Two 2026 studies challenge the conventional wisdom on powered staplers in thoracic surgery — and point to a new competitive force in stapler design.
Lexington Medical designs and manufactures AEON™, an endoscopic surgical stapling system for minimally invasive surgery. This guide explains how a surgical stapler works, why components like the handle, I-beam, cartridge, anvil, knife, and staple reload matter, and how AEON™ is engineered to support consistent staple formation across tissue types.
Introduction
For most of the past decade, the clinical narrative around surgical staplers has been straightforward: powered is better. Lower complication rates, less bleeding, fewer air leaks that close sooner, and lower total hospital costs [1]. The data supporting powered staplers across a range of thoracic procedures has been largely consistent — until recently.
Two independent peer-reviewed, head-to-head studies published in 2026 have now documented cases where a manual stapler outperformed the competitors’ powered alternatives[2, 3]. What makes these findings noteworthy is not simply that a manual stapler did very well — it’s which manual stapler. Both studies featured the AEON Manual surgical stapler (Lexington Medical, Bedford, MA), a device from a company that focuses exclusively on stapling technology. The results are worth a closer look.
Lexington Medical has recently introduced a powered version of the AEON surgical stapler. It is logical to assume that, given the overall superiority of other manufacturers’ powered staplers over their manual staplers, that the performance of the powered AEON surgical stapler will be better than the manual version.
Study 1: Nimietz et al. — Prospective RCT in LVRS
(Macharia-Nimietz EF, et al. Efficacy of non-powered stapler in lung volume reduction surgery of severe lung emphysema: A prospective randomized single-blinded monocentric study. Interdiscip CardioVasc Thorac Surg. 2026. doi: 10.1093/icvts/ivag071)
This is a prospective, randomized trial from the University Hospital Basel, comparing the AEON Manual surgical stapler against the Echelon Flex Powered Plus (Ethicon) in lung volume reduction surgery (LVRS) for severe pulmonary emphysema.
The study enrolled 19 patients (32 procedures), with 13 patients undergoing bilateral LVRS (in those patients both staplers were used, one per side) allowing a within-patient comparison that controlled for individual physiologic variability. All procedures were performed by a single experienced LVRS surgeon using VATS.
Due to sample size none of these differences reached conventional statistical significance, although the trend is powerful. The authors appropriately emphasize effect sizes over p-values, and the effect sizes here are substantial.
Nimietz 2026 — Clinical Key Results
AEON Manual surgical stapler vs. Echelon Flex Powered Plus — postoperative air leak outcomes following Lung Volume Reduction Surgery (LVRS)
- AEON Manual surgical stapler
- Echelon Flex Powered Plus
Median time to air leak closure
14.3 h
vs. 93.2 h (Echelon Flex Powered Plus)
Total median air leak volume (AUC)
1,925 mL
vs. 12,310 mL — 32% of Echelon
Chest tube duration
3.1 days
vs. 4.9 days (Echelon Flex Powered Plus)
| Outcome | AEON Manual surgical stapler | Echelon Flex Powered Plus |
|---|---|---|
| Air leak incidence | 35.3%41% lower | 60.0% |
| Prolonged air leak (>7 days) | 11.8%56% lower | 26.7% |
| Leaks closed within 24 hours | 64.7%+24.7 pts | 40.0% |
| Median time to air leak closure | 14.3 h6.5x faster | 93.2 h |
| Total air leak volume | 1,925 mL32% of Echelon | 12,310 mL |
| Chest tube duration | 3.1 days37% shorter | 4.9 days |
| Length of stay | 11 days | 11 days |
Source: Nimietz et al. 2026. LVRS cohort. Length of stay driven primarily by rehabilitation wait times, not complication burden.
Nimietz 2026 — Air Leak Outcomes
AEON Manual surgical stapler vs. Echelon Flex Powered Plus — LVRS cohort. Click any bar to see detail.
- AEON Manual surgical stapler
- Echelon Flex Powered Plus
Source: Nimietz et al. 2026. LVRS cohort (n=32 procedures, 19 patients). Prolonged air leak defined as >7 days.
Nimietz 2026 — Median Time to Air Leak Closure
AEON Manual surgical stapler vs. Echelon Flex Powered Plus — LVRS cohort. Click any bar to see detail.
- AEON Manual surgical stapler
- Echelon Flex Powered Plus
Source: Nimietz et al. 2026. Median time reported with IQR: AEON 14.3h [6.7, 116] vs. Echelon Flex Powered Plus 93.2h [2.1, 159]. Cox regression HR 1.55 (95% CI 0.73, 3.30), p=0.25.
The AEON's total air leak volume was [...68% lower than ...] the competitive powered stapler's — a clinically meaningful difference that a larger trial is warranted to confirm.
The mechanistic hypothesis offered is compelling. The AEON’s gear system reduces firing force by approximately 50%, and crucially, allows the surgeon to pause and restart firing mid-sequence — adjusting compression speed to tissue quality in real time. The powered Echelon, by contrast, fires at constant speed once activated, with no mid-fire adjustment.
In emphysematous lung, where tissue is fragile and heterogeneous, this distinction may matter considerably. The Echelon stapler reuses its knife with each reload, potentially increasing tissue tearing risk over the course of a case, while the AEON uses a fresh blade with each reload.
Study 2: Alomari et al. — Retrospective Cohort in VATS Wedge Resection
(Alomari M, et al. Outcome comparison between two staplers used for pulmonary resection: a retrospective cohort study. Video-Assist Thorac Surg. 2026. doi:10.21037/vats-25-31)
Published in Video-Assisted Thoracic Surgery, this retrospective study from Mayo Clinic Jacksonville compared AEON against the Signia (Medtronic) powered stapler across 79 patients undergoing VATS wedge resection between 2018 and 2024 — with Signia as the institutional standard prior to 2021, and AEON adopted thereafter.
Wedge resections were chosen specifically to minimize confounding from procedural complexity, and all cases were performed by one of two experienced surgeons.
Alomari 2026 — Clinical Key Results
AEON Manual surgical stapler vs. Signia Stapler — postoperative outcomes following VATS pulmonary wedge resection (Mayo Clinic Jacksonville)
Zero complications in both groups. Prolonged air leak (>5 days), bleeding, pneumothorax, reoperation, and readmission were all 0% for both AEON Manual surgical stapler and Signia Stapler.
Median length of stay
AEON Manual surgical stapler
1day
vs. 2 days (Signia)
Signia Stapler
2days
p=0.08 — trend toward shorter stay with AEON; stapler type was not independently associated with LOS in adjusted analysis (p>0.05).
* Baseline oncologic profiles differed between groups: AEON cases were more often primary lung cancer (61.8% vs. 33.3%); Signia cases were more often metastatic disease (46.7% vs. 20.6%). In multivariate analysis adjusting for sex and pathology subtype, stapler type was not independently associated with length of stay. Interpret comparative outcomes in this context.
Source: Alomari et al. Video-assist Thorac Surg 2026. doi: 10.21037/vats-25-31.
The conclusion is one of equivalence: both devices are safe and effective for VATS wedge resection, with no statistically significant outcome differences. For an institution considering a stapler transition, this study provides reassurance that clinical performance is preserved.
Although the lead author received a research grant from Lexington Medical, data collection, analysis, and manuscript preparation were conducted independently of the sponsor — and the results, which show equivalence rather than superiority, are consistent with that claim.
Alomari 2026 — Reintervention Rate & Length of Stay
AEON Manual surgical stapler vs. Signia Stapler — VATS pulmonary wedge resection (Mayo Clinic Jacksonville). Click any bar to see detail.
- AEON Manual
- Signia Stapler
* Reintervention rate: 0% with AEON Manual surgical stapler vs. 2.2% with Signia Stapler (p>0.99).
Source: Alomari et al. Video-assist Thorac Surg 2026. doi: 10.21037/vats-25-31. LOS p=0.08; stapler type not independently associated with LOS in adjusted analysis (p>0.05).
What Makes the AEON Surgical Stapler Different?
Lexington Medical’s design philosophy differs from other manufacturers in several concrete ways that are directly relevant to these results. The stapler design:
- reduces firing force by ~50%, with manual pause/restart capability during firing
- provides gradual tissue compression across the staple line and uses fixed anvil architecture
- is optimized for pulmonary tissue characteristics with teardrop-shaped anvil buckets and uniform staple heights
- allows staple application closer to the blade, reducing overlap gaps between loads
- provides a proprietary short reload tip for navigating tight spaces with reduced tissue trauma
- eliminates the dulling effect seen with reusable knives in some powered devices
- in the original powered AEON (launched 2024), tactile feedback is preserved via a manual closure mechanism — addressing a known criticism of battery-powered devices
- for the new AEON Powered Handle does not have a battery, so it provides consistent power and limits waste
Published bench data from Lexington Medical’s own testing (cited in the white paper literature) shows the AEON achieving properly formed staples in 88% of firings through 4.5 mm ex vivo porcine stomach, compared with 58% for Medtronic and 56% for Ethicon. While internal data warrants independent replication, it provides a plausible mechanism for the clinical observations reported in these trials.
Study Limitations
Although these studies are encouraging, neither is definitive. The Nimietz trial is underpowered (the observed air leak closure time (~70 hours) was substantially larger than the assumed 48 hours used in power calculations, meaning 32 bilateral pairs would have been required.) A well-powered, multicenter RCT comparing AEON against the major powered staplers in LVRS is clearly needed.
The Alomari study is retrospective, single-center, and limited to wedge resections. Since complication rates were extremely low in both groups, it is difficult to show differences. Larger prospective comparisons in LVRS and anatomic resections are a logical next step.
It is also worth noting that neither study includes the powered AEON (launched 2024), which will be the more relevant comparison point going forward. If the pattern seen across other manufacturers holds — powered versions outperforming their own manual counterparts — the powered AEON’s clinical performance will be of considerable interest.
The Practical Takeaway for Thoracic Surgeons
The broader literature still favors powered staplers over most manual alternatives for thoracic procedures. But the AEON data introduces a meaningful nuance: the performance gap between powered and manual may be device-specific rather than inherent to the power mechanism itself. A well-engineered manual stapler, designed with attention to tissue interaction, staple geometry, and surgeon control, can match or outperform some competitive powered devices — at least in specific procedural contexts.
For surgeons performing LVRS in particular, the Nimietz data suggests the AEON merits serious consideration, especially given the fragility of emphysematous tissue and the premium placed on minimizing air leak in that population. The ability to modulate compression speed mid-firing is a feature that maps directly onto the intraoperative challenges of LVRS.
For institutions undergoing contract review or stapler procurement decisions, the clinical evidence demonstrated by both papers provides legitimate clinical and financial rationale for including the AEON in the evaluation.
The performance gap between powered and manual staplers may be device-specific, not fundamental. The right question is no longer just powered versus manual — it is which device, in which tissue, in which hands.
University Hospital Basel
Department of Thoracic Surgery,
Key Takeaways
- Powered staplers don’t always outperform manual ones in thoracic surgery. Two independent peer-reviewed studies published in 2026 show the AEON Manual surgical stapler (Lexington Medical, Inc.) matching or outperforming powered stapler alternatives in VATS pulmonary procedures — suggesting the performance gap is device-specific, not inherent to the power mechanism.
- AEON reduced median time to air leak closure from 93.2 hours to 14.3 hours in LVRS. In a prospective randomized trial (Nimietz et al. 2026, University Hospital Basel), total air leak volume with AEON was 32% of the Echelon Flex Powered Plus — a clinically substantial difference in a fragile-tissue population.
- AEON’s pause-and-restart firing gives surgeons real-time control that powered staplers don’t. Its gear system reduces firing force by approximately 50% and allows mid-sequence adjustment — a direct mechanical advantage in emphysematous lung, where the Echelon Flex Powered Plus fires at constant speed with no adjustment once activated.
- At Mayo Clinic Jacksonville, AEON matched Signia across every measured safety outcome in VATS wedge resection. Prolonged air leak, bleeding, pneumothorax, reoperation, and readmission were all 0% in both groups (Alomari et al. 2026, n=79) — with median length of stay trending shorter with AEON at 1 day versus 2 days (p=0.08).
- The AEON Powered Handle is the next comparison that thoracic surgery needs. Neither 2026 study evaluated it — and given the manual AEON’s baseline performance, its clinical results will be of considerable interest to surgeons and procurement teams alike.
Frequently Asked Questions
A surgical stapler, also called an endoscopic stapler (endostapler) or laparoscopic stapler, is a minimally invasive surgical stapling device used to simultaneously cut and seal tissue during procedures like VATS, LVRS, and pulmonary resection. For most of the past decade, powered surgical staplers have been considered the clinical standard over manual alternatives. Two peer-reviewed studies published in 2026 challenge that assumption, finding that device engineering matters more than power mechanism alone. (Nimietz et al., 2026; Alomari et al., 2026)
The AEON surgical stapler’s gear system allows surgeons to pause and restart firing mid-sequence, enabling real-time compression adjustment to tissue quality. Competing powered staplers fire at constant speed once activated with no mid-fire adjustment. AEON also provides a fresh blade with each reload, eliminating the dulling effect associated with reusable knives across multiple firings in a single case. (Nimietz et al., 2026)
In a prospective randomized trial at University Hospital Basel, AEON was associated with a 41% lower air leak incidence and a 56% lower rate of prolonged air leak compared to a leading powered stapler. Median time to air leak closure was 14.3 hours with AEON versus 93.2 hours with the powered comparator, and total air leak volume was 32% of the comparator. Chest tube duration was 3.1 days versus 4.9 days. (Nimietz et al., 2026)
Yes. In a retrospective cohort study at Mayo Clinic Jacksonville, AEON and a leading powered stapler both achieved zero complications across all measured safety endpoints, including prolonged air leak, bleeding, pneumothorax, reoperation, and readmission. Median length of stay trended shorter with AEON at 1 day versus 2 days, though this did not reach statistical significance. The authors concluded clinical performance was preserved with AEON for institutions considering a transition. (Alomari et al., 2026)
Emphysematous lung tissue is fragile and heterogeneous, making constant-speed powered firing a liability. AEON’s pause-and-restart firing capability allows surgeons to modulate compression speed in real time based on tissue response, a mechanical advantage that maps directly onto the demands of LVRS. Additionally, AEON uses a fresh blade with each reload, reducing the tissue tearing risk associated with blade dulling over multiple firings in the same case. (Nimietz et al., 2026)
What Surgeons Should Look for in a Better Surgical Stapler
When evaluating surgical staplers, surgeons may consider staple formation consistency, staple-line hemostasis, tissue compression, articulation control, knife sharpness, reload selection, ease of use, clinical evidence, and manufacturing quality control.
AEON™ was designed around these performance factors, including smooth articulation, a new blade with every reload, proprietary quality-control processes, and published clinical evidence evaluating hemostasis and intra-operative and post-operative outcomes and complications.
References
- Ho, S. Y., Muthiah, V. K., & Tay, K. V. (2024). Comparing Surgical Outcomes of Powered Versus Manual Surgical Staplers: A Systematic Review and Meta-analysis. Langenbeck’s Archives of Surgery, 409(1), 331. https://doi.org/10.1007/s00423-024-03490-x
- Alomari, M., Delgado, J. L., Khalifa, H., London, J., Coffman, D., Vaca, B. F., Mateus, A. Y. L., Al-Botros, L., & Makey, I. (2026, February 25). Outcome comparison between two staplers used for pulmonary resection: A retrospective cohort study. Video-Assisted Thoracic Surgery. https://dx.doi.org/10.21037/vats-25-31
- Macharia-Nimietz, E. F., Mallaev, M., Gecas, P., Vujic, J., Simmen, U., Hojski, A., Tamm, M., & Lardinois, D. (2026). Efficacy of Non-Powered Stapler in Lung Volume Reduction Surgery of Severe Lung Emphysema: A Prospective Randomized Single-Blinded Monocentric Study. Interdisciplinary CardioVascular and Thoracic Surgery. https://doi.org/10.1093/icvts/ivag071
