LigaSure compared with ligatures and endoclips in experimental appendectomy: how safe is it?

Evaluation of the Appropriate LigaSure™ Device to Transect the Appendix-A Comparison between 5 mm and 10 mm Laparoscopic Devices in an Ex Vivo Trial

Background and Objectives: A topic of greatinterest in the surgical field comprises cost and time reduction operative techniques with high efficiency rates. Thus, the aim of this paper is to evaluate whether a transection of the appendix using only a laparoscopic LigaSure™ device is feasible and, if so, which size of the laparoscopic device is optimal. Materials and Methods: Appendectomy specimens were sealed and cut using LigaSure^TM V (5 mm) and LigaSure Atlas^TM (10 mm) devices ex vivo. Analysis criteria included handling, resistance to bursting pressure of the appendicular stump (adequacy), eligibility, durability and airtightness. Results: Twenty sealed areas were measured. While the 5 mm instrument was not able to transect the appendix in one attempt in any of the cases, the 10 mm device could be applied successfully without any handling difficulties. The adequacy of the sealed area was rated as complete and dry in all 10 cases using the 10 mm device and as oozing in 8 of the cases using the 5 mm device. There was no leakage in terms of air and liquid tightness using the 10 mm device, in contrast to six sealed segments with air and liquid leakage when using the 5 mm device. The resistance to bursting pressure was on average 285 mmHg and 60.5 mmHg with the 10 mm and 5 mm devices, respectively. The durability and eligibility of the 10 mm device were rated as very sufficient in 9 of 10 cases (1 perforation) in contrast to the 5 mm device, where the sealing in 9 of 10 cases was not sufficient (9 perforations). Conclusions: Using the 10 mm laparoscopic LigaSure™ device for the transection of the appendix seems to be feasible, safe and resistant to 300 mmHg bursting pressure. The 5 mm LigaSure™ instrument is inadequate to seal the appendix in humans.

Use of a bipolar device (LigaSure) to seal the appendiceal stump in pediatric laparoscopic appendectomy: 10-year Latin-American experience

BACKGROUND

Closure of the appendiceal stump is a critical step during an appendectomy. There is a lack of knowledge about the feasibility of using electrosurgical devices for the occlusion of the appendix. This study aims to determine the safety of this technique in pediatric patients.

METHODS

We performed a cross-sectional analytical study in patients less than 18 years of age treated at Hospital Militar Central Colombia between 2012 and 2021. Our institution's ethics committee approved the study. We analyzed the data using SPSS 22 statistical program. We present frequencies for qualitative variables and measures of central tendency or dispersion for quantitative variables depending on the distribution measured by the Kolmogorov-Smirnov test. In addition, we measured the association of nominal variables with the Chi-square test or Fisher's exact test. For numerical variables, the difference of means with the Student's t-test or the difference of medians with the Mann-Whitney U test.

RESULTS

We treated 209 patients. One hundred sixteen (55.5%) were boys, and the mean age was 9.7 years (SD 3.2). The median intraoperative time was 60 min, and the hospital stay was 2.8 days on average. There were no cases of stump leakage, and only two patients (1%) had an organ-space surgical site infection, which was unrelated to the closure technique. We found no association between procedural complications and appendicular status (p = 0.450).

CONCLUSIONS

Our research suggests that using a bipolar sealing device (Ligasure, Medtronic, USA) for appendiceal stump closure in pediatric patients undergoing laparoscopic appendectomy is feasible and should be further studied.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Comparison of the Electrothermal Bipolar Sealing System (LigaSure) Versus Endoloop in Pediatric Laparoscopic Appendectomy

Background: Laparoscopic appendectomy has long been in the process of replacing open appendectomy owing to a better wound healing, better cosmetic appearance, less pain, and less postoperative adhesion. Although there are many methods for ligating the appendix stump, studies on energy-based coagulation methods have attracted great interest in recent years. In our study, we aimed to compare the use of LigaSure™ appendiceal sealing and ligation of appendiceal stump by endoloop with regard to duration of surgery, length of hospital stay, and complications in laparoscopic appendectomies. Materials and Methods: A total of 174 consecutive patients under the age of 18 who underwent laparoscopic appendectomy in our clinic between September 2016 and February 2021 were retrospectively analyzed. Patients with perforated appendicitis were excluded from the study. The patients were divided into two groups as the appendix stump was ligated with endoloop (Group 1) and sealed with LigaSure (Group 2). Demographic characteristics of the patients, duration of surgery, length of hospital stay, and complications were recorded. Results: Of the 132 patients who were included in the study, Group 1 consisted of patients using endoloop (n = 39) and Group 2 comprised patients that LigaSure was employed (n = 93). There was no significant difference between Groups 1 and 2 in terms of age and length of hospital stay (P = .126 and P = .784, respectively); however, the operation time was found to be significantly shorter in Group 2 (P < .001). Conclusion: The use of LigaSure is a safe and fast method to seal the mesoappendix and appendix stump in pediatric laparoscopic appendectomy. We think that infection complications due to stump leakage and intra-abdominal spillage will less be encountered.

Sutureless Appendectomy by Using Harmonic Scalpel: Is It Possible?

Introduction: Laparoscopic appendectomy is a commonly performed procedure. The base of appendix is secured by various techniques (suture, LigaSure, endoloop, or hamlock clip). Harmonic scalpel (HS) may be used to seal the base of the appendix. The study was conducted to assess the efficacy of HS in laparoscopic appendectomy for sealing the base of the appendix. Materials and Methods: The patients were divided into two groups: group 1 in which base was secured by endoloop and group 2 in which base of the appendix was sealed by HS in a stepwise manner. We made a record of patients' age and gender, and operative time. The patients were followed for a period of 3 months from the time of discharge. Results: During the study period of 4.5 years, 102 patients were in group 1 and 108 patients in group 2. Both groups were age and gender matched. Mean operating time for group 1 was 43.34 ± 6.7 minutes and that for group 2 was 28.46 ± 7.19 minutes (P < .0001). Complications included postoperative ileus (group 1 = 8, group 2 = 10) and surgical site infection (group 1 = 4, group 2 = 4, P > .05). Conclusion: It appears that use of HS for laparoscopic appendectomy is feasible and safe. Its results appear to be comparable with other methods of laparoscopic appendectomy. Complications are minimal. Further studies at other centers may substantiate our efforts.

Technological Advances in Surgical Equipment in Exotic Pet Medicine

Surgery can be challenging in exotic pets owing to their small size and blood volume, and their increased anesthetic risk compared with small animals. Various devices are available to facilitate suturing, cutting, and hemostasis in the human and veterinary fields. These surgical equipment improve the simplicity, rapidity, and effectiveness of surgery. Vessel-sealing devices, radiosurgery, lasers, and ultrasound devices are commonly used because of their ease of use and increase in surgical efficiency. Other surgical devices are available (eg, stapling devices) but are not discussed in this article.

Laparoscopic ovariohysterectomy in goats

OBJECTIVE To describe a minimally invasive 3-portal laparoscopic approach for elective ovariohysterectomy and the outcome of that procedure in a population of goats. DESIGN Descriptive clinical study. ANIMALS 16 healthy client-owned goats. PROCEDURES Food but not water was withheld from all goats for 24 hours before the procedure. Goats were anesthetized and positioned in dorsal recumbency. Three laparoscopic portals were created in the caudoventral portion of the abdomen, and the abdomen was insufflated to a maximum pressure of 10 mm Hg. A blunt-tip vessel sealer and divider device was used to transect the left and right mesovarium and mesometrium and uterus, and the resected tissue was removed from the abdomen. After hemostasis was verified, the portals were closed in a routine manner and anesthesia was discontinued. Goats were discharged from the hospital 24 hours after the procedure, and owners were contacted by telephone or email to obtain short- and long-term follow-up information by use of standardized questions. RESULTS All procedures were performed by a surgeon and assistant surgeon. The procedure was not complex and was easily learned. No intraoperative complications were reported, and only 1 goat required rescue analgesia post-operatively. No other postoperative complications were recorded. Median surgery time was 43 minutes (range, 20 to 65 minutes). All owners were satisfied with the outcome of the procedure, and several perceived that the procedure improved goat behavior. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that laparoscopic ovariohysterectomy was a viable alternative for elective sterilization of female goats.

Cecal Resection with Bipolar Sealing Devices in a Rat Model

Background: Bipolar sealing devices are routinely used to seal blood vessels. The aim of the study is to evaluate the feasibility and safety of colonic sealing with the use of the bipolar energy devices in rats as model for experimental appendectomy. Methods: Seventy-five male Wistar rats underwent a cecal resection with four different bipolar sealing devices or a linear stapler. The harvesting procedure was performed immediately or at postoperative day (POD) 7. The sealing front bursting pressure (BP) was measured in both groups. At POD7, the resection line was clinically examined and the hydroxyproline (HDP) levels were determined. Hematoxylin and Eosin (H&E) staining was used for histopathological evaluation of the sealing front as well. Results: There was no mortality and no insufficiency. The BPs between the bipolar sealing devices showed no statistical differences. The early phase of the seal (POD 0) provides a low BP with an 30.8% increase until POD 7. The BPs in the stapler group showed significant better values. The hydroxyproline levels did not differ statistically between the groups. Histopathologically, there were more signs of ischemic necrosis in the stapler group than in the sealing devices groups. Conclusion: The resection and sealing of the cecum as an experimental appendectomy model with the use of bipolar energy devices proved feasible and safe in rats. The different energy devices in this study produce comparable results. To justify clinical practice in humans, several studies on the underlying mechanisms of early stage wound healing are needed.

Comparison of the safety of electrotome, Harmonic scalpel, and LigaSure for management of thyroid surgery

BACKGROUND

Energy-based surgical devices, including electrotome, the Harmonic scalpel, and LigaSure, have been widely applied in thyroid surgery, although a comparison of their safety and efficacy has not been reported yet. In this study, we investigated the feasibility of using hemostatic energy-based surgical devices during thyroid surgery in a canine model.

METHODS

Twenty-four beagle dogs were randomly divided into the following groups: electrotome (30 kW), electrotome (15 kW), the Harmonic scalpel (output level 3), and LigaSure (middle gear). The hemostatic devices were applied on the thyroid surface for 3 seconds and then near the recurrent laryngeal nerve (RLN; distance of 5 mm, 3 mm, or 1 mm) for 3 seconds. Evoked electromyography (EMG) amplitudes were recorded by intraoperative neuromonitoring (IONM). Acute microstructural morphological damage to thyroid tissues and the RLN were evaluated immediately after the procedure by light and electron microscopy.

RESULTS

Electrotome caused a significant decrease in evoked EMG amplitudes when applied at a vertical distance of 1 mm from the RLN, both at 30 kW (1046 ± 404.3 μV vs 153 ± 245.5 μV; p < .001) and 15 kW (1197 ± 589.2 μV vs 986.3 ± 797.3 μV; p = .037), compared with those evoked under normal conditions. Furthermore, distinct acute microstructural morphological changes of the RLNs were observed by light and electron microscopy. However, no significant functional or histological changes were induced by the electrotome at a vertical distance of 5 mm or 3 mm from the RLN. The Harmonic scalpel and LigaSure induced neither marked changes in evoked EMG amplitudes when applied at vertical distances of 5 mm, 3 mm, or 1 mm (all p > .05) nor microstructural morphological changes in the RLNs. The electrotome (15 kW) caused more serious thermal damage to thyroid tissues than that caused by either the Harmonic scalpel or LigaSure (thermal damaged depth: 0.951 ± 0.061 vs 0.756 ± 0.074, p < .001; 0.951 ± 0.061 vs 0.724 ± 0.116, p < .001). Nevertheless, there were no differences between the Harmonic scalpel and LigaSure groups (p = .435).

CONCLUSION

LigaSure and the Harmonic scalpel might be safer than electrotome when used in thyroid operations. LigaSure generates less heat than the Harmonic scalpel and electrotome. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1078-1085, 2017.

Lateral thermal damage of mesoappendix and appendiceal base during laparoscopic appendectomy in children: comparison of the harmonic scalpel (Ultracision), bipolar coagulation (LigaSure), and thermal fusion technology (MiSeal)

BACKGROUND

The aim of this study was to compare lateral thermal damage of mesoappendix and appendiceal base using three different instruments for sealing and cutting of mesoappendix.

MATERIALS AND METHODS

A total number of 99 patients (54 males and 45 females) who underwent laparoscopic appendectomy because of suspected appendicitis between December 2013 and May 2015 were enrolled in the study. The patients were divided in three groups based on instrument used for sealing of mesoappendix: group 1 (Ultracision; n = 36), group 2 (LigaSure; n = 32), and group 3 (MiSeal; n = 31). Lateral thermal damage, intraoperative and postoperative complications, duration of surgery, hospital stay, and economic value were compared within groups.

RESULTS

The median age of patients was 14 y (range 3-17). A histopathologic analysis revealed a positive diagnosis of appendicitis in 84 patients (85%). The median lateral thermal damage on appendiceal base using Ultracision, LigaSure, and MiSeal was 0.10 mm, 0.16 mm, and 0.10 mm respectively, and on mesoappendix, 0.08 mm, 0.13 mm, and 0.08 mm, respectively. Significantly higher thermal damage was found on mesoappendix (P = 0.015) and appendiceal base (P = 0.012) in patients treated with LigaSure than in patients from other groups. There were no statistical differences among the groups regarding intraoperative and postoperative complications (P = 0.098). No significant difference in thermal damage between appendicitis and nonappendicitis group was found (P = 0.266).

CONCLUSIONS

Using of Ultracision, LigaSure, and MiSeal for sealing of mesoappendix in laparoscopic appendectomy in children is safe and useful. LigaSure produces significantly greater lateral thermal damage compared with other instruments.

Evaluation of the LigaSure(™) Vessel Sealing System for bowel transection and intestinal anastomosis-an experimental study in a porcine model

BACKGROUND

The purpose of the present study is to assess the value of the LigaSure™ Vessel Sealing System (LVSS) as a means for bowel transection and intestinal anastomosis.

METHODS

We compared the LVSS for (1) transecting bowel and (2) creation of an intestinal anastomosis with standard methods such as stapler (S) and hand-sewn (HS) in a porcine model. For each study arm, i.e., bowel transection and anastomosis creation, both the small bowel and colon were examined. In total, ten transections and ten anastomoses were performed for each. Burst and anastomotic leak pressures were compared.

RESULTS

In the study arm 1, LVSS achieved lowest burst pressures in both small bowel (LVSS 39.8 ± 3.6 mmHg, S 81.9 ± 3.9, HS 111.9 ± 14.7 mmHg, p < 0.0001) and colon transections (LVSS 21.5 ± 2.6 mmHg, S 79.5 ± 4.9, HS 91.0 ± 5.2 mmHg, p < 0.0001). There was no difference in burst pressures between S and HS in both small bowel and colon transections. In the study arm 2, LVSS showed the lowest anastomotic leak pressures for small bowel (LVSS 26.4 ± 2.6 mmHg, S 52.1 ± 6.2, HS 87.4 ± 7.0 mmHg, p < 0.0001) and colonic anastomoses (LVSS 16.9 ± 1.3 mmHg, S 55.9 ± 4.3, HS 74.4 ± 4.4 mmHg, p < 0.0001). Furthermore, small bowel and colonic anastomoses using S demonstrated significantly lower leak pressures than HS anastomosis p < 0.001 and p = 0.004, respectively.

CONCLUSIONS

The LVSS achieves significantly lower burst pressures and anastomotic leak pressures for bowel transection and intestinal anastomosis than S and HS techniques. However, due to the achieved pressure levels of 39.8 ± 3.6 mmHg, LVSS appears to be a sufficient stand-alone method for bowel transection. Whether it can be used to perform intestinal anastomosis warrants further research in a survival model.

Surgical Efficacy Among Laparoscopic Ultrasonic Dissectors: Are We Advancing Safely? A Review of Literature

The specialty of laparoscopy has evolved with the advent of new technologies over the last few years. Energy-based devices and Ultrasonic dissectors are used with a lot of factors in play-including ergonomics and economics during surgery. Here an attempt is based to review the surgical efficacy and safety of these dissectors with importance to plume production and lateral thermal damage. The factors contributing to adversities to the dissectors are also to be noted. The strategy adopted was aimed at finding relevant studies from PubMed from 1995 to 2014. The basic principle of plume production and thermal damage are studied in this review. Factors contributing to the same that can lead to adversities during laparoscopic surgeries are identified. Summarizing key points that increase lateral thermal damage and plume production amongst different ultrasonic shears and suggesting a technique to identify the right balance between the existing dissectors was possible. The RF Device and USS are both useful and widely used and are more safer than monopolar devices. RF Device is considerably slower than USS, as it cannot achieve coagulation and cutting at the same time. Although USS definitely improvises dissection and has less thermal injury than RF Device, the clinical implications in balancing dissection efficacy with hemostasis need to be investigated further. The ideal haemostatic energy-based shear device would be one with excellent hemostatic results and visual acuity while allowing none or minimal thermal energy escape at the point of application. In our current setting, a combined use of both RF and USS device usage as applied in the particular situations has potential.

Methods for closure of appendix stump during laparoscopic appendectomy procedure

The most frequent abdominal pathology requiring emergent surgery is acute appendicitis. Laparoscopic appendectomy has been performed for the treatment of acute appendicitis since 1983. Closure of the appendix stump is vital to prevent severe postoperative complications. Different methods are described for closure such as stapler, endoloop, titanium clips, non-absorbable polymer clips (hem-o-lok clip), handmade loops, transsection by Ligasure or with bipolar cautery. The ideal method should be safe, applicable and cheap. The most appropriate method remains to be controversial. All methods are reported as safe, but some have higher costs, and some prolong the operation. In this article, we reviewed clinical and experimental studies on different methods of stump closure, and we tried to compare the benefit of these methods over others.

Single incision cholecystectomy using a clipless technique with LigaSure in a resource limited environment: The Bahamas experience

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SILC in the third world.

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The addition of LigaSure to enhance procedure.

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Look at feasibility.

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Look at cost different.

Background

Scarless/single-incision laparoscopic cholecystectomy (SILC) is a new procedure. It affords a superior cosmetic outcome when compared to conventional laparoscopic cholecystectomy. We examine the application of this technique using LigaSure via a clipless method. The present study looks at the experience of a single surgeon using this method with initial evaluation of the safety, feasibility, affordability, and benefits of this procedure.

Methods

Twenty-eight patients underwent transumbilical SILC at Doctors Hospital from January to December, 2014. The cohort included both emergency and elective patients. There was no difference in the preoperative work-up as indicated. To perform the operation, a 2–2.5-cm linear incision was made through the umbilicus and the single port platform utilized. A 10 mm 30-degree laparoscope, a 5 mm LigaSure and straight instruments were used to perform the laparoscopic cholecystectomy procedure.

Results

All patients except two were operated on successfully. Conversion was considered the placement of an additional epigastric/Right upper quadrant (RUQ) port. The conversion rate to standard LC was 7%. No patient was converted to open cholecystectomy. In the 28 successfully completed patients, the median duration of the operation was 38.5 min and estimated operative blood loss was 24 ml. Patients were commenced on liquid diet immediately on being fully conscious and after return to the ward with an estimated time of 6 h. The mean postoperative hospital stay was 1.4 days. Follow-up visits were conducted for all patients at 2-weeks intervals and continued for 6 weeks after surgery where possible. Two patients developed wound infections. All patients were satisfied with the good cosmetic effect of the surgery. The total satisfaction rate was 100%.

Conclusions

SILC is a safe and feasible technique for operating with scarless outcomes and reducing perioperative discomfort at the same time. The GelPOINTTM is a safe and feasible platform to be used. The procedure can be accomplished using regular instruments and laparoscope. Curved instruments and a bariatric length laparoscope may make the procedure easier and result in greater time saving. The addition of LigaSure™ decreases the complexity of the operation, decreases operative time and blood loss. The technique is economical in a resource-limited environment.

The Feasibility of LigaSure to Create Intestinal Anastomosis

Objective. To evaluate the feasibility and the effectiveness of LigaSure Forced Triad to create intestinal anastomosis in an ex vivo porcino model. Methods. Colon samples (n = 100) were prospectively randomized into 2 groups: LigaSure group (n = 90) and Stapler group (n = 10). The LigaSure group was divided into 9 subgroups, each of 10 samples, according to the different power levels of the LigaSure system (Bar 1, Bars 2, and Bars 3) and radiofrequency application (1 application, 2 applications, and 3 applications) used. All anastomoses were tested for early burst pressure. The LigaSure subgroup having the highest burst pressure was compared with the Stapler group. Finally, the specimen was reviewed by the same pathologist. Results. The burst pressures of the 9 subgroups of LigaSure segments were the following: 29.7 ± 4.5 (Subgroup a); 27.4 ± 3.1 (Subgroup b); 25.3 ± 4 (Subgroup c); 32.9 ± 2.3 (Subgroup d); 30.7 ± 3.8 (Subgroup e); 25.7 ± 4.8 (Subgroup f); 42 ± 4.7 (Subgroup g); 31.8 ± 3.8 (Subgroup h); and 28.5 ± 3 (Subgroup j). Subgroup g (3 bars-power levels/1 frequency application) had the highest burst pressure ( P < .001; ANOVA test). No significant difference was found between burst pressure of Subgroup g and Stapler group (42 ± 4.7 vs 42 ± 4.3, respectively, P = .9). On histological view, the LigaSure anastomosis was formed by collagen sealed without cavitation defects. Conclusions. Our study seems to confirm the feasibility of creating intestinal anastomosis using LigaSure. However, further researches in in vivo models are mandatory before recommending its clinical usage in such settings.

Development of a standardized laparoscopic caecum resection model to simulate laparoscopic appendectomy in rats

Background

Laparoscopic appendectomy (LA) has become one of the most common surgical procedures to date. To improve and standardize this technique further, cost-effective and reliable animal models are needed.

Methods

In a pilot study, 30 Wistar rats underwent laparoscopic caecum resection (as rats do not have an appendix vermiformis), to optimize the instrumental and surgical parameters. A subsequent test study was performed in another 30 rats to compare three different techniques for caecum resection and bowel closure.

Results

Bipolar coagulation led to an insufficiency of caecal stump closure in all operated rats (Group 1, n = 10). Endoloop ligation followed by bipolar coagulation and resection (Group 2, n = 10) or resection with a LigaSure™ device (Group 3, n = 10) resulted in sufficient caecal stump closure.

Conclusions

We developed a LA model enabling us to compare three different caecum resection techniques in rats. In conclusion, only endoloop closure followed by bipolar coagulation proved to be a secure and cost-effective surgical approach.

Colorectal anastomosis facilitated by the use of the LigaSure(®) sealing device: comparative study in an animal model

BACKGROUND

Recently, there has been speculation about the possibility of fusing intestinal tissue using bipolar sealing devices. In this study we compare in a porcine model the anastomoses created using the LigaSure(®) device with those created with a stapler after section and closure of a rectal stump.

METHODS

Thirty pigs underwent laparoscopic colorectal anastomosis. In group A (n = 15), the division of the intestine and distal stump closure were done with a 10-mm LigaSure Atlas(®) device. In group B, these steps were carried out using an endoscopic stapler. Subsequently, the colorectal anastomosis was performed using circular stapling in both groups. The 4-week follow-up included health status, weight gain, blood tests, X-rays, and colonoscopy. Anastomotic tissue was processed to study the mechanical tensile strength and histopathology.

RESULTS

There was no difference in the rate of conversion to open surgery or in average operating time between the groups. In the sealing device group, there was a significantly higher rate of failure in rectal stump closure (p = 0.042). There was one death in group B due to anastomotic leak. There was no difference in adhesion formation or stenosis. Mid-section anastomosis area was 89.7 mm(2) in group A compared with 100 mm(2) in group B (p = 0.52). In tensile strength studies, the maximum load resisted by the sample was 13.8 ± 4.9 N (group A) versus 15.7 ± 4.4 N (group B) (p = 0.17). There was no difference between the groups in degree of reepithelialization, number of inflammatory cells, or the presence of microabscesses.

CONCLUSIONS

Division and sealing of the rectal stump with the LigaSure(®) device is feasible in the proposed experimental model, but it is less reliable than conventional closure with a stapler, since it has a significantly greater failure rate. Therefore, The LigaSure(®) device should not be used for this purpose in the clinical setting as this could lead to serious and dramatic complications.

Comparison of lateral thermal damage of the human peritoneum using monopolar diathermy, Harmonic scalpel and LigaSure

BACKGROUND

New hemostatic technologies are often employed in open and laparoscopic surgery to reduce duration of surgery and complications. Monopolar diathermy, Harmonic scalpel and LigaSure are routinely used in open and laparoscopic surgery for tissue cutting and hemostasis. We compared lateral thermal damage following in vivo application of 3 commonly used instruments.

METHODS

We used monopolar diathermy, Harmonic scalpel and LigaSure to coagulate and divide the peritoneum of patients who underwent median laparotomy. After anesthesia, median supraumbilical laparotomy was performed, and the peritoneum of each patient was coagulated using different devices. Using light microscopy and morphometric imaging analysis, the width of tissue lateral thermal damage was measured from the point of the peritoneal incision.

RESULTS

We included 100 patients in our study. After a peritoneal incision, the mean lateral thermal damage of monopolar diathermy, Harmonic scalpel (output power 3), Harmonic scalpel (output power 5) and LigaSure were 215.79 μm, 90.42 μm, 127.48 μm and 144.18 μm, respectively.

CONCLUSION

The degree of lateral thermal spread varied by instrument type, power setting and application time. LigaSure and Harmonic scalpel were the safest and most efficient methods of tissue coagulation. Monopolar diathermy resulted in the greatest degree of thermal damage in tissues.

Application of high frequency bipolar electrocoagulation LigaSureTM in appendix vermiformis of rabbits with or without acute inflammatory process

PURPOSE: To evaluate the efficacy of the use of LigaSureTM in appendectomy, with or without acute inflammatory process, and to compare with simple ligature and conventional therapy. METHODS: A total of 30 rabbits (Oryctolagus cuniculus) randomly allocated in two groups, group A and B, of 15 animals each were used. The group A without acute appendicitis and the group B with acute appendicitis were submitted to appendectomy. After, the groups were subdivided into three groups, each group containing five rabbits submitted to simple ligature, conventional therapy and application of LigaSureTM. We assessed macroscopic and microscopy parameters of appendiceal stump and operative wound. RESULTS: The group with acute appendicitis that LigaSureTM was applied had fibrosis in 100% of animals, as well as in the other operative techniques used. It suggested that application of LigaSureTM is efficient as other techniques used in healing of appendiceal stump. CONCLUSIONS: The application of LigaSureTM induces the formation of fibrosis in the appendiceal stump. The technique proved efficacy to induce enough fibrous tissue to obstruct leakage of enteric content.

Comparison of bipolar electrosurgical devices with ligatures and endoclips in the rat appendicitis model

PURPOSE

The aim of this study is to compare bipolar radiofrequency-driven vessel sealer, bipolar electrocautery, polyglactin 910 sutures, and endoclips in appendiceal stump closure with respect to operative time, appendiceal stump strength, and inflammation in a rat appendiceal model.

METHODS

Forty-eight Wistar-Albino rats, which had previously created appendicitis, were divided into 2 (groups A and B). Each group was further subdivided into 4 subgroups (AL, ABPC, AC, AS, BL, BBPC, BC, and BS) each containing 6 rats. An appendectomy was performed, and the stump was closed by bipolar radiofrequency-driven vessel sealer in the L, bipolar electrocautery in the BPC, endoclips in the C, and ligatures in the S subgroups. Cecum bursting pressures were determined instantly after the operation in group A and on the seventh postoperative day in group B. All operative times were measured. Appendices and appendiceal stumps underwent histopathologic examination. Statistical analyses were performed with Kruskal-Wallis and Mann-Whitney U tests. P < .05 was considered significant.

RESULTS

Bursting pressures of the subgroups were comparable on postoperative immediate period and day 7. Operative times were significantly shorter in the L and BPC subgroups in A and B. Histopathologic examination showed that the inflammation scores were similar in group A. In group B, inflammation parameters were also similar except the necrosis status, which was found to be decreased in BL compared with BC and BS. Necrosis status was significantly lower, and lymphocyte quantity was significantly higher in BL and BBPC compared with AL and ABPC.

CONCLUSIONS

Bipolar radiofrequency-driven vessel sealer and bipolar electrocautery achieve safe stump closure with satisfactory bursting pressure values in an experimental rat appendicitis model. Decreased operative time and unimpaired healing are encouraging.

The impact of surgeon choice on the cost of performing laparoscopic appendectomy

INTRODUCTION

While laparoscopic appendectomy (LA) can be performed using a myriad of techniques, the cost of each method varies. The purpose of this study is to analyze the effects of surgeon choice of technique on the cost of key steps in LA.

METHODS

Surgeon operative notes, hospital invoice lists, and surgeon instrumentation preference sheets were obtained for all LA cases in 2008 at Cambridge Health Alliance (CHA). Only cases (N = 89) performed by fulltime staff general surgeons (N = 8) were analyzed. Disposable costs were calculated for the following components of LA: port access, mesoappendix division, and management of the appendiceal stump. The actual cost of each disposable was determined based on the hospital's materials management database. Actual hospital reimbursements for LA in 2008 were obtained for all payers and compared with the disposable cost per case.

RESULTS

Disposable cost per case for the three portions analyzed for 126 theoretical models were calculated and found to range from US $81 to US $873. The surgeon with the most cost-effective preferred method (US $299) utilized one multi-use endoscopic clip applier for mesoappendix division, two commercially available pretied loops for management of the appendiceal stump, and three 5-mm trocars as their preferred technique. The surgeon with the least cost-effective preferred method (US $552) utilized two staple firings for mesoappendix division, one staple firing for management of the appendiceal stump, and 12/5/10-mm trocars for access. The two main payers for LA patients were Medicaid and Health Safety Net, whose total hospital reimbursements ranged from US $264 to US $504 and from US $0 to US $545 per case, respectively, for patients discharged on day 1.

DISCUSSION

Disposable costs frequently exceeded hospital reimbursements. Currently, there is no scientific literature that clearly illustrates a superior surgical method for performing these portions of LA in routine cases. This study suggests that surgeons should review the cost implications of their practice and to find ways to provide the most cost-effective care without jeopardizing clinical outcome.