscopic resections of congenital lung malformations; however, no data were available on the age range [6].

The largest study was retrospectively conducted by a single institution, deploying 60 staple loads over 32 operative procedures ranging from appendectomies, bowel resection, lung resection, bronchus closure, bowel anastomosis and one case of gastrostomy closure and cystic duct division each [1]. Four intraoperative complications were noted and all were corrected intraoperatively; these included bleeding at the mesoappendix staple line, failed saline test during bowel anastomosis, air leak at the bronchus and failed hemostasis on the lung parenchyma. The authors noted that there was no significant difference in intraoperative complications compared to 10 mm endostapler; moreover, two of the complications related to operator and tissue-related factors, not the use of the 5 mm endostapler.

The use of the 5 mm endostapler has been further described in small bowel and colonic anastomoses in 11 patients ranging from 1 to 375 days [2]. Stapling difficulties were found in 3 patients out of 11, with one instance where the anastomosis could not be completed with a 5 mm staple, but a 12 mm staple instead. The other two cases could eventually be performed with the 5 mm staple, suggesting operator dependency. These intraoperative complications occurred during colostomy closure in older infants, which the authors suggested could be explained by excessive thickness of tissue with respect to the closed staple line. One post-operative complication of bowel obstruction was thought not to be related to the use of the endostapler.

The 5 mm endostapler was also used in a 2-month-old girl diagnosed with a choledochal cyst, who underwent laparoscopic choledochal cyst excision and hepaticojejunostomy, including intra-abdominal Roux-Y reconstruction. The 5 mm endostapler was used for a jejuno-jejunostomy anastomosis. No intraoperative complications were noted and the patient recovered without any post-operative complications [3].

Two reports described the use of the 5 mm endostapler in laparoscopic anorectoplasty for division of fistulas. [4, 5]. Four patients from 2 to 5 months with rectoprostatic and rectobladder fistulas underwent anorectoplasty, with division of the fistula with the 5 mm stapler. There were no intraoperative or post-operative complications. A separate case report described the use of the stapler for laparoscopic anorectoplasty in a recto-bulbar urethral fistula. There were no intraoperative complications and no post-operative residual fistula during 15-month follow-up.

The 5 mm endostapler has been further used in thoracoscopic resection of congenital lung malformations in children. The average length of surgery was shorter with this approach although no significant difference was found for length of stay or number of complications. [6].

The 5 mm endostapler has, therefore, proven to be a safe and useful tool in a range of endoscopic pediatric interventions, most commonly bowel and colonic anastomoses, however, the benefits are part dependent on operator-related technical skills and familiarity and on the type of tissue selected for stapling. The endostapler allows flush division and secure transection of fistulas in the use of laparoscopic anorectoplasty and has also been demonstrated in thoracoscopic of congenital lung malformations successfully.

In the context of endoscopic pediatric surgery, the use of 5 mm endostaplers have significant advantages associated with them over alternative approaches of using larger, often 10 mm or 12 mm staplers. The reduced size of the device allows additional maneuverability and a better view of the operative field. The increased size of incisions also increases the risk of a post-operative incisional hernia and may not be always possible in neonates and infants undergoing endoscopic procedures.

The main disadvantages of the 5 mm endostapler include its intraoperative difficulty in use. The endostapler encountered issues when being utilized on thicker tissue and irradiated tissue. While the absolute number of complications were higher in the 5 mm endostapler versus the 10 mm stapler, this difference was not statistically significant.

The number of published reports in pediatric surgery with regard to the application of the 5 mm endostapler in laparoscopic and thoracoscopic procedures are limited. The experiences reported are also with smaller number of patients. The efficacy of their use in the application of laparoscopic and thoracoscopic procedures should be reviewed once more, and the disseminated use of the technique is evident with reports on larger number of patients and compared to the 10 mm endostapler.