During a laparoscopic appendectomy, the closure of the appendiceal stump is an important step because of postoperative complications from its inappropriate management. The development of life-threatening events such as stercoral fistulas, postoperative peritonitis, and sepsis is feared and unwanted. The tactical modification of the appendiceal stump closure with a single endoligature, replacing the invaginating suture, adjusted very well to laparoscopic appendectomy, and nowadays is the procedure of choice, whenever possible. Among the alternatives that do not make use of an invaginating suture, studies advocate the use of an endostapler, endoligature (endo-loop), metal clips, bipolar endocoagulation, and polymeric clips. All alternatives have advantages and disadvantages against the different clinical stages of acute appendicitis, and it should be noted that the different forms of appendiceal stump closure have never been assessed in prospective randomized studies. Knowledge about and appropriate use of all of them are important for a safe and more cost-effective procedure.

Seton techniques have been used in the successful management of fistula in ano for thousands of years. In particular, the cutting seton is useful for complex high anal fistula, and drainage setons may have a significant role in the treatment of sepsis related to Crohn's disease and in immunocompromised patients.

The rationale for our current day use of absorbable and nonabsorbable suture materials is based upon the biology of wound healing and the physiologic response of tissue to implanted sutures. An understanding of the fundamental characteristics of suture materials and surgical needles is necessary if one is to obtain optimal surgical results.

During the 19th century, the principles of suturing and operating upon the bowel were developed. Lembert published his technique, emphasizing the importance of the serosa in 1826. This brought about sudden transition from the ancient methods of intestinal surgery. Considerable controversy followed. Dieffenbach reported the first clinical success with this suture in 1836. Lister introduced aseptic sutures and the principles of antisepsis to the intestine which allowed the subsequent developments. The importance of the submucosa in anchoring a stitch, so that divided surfaces could stay opposed, was drawn to surgeons' attention by Gross and by Halsted. Mall described the histologic changes and pointed out that necrosis would occur if sutures were too close or too tight. More than 200 modifications were described by the beginning of the 20th century. During the 1950s, everting suture was compared with inverting anastomoses, and the safety of this method was realized.

Because of the development of less invasive surgical techniques, there is an increasing demand for vascular anastomosing techniques that require less exposure of the operating field. This paper reviews the most important representatives of staples, clips, and other mechanical devices for vascular anastomosing described over the last five decades. This report is organized in three parts:(1) the history of clipping and stapling devices,(2) development of the Vessel Closure System (VCS) clips, and (3) current and potential status of mechanical vascular anastomotic devices. A Medline literature search was conducted and publications on the use of staples and/or clips for the creation of vascular anastomoses identified with extensive cross-referencing. The first literature description of a mechanical vascular stapling device was by Gudov in 1950. This and other reports from the Soviet Union stimulated brisk, competitive development of vascular anastomotic devices in Europe, North America, and Japan. Fasteners included staples, penetrating pin-rings, or toothed stainless steel clips, none of which gained acceptance because of their complexity and inability to facilitate end-to-side anastomoses. A more convenient and less traumatic anastomotic system (VCS Clip applier system) was introduced into clinical practice in 1995. This system differs from staples in that it is non-penetrating. A wide variety of reports have described the advantages, both technical and biological, that clips provide over conventional needle-and-suture, particularly for the construction of vascular access for hemodialysis. A steady evolution of mechanical vascular anastomotic devices has sought to eliminate the technical and biological disadvantages of conventional suturing. Although the conventional hand-sewn, overcast non-absorbable suture remains the "gold" standard, newer techniques such as the non-penetrating arcuate-legged VCS clips are gaining acceptance as a useful addition to the vascular surgeons' armamentarium.

In the context of continuous development in the area of anastomotic sutures leading to exceptional results in surgical practice, the biofragmentable anastomosis ring (BAR) described in 1985 by Hardy et al. represents a breakthrough in a 100 years' search of a paradigm. The first anastomotic button created in 1892 by J.B. Murphy was at once accepted as a quick and safe method of intestinal anastomosis. In 1896 Czerny demanded the following:"The task of technology is ... to create buttons with material that is entirely or partly dissolved in the intestinal lumen." Polyglycolic acid--developed in the sixties and now in widespread use for resorbable surgical sutures--was the material to fulfill the requirements already stated in the relevant literature 100 years ago, namely in the form of Hardy's BAR, which represents a redesigned Murphy button exploiting the recent biotechnological developments of this century.