Efficacy and quality of vessel sealing

Advanced bipolar vessel sealing devices vs conventional bipolar energy in minimally invasive hysterectomy: a systematic review and meta-analysis

PURPOSE

To compare conventional bipolar electrosurgery with advanced bipolar vessel sealing (ABVS) devices for total laparoscopic hysterectomy (TLH).

METHODS

A systematic review was conducted by searching Scopus, PubMed/MEDLINE, ScienceDirect, and Cochrane Library from January 1989 to November 2021. We identified all studies comparing ABVS devices with conventional bipolar electrosurgery in TLH and reporting at least one of the following outcomes: total blood loss, total operative time, hospital stay, perioperative complications, or costs. Meta-analysis was conducted with a random effect model reporting pooled mean differences and odds ratios (ORs) with related 95% confidence intervals (CIs).

RESULTS

Two randomized controlled trials and two retrospective studies encompassing 314 patients were included out of 615 manuscripts. The pooled estimated total blood loss in the ABVS devices group was lower than conventional bipolar electrosurgery of 39 mL (95% CI - 65.8 to - 12.6 mL; p = .004). The use of ABVS devices significantly reduced the total operative time by 8 min (95% CI - 16.7 to - 0.8 min; p = .033). Hospital stay length did not differ between the two groups, and a comparable overall surgical complication rate was observed [OR of 0.9 (95% CI 0.256 - 3.200; p = .878].

CONCLUSIONS

High-quality evidence comparing ABVS devices with conventional bipolar electrosurgery for TLH is lacking. ABVS devices were associated with reduced total blood loss and operative time; however, observed differences seem clinically irrelevant. Further research is required to clarify the advantages of ABVS devices over conventional bipolar electrosurgery and to identify cases that may benefit more from their use.

"In Vitro" Evaluation of Energy-Based Sealing of Graft Side Branches in Bypass Surgery

INTRODUCTION

Our objective was to compare the in vitro efficacy of electrothermal bipolar [EB] vessel sealing and ultrasonic harmonic scalpel [HS] versus mechanical interruption, with conventional ties or surgical clips (SC), in sealing saphenous vein (SV) collaterals, during its eventual preparation for bypass surgery.

METHODS

Experimental in vitro study on 30 segments of SV. Each fragment included two collaterals at least 2 mm in diameter. One of them was sealed by ligation with 3/0 silk ties (control) and the other one with EB (n = 10), HS (n = 10) or medium-6 mm SC (n = 10). After incorporation in a closed circuit with pulsatile flow, the pressure was progressively increased until causing rupture. Collateral diameter, burst pressure, leak point, and histological study were recorded.

RESULTS

Burst pressure was higher for SC (1320.20 ± 373.847 mmHg) as compared with EB (942.2 ± 344.9 mmHg, p = 0.065), and especially with HS (637.00 ± 320.61 mmHg, p = 0.0001). No statistically significant difference between EB and HS was found, and bursting always happened at supraphysiological pressures. The leak point for HS was always detected in the sealing zone (10/10), while for EB and SC, it occurred in the sealing zone only in 6/10(60%) and 4/10(40%), respectively (p = 0.015).

CONCLUSIONS

Energy delivery devices showed similar efficacy and safety in sealing of SV side branches. Although bursting pressure was lower than with tie ligature or SC, non-inferiority efficacy was shown at the range of physiological pressures in both, EB and HS. Due to their speed and easy handling, they may be useful in the preparation of the venous graft during revascularization surgery. However, remaining questions about healing process, potential spread of tissue damage and sealing durability, will require further analysis.

LigaSure technique for splenectomy: A systematic review and meta-analysis

BACKGROUND

This study aimed to clarify the optimal management of the LigaSure technique and conventional techniques during splenectomy.

METHODS

All databases, including CBM, CNKI, WFPD, Medline, EMBASE, PubMed, and Cochrane databases up to April 2023, were searched for relevant studies comparing the LigaSure technique with conventional techniques. Six studies, extracted by 2 independent reviewers, were evaluated for blood loss, operative time, conversion, mortality, hospital stay, and transfusion.

RESULTS

The blood loss was significantly higher in the convention group than in the LigaSure group (WMD = -48.98, 95% CI: -62.41 to -35.55, P < .00001). Meanwhile, the mean operative time was significantly shorter in LigaSure group than in convention group (WMD = -10.57; 95% CI: -12.35 to -8.78), P < .00001). No significant differences were found regarding the conversion rate, hospital stay, morbidity, and transfusion.

CONCLUSIONS

The LigaSure technique has comparable effects to conventional techniques, but to some extent reduces blood loss and operative time.

A new bipolar device for sealing and cutting: ex and in vivo studies for performance evaluation

INTRODUCTION

A novel multipurpose bipolar radiofrequency instrument, the Erbe Dissector (EDS), which simultaneously seals and cuts tissue, was developed. Ex vivo sealing rate and time, burst pressure, jaw temperature and thermal spread were studied in porcine renal arteries.

MATERIAL AND METHODS

In vivo, 13 surgical tasks were performed in two pigs: beside sealing rate and time, overall performance in sharp and blunt dissection, tissue sticking, hemostasis, precision, etc., were evaluated by four surgeons compared with ENSEAL G2 (EG2) using surveys on a Likert scale (1 = very poor; 5 = very good).

RESULTS

Ex vivo, the EDS sealing rate was 91.7% (33/36 arteries) at an average sealing time of 2.1 s (range 1.7-2.8) and a burst pressure of 1040 ± 350 mmHg. The maximum jaw temperature was 87 ± 4 °C and the mean lateral thermal spread was 0.8 ± 0.2 mm. In vivo, the sealing rate for arteries and veins was 92.6% (50/54) and the median seal and cut time was 1.6 s (range: 1.3-2.9). The average EDS performance score across all tasks was 4.4 ± 0.6 Likert points. For five shared tasks, EDS was better than EG2 (4.4 ± 0.5 versus 3.4 ± 0.6 Likert points; p = 0.016).

CONCLUSIONS

EDS seals and cuts arteries and veins rapidly with good safety and user-friendliness.

Evaluation of the performance of an endoscopic 3-mm electrothermal bipolar vessel sealing device intended for single use after multiple use-and-resterilization cycles

OBJECTIVE

To evaluate the performance of an endoscopic 3-mm electrothermal bipolar vessel sealing device (EBVS) intended for single use after multiple use-and-resterilization cycles.

STUDY DESIGN

Ex vivo study.

SAMPLE POPULATION

Eight 3-mm EBVS handpieces.

METHODS

Handpieces were subjected to a maximum of 15 cycles of testing, including simulated surgery, sealing and burst pressure testing of porcine carotid arteries, reprocessing, and hydrogen peroxide plasma resterilization. Failure was defined as two sequential vascular seal leakage events occurring at <250 mm Hg. Histological evaluation, maximum external temperature of the jaws, sealing time, tissue adherence, jaw surface characterization, and mechanical deterioration were studied. Failure rate was analyzed by using a Kaplan-Meier curve. Linear and ordinal logistic mixed models were used to analyze sealing time, handpiece jaw temperature, and adherence score.

RESULTS

Mean ± SD diameter of arteries was 3.22 ± 0.35 mm. Failure was observed starting at cycle 10 and going up to cycle 13 in 37.5% (3/8) of the handpieces. Tissue adherence increased after each cycle (P < .001). Maximum external temperature (79.8°C ± 13.9°C) and sealing time (1.8 ± 0.5 seconds) were not significantly different throughout cycles up to failure. A flatter surface and large scratches were observed microscopically throughout the jaw surface after repeated use and resterilization.

CONCLUSION

The 3-mm EBVS handpiece evaluated in this study can be considered safe to use for up to nine reuse-and-resterilization cycles.

CLINICAL SIGNIFICANCE

These data provide the basis for establishing preliminary guidelines for the reuse and hydrogen peroxide plasma resterilization of an endoscopic 3-mm EBVS handpiece.

Safety and effectiveness of a novel generator algorithm for bipolar vessel sealing: a randomised controlled chronic animal study

BACKGROUND

Electrosurgical vessel sealers are gradually replacing conventional techniques such as ligation and clipping. Algorithms that control electrosurgical units (ESU), known as modes, are important for applications in different surgical disciplines. This chronic porcine animal study aimed to evaluate the safety and effectiveness of the novel thermoSEAL electrosurgical vessel sealing mode (TSM). The BiClamp® mode (BCM) of the renowned VIO® 300 D ESU served as control. BCM has been widely available since 2002 and has since been successfully used in many surgical disciplines. The TSM, for the novel VIO® 3 ESU, was developed to reduce sealing time and/or thermal lateral spread adjacent to the seal while maintaining clinical success rates. The primary aim of this study was to investigate the long-term and intraoperative seal quality of TSM.

METHODS

The BiCision® device was used for vessel sealing with TSM and BCM in ten German Landrace pigs which underwent splenectomy and unilateral nephrectomy during the first intervention of the study. The seals were cut with the BiCision® knife. Ninety-nine arteries, veins and vascular bundles were chronically sealed for 5 or 21 days. Thereafter, during the second and terminal intervention of the study, 97 additional arteries and veins were sealed. The carotid arteries were used for histological evaluation of thermal spread.

RESULTS

After each survival period, no long-term complications occurred with either mode. The intraoperative seal failure rates, i.e. vessel leaking or residual blood flow after the first sealing activation, were 2% with TSM versus 6% with BCM (p = 0.28). The sealing time was significantly shorter with TSM (3.5 ± 0.69 s vs. 7.3 ± 1.3 s, p < 0.0001). The thermal spread and burst pressure of arteries sealed with both modes were similar (p = 0.18 and p = 0.61) and corresponded to the histological evaluation. The measured tissue sticking parameter was rare with both modes (p = 0.33). Tissue charring did not occur. Regarding the cut quality, 97% of the seals were severed in the first and 3% in the second attempt (both with TSM and BCM).

CONCLUSIONS

The novel TSM seals blood vessels twice as fast as the BCM while maintaining excellent tissue effect and clinical success rates.

TRIAL REGISTRATION

Not applicable.

Performance and microbiological safety testing after multiple use cycles and hydrogen peroxide sterilization of a 5-mm vessel-sealing device

OBJECTIVE

To evaluate the functional and microbiological safety of a single-use laparoscopic vessel-sealing device in a multiuse setting.

STUDY DESIGN

Ex vivo study.

SAMPLE POPULATION

Twelve 5-mm LigaSure Maryland jaw devices.

METHODS

Handsets underwent repeated test cycles until failure. The handset packaging was opened, and handsets were agitated in phosphate-buffered saline (PBS). The PBS was removed, centrifuged, and submitted for culture. Canine ovariectomy was simulated on cadaveric tissue, after which vascular seal quality was evaluated by pressure testing of sealed porcine carotid arteries. The handsets were cleaned and sterilized with hydrogen peroxide gas and repackaged.

RESULTS

Mean ± SD cycles to failure was 7.7 ± 2.8, with a minimum of 4 and a maximum of 12 use cycles achieved. Eleven of the 12 handsets failed by failure of handset activation after depression of the activation trigger. Only 1 handset failed to hold an adequate vascular seal under 300 mm Hg of pressure. No handset exhibited positive bacterial culture at any cycle.

CONCLUSION

The sterilization method used in this study resulted in an excellent microbiological safety profile. Most of the handsets failed by activation button failure.

CLINICAL SIGNIFICANCE

Under the conditions of this study, hydrogen peroxide sterilization achieved microbiological safety. Handsets can successfully be reused until activation button failure without negative effects on the vascular seal or increased risk of infection to the patient.

Bipolar vessel-sealing devices in laparoscopic hysterectomies: a multicenter randomized controlled clinical trial

OBJECTIVE

To compare operating time and blood loss in patients undergoing total laparoscopic hysterectomies (TLH) for benign conditions with either the Marseal™ IQ 5 mm (MS) or the Ligasure™ 5 mm (LS) vessel-sealing device.

DESIGN AND SETTING

A randomized controlled clinical trial (RCT) in two German gynecology departments.

PATIENTS

74 patients scheduled to undergo TLH for a symptomatic fibroid uterus, adenomyosis or severe meno-metrorrhagia.

INTERVENTIONS

Patients were randomized to receive a TLH with either the MS or the LS device. 27 variables were prospectively collected to address potential confounding issues.

MEASUREMENT AND MAIN RESULTS

Operating time, defined as the time period between the first (round ligament dissection) and the last (uterine vessels sealing) use of the device, estimated and calculated intraoperative blood loss. The mean operating time (95% confidence interval, CI) was 22.7 min (95% CI 17.6-27.7) for LS and 26.4 min (95% CI 20-32.8) for the MS device (p = .89). The estimated intraoperative blood loss was 164 ml (95% CI 110-217) for LS and 160 ml (95% CI 116-203) for the MS device (p = .36). The multivariate analyses accounting for BMI, endometriosis, uterine weight and appearance of fibroids did not reveal any significant effect of the type of device used on operating time and estimated blood loss.

CONCLUSION

In this RCT, both devices provided reliable and effective sealing and dissection. The reusable MS showed non-inferiority against the disposable LS device with regard to operating time and estimated intraoperative blood loss.

Randomized clinical trial of ligasure™ versus conventional splenectomy for injured spleen in blunt abdominal trauma

BACKGROUND

Spleen is the most common organ damaged in cases of blunt abdominal trauma and splenectomy and splenorrhaphy are the main surgical procedures that are used in surgical treatment of such cases. In routine open splenectomy cases, after laparotomy, application of sutures in splenic vasculature is the most widely used procedure to cease the bleeding. This clinical trial evaluates the role and benefits of the Ligasure™ system in traumatic splenectomy without using any suture materials and compares the result with conventional method of splenectomy.

METHODS

After making decision for splenectomy secondary to a blunt abdominal trauma, patients in control group (39) underwent splenectomy using conventional method with silk suture ligation of splenic vasculature. In the interventional group (41) a Ligasure™ vascular sealing system was used for ligating of the splenic vein and artery. The results of operation time, volume of intra-operation bleeding and post-operative complications were compared in both groups.

RESULTS

The mean operation times in control and interventional group were 21 and 12 min respectively (p < 0.05). The average volume of bleeding in control group during open splenectomy was 280 cc, but in the interventional group decreased significantly to 80 ml (p < 0.05) using the Ligasure system. Post-operative complications such as bleeding were non-existent in both groups.

CONCLUSION

The application of Ligasure™ in blunt abdominal trauma for splenectomy not only can decrease the operation time but also can decrease the volume of bleeding during operation without any additional increase in post-operative complications. This method is recommendable in traumatic splenic injuries that require splenectomy in order to control the bleeding as opposed to use of traditional silk sutures.

A new era of Asian urology: a SWOT analysis

Economic prosperity and increasing connectivity have made Asia an emerging centre of growth in health care, including in the field of urology. Large and varied patient populations, the availability of a trained workforce, the use of English as a common communication language, and overall low costs have contributed to this change. Rapid growth of regional urological associations and journals has fuelled the aspirations and abilities of Asian urologists to not only keep abreast of but often lead the change in urological disease management. Asian urology has immense potential to expand in areas in which it currently lags behind, the most important being research. The increasing ability to travel aids in developing networks for collaboration. However, Asian urologists will need to look at sustainable models of engagement and temper the need for short-term results if these opportunities are to reach their maximal potential.

Variation in electrosurgical vessel seal quality along the length of a porcine carotid artery

Electrosurgical vessel sealing has been demonstrated to have benefits for both patients and practitioners, but significant variation in the strength of the seal continues to be a concern. This study aims to examine the variation in electrosurgical seal quality along the length of a porcine common carotid artery and explore the relationships between seal quality, vessel size and morphology. Additionally, the study aimed to investigate the minimum safety threshold for successful seals and the influence of vessel characteristics on meeting this requirement. A total of 35 porcine carotid arteries were sealed using the PlasmaKinetic Open Seal device (Gyrus). Each seal was burst pressure tested and a sample taken for staining with elastin van Gieson's stain, with morphological quantification using image processing software ImageJ. With increasing distance from the bifurcation, there was an increase in seal strength and a reduction in both elastin content and vessel outer diameter. A significant correlation was found between burst pressure with both outer diameter (p < 0.0001) and elastin content (p = 0.001). When considering the safe limits of operation, vessels of less than 5 mm in outer diameter were shown to consistently produce a seal of a sufficient strength (burst pressure > 360 mmHg) irrespective of vessel morphology.

Novel concave-convex electrode for colonic anastomoses by radiofrequency thermo-fusion

BACKGROUND

Successful vascular sealing by radiofrequency (RF)-induced tissue fusion is well established. The present study reports on a novel electrode structure design together with its experimental assessment for RF thermo-fusion of porcine colonic segments.

MATERIALS AND METHODS

Two types of electrode were constructed and used in the present study: one with a conventional smooth surface (S) and the other with a novel reciprocating concave-convex (CC) configuration. Finite element modeling was used to study the thermal distribution profile of the CC electrode. Ex vivo porcine colonic segments were used to create end-to-end serosa-to-serosa colonic anastomoses by applying a pulse of 160 W RF power for 20 s. Different compression pressures (S1, S2, S3) and (C1, C2, C3, C4, C5), were applied, via specially designed ring carriers, to the S and CC electrodes, respectively. Assessment was based on anastomotic burst pressures and histological appearances using light microscopy of paraffin sections.

RESULTS

In total, 22 RF-induced circular anastomoses were performed. Similar burst pressures were observed for anastomoses created by the two types of electrodes (S, CC) performed under the same compression pressure. In contrast, significant differences were observed on histological examination of tissue anastomotic site. In particular, fusion areas between gaps of the CC electrode showed normal histological appearance, while the S electrode produced a completely flat featureless appearance. Furthermore, the CC electrode produced significantly different burst pressures depending on the applied compression pressure during thermo-fusion: compression pressures C1 vs. C4 produced circular anastomotic fusions with burst pressures of 21.9 ± 9.3 vs. 44.6 ± 8.9 mmHg, (p = 0.034); but the burst pressure beyond C4, declined significantly, with C4 vs. C5, burst pressures of 44.6 ± 8.9 vs. 24.7 ± 8.0 mmHg, (p = 0.034).

CONCLUSIONS

The CC electrode exhibits larger and faster thermal diffusion profiles resulting in normal histological appearances in the gaps between CC electrode by protecting tissue from mechanical and thermal damage.

Comparative studies of energy sources in gynecologic laparoscopy

Energy sources incorporating "vessel sealing" capabilities are being increasingly used in gynecologic laparoscopic surgery although conventional monopolar and bipolar electrosurgery remain popular. The preference for one device over another is based on a combination of factors, including the surgeon's subjective experience, availability, and cost. Although comparative clinical studies and meta-analyses of laparoscopic energy sources have reported small but statistically significant differences in volumes of blood loss, the clinical significance of such small volumes is questionable. The overall usefulness of the various energy sources available will depend on a number of factors including vessel burst pressure and seal time, lateral thermal spread, and smoke production. Animal studies and laboratory-based trials are useful in providing a controlled environment to investigate such parameters. At present, there is insufficient evidence to support the use of one energy source over another.

Common uses and cited complications of energy in surgery

BACKGROUND

Instruments that apply energy to cut, coagulate, and dissect tissue with minimal bleeding facilitate surgery. The improper use of energy devices may increase patient morbidity and mortality. The current article reviews various energy sources in terms of their common uses and safe practices.

METHODS

For the purpose of this review, a general search was conducted through NCBI, SpringerLink, and Google. Articles describing laparoscopic or minimally invasive surgeries using single or multiple energy sources are considered, as are articles comparing various commercial energy devices in laboratory settings. Keywords, such as laparoscopy, energy, laser, electrosurgery, monopolar, bipolar, harmonic, ultrasonic, cryosurgery, argon beam, laser, complications, and death were used in the search.

RESULTS

A review of the literature shows that the performance of the energy devices depends upon the type of procedure. There is no consensus as to which device is optimal for a given procedure. The technical skill level of the surgeon and the knowledge about the devices are both important factors in deciding safe outcomes.

CONCLUSIONS

As new energy devices enter the market increases, surgeons should be aware of their indicated use in laparoscopic, endoscopic, and open surgery.

Principles and safety measures of electrosurgery in laparoscopy

This report stresses that a thorough knowledge of electrosurgical fundamentals by the entire operative team is essential for patient safety and recognizing potential complications.

Background:

Electrosurgical units are the most common type of electrical equipment in the operating room. A basic understanding of electricity is needed to safely apply electrosurgical technology for patient care.

Methods:

We reviewed the literature concerning the essential biophysics, the incidence of electrosurgical injuries, and the possible mechanisms for injury. Various safety guidelines pertaining to avoidance of injuries were also reviewed.

Results:

Electrothermal injury may result from direct application, insulation failure, direct coupling, capacitive coupling, and so forth.

Conclusion:

A thorough knowledge of the fundamentals of electrosurgery by the entire team in the operating room is essential for patient safety and for recognizing potential complications. Newer hemostatic technologies can be used to decrease the incidence of complications.

BiClamp(®) forceps was significantly superior to conventional suture ligation in radical abdominal hysterectomy: a retrospective cohort study in 391 cases

OBJECTIVE

To evaluate the efficacy and security of ERBE BiClamp(®) forceps in radical abdominal hysterectomy for managing those cervical cancers, extending to other gynecologic cancers such as endometrial cancer and ovarian cancer as well.

METHODS

A retrospective cohort study was made in 391 cases from 450 FIGO IA2-IIB cervical cancers between November 2005 and September 2010. After baseline character analysis, the conventional group (n = 195) was compared with the BiClamp group (n = 196) on the basis of surgical outcome and complications. Data analysis was based on intention to treat with statistics software SPSS17.0.

RESULTS

Comparison between conventional suture ligation and BiClamp(®) forceps is as follows: the operation time was 247.7 ± 47.7 min for the conventional suture ligation versus 224.1 ± 36.2 min (P < 0.001) for BiClamp(®) forceps, estimated blood loss was 769.2 ± 310.4 ml versus 534.8 ± 232.5 ml (P < 0.001), gauze consumption was 35.3 ± 10.6 sheets versus 28.2 ± 7.4 sheets (P < 0.001), intra-operative blood transfusion rate was 75.9 versus 28.1% (P < 0.001), hemoglobin decline was 29.2 ± 10.1 g/L versus 26.5 ± 9.2 g/L (P = 0.085), postoperative blood transfusion rate was 17.0 versus 15.6% (P = 0.818), closed suction drainage was 268.8 ± 162.0 ml versus 208.3 ± 141.7 ml (P < 0.001), hospital stay was 8.8 ± 2.5 days versus 7.1 ± 2.2 days (P < 0.001), postoperative complications was 23.6 versus 14.8% (P = 0.027).

CONCLUSION

With obvious decrease of operation time, blood loss, postoperative complications, hospital stay and particularly, intra-operative blood transfusion rate, BiClamp(®) forceps has been proved more efficient and controllable in radical abdominal hysterectomies of cervical cancers than conventional suture ligations, extending to endometrial cancers and ovarian cancers, hence deserves to be popularized.

The nightknife©: evaluation of efficiency and quality of bipolar vessel sealing

BACKGROUND

Nightknife(©) is a novel reusable bipolar vessel sealing device. In the present study we analyzed its efficiency and quality of vessel sealing in comparison to a standard instrument (LigaSure™).

MATERIALS AND METHODS

Mesenteric veins and arteries of 5 Swabian-Hall pigs were sealed by means of Nightknife and LigaSure. Thermal performance of both devices was assessed by dynamic thermography. Analysis of the sealed vessels included the determination of seal failure rates and heat-associated macroscopic tissue appearance.

RESULTS

The overall sealing rate of Nightknife was significantly higher than that of LigaSure (95.8% versus 87.0%; P=.012). This was associated with a more pronounced thermal spread (8.22±0.13 versus 7.12±0.10 mm; P=.012) and tissue desiccation (2.15±0.06 versus 1.86±0.07; P=.003). Moreover, sealing time (12.30±0.17 versus 7.72±0.17 seconds; P=.038) and tissue temperature (93.73°C±0.69°C versus 66.71°C±2.18°C; P=.001) were significantly higher with the use of Nightknife. Logistic regression analysis revealed that the degree of tissue desiccation correlated with the overall sealing success.

CONCLUSION

Nightknife is as appropriate as LigaSure for the successful sealing of mesenteric vessels despite significant differences in tissue alterations and sealing time between the two devices.

Thyroidectomy with LigaSure

PURPOSE

A new method for ensuring hemostasis during thyroid surgery has recently been introduced. This technique, electrothermal (LigaSure) and ultrasound blood vessel sealing, is still experimental. The aim of the present study was to evaluate the applications and efficacy of LigaSure by analyzing the duration of the surgery and the rate of complications of the surgical procedure.

METHODS

A total of 23 patients who underwent the LigaSure operation (n(LS) group) were analyzed in a prospective nonrandomized/partly randomized clinical study, and were compared with patients who underwent treatment using the conventional (ligature) surgical technique.

RESULTS

At our institutions, 187 patients were treated surgically for thyroid disease in 2006, and 23 of these patients were treated using LigaSure. The complication rate in the patients treated with LigaSure (n(LS): 4.3%) was lower than those who received conventional ligature surgery. However, given the small number of patients, this difference was not statistically significant (retrospective group n(1): 10.7%; nonrandomized group n(2): 9.8%; and randomized group n(3): 9.1%). The length of surgery in the LigaSure group (n(LS) = 65 ± 3 min) was significantly shorter (P < 0.001) compared with both nonrandomized (n(2) = 71 ± 6 min) and randomized (n(3) = 70 ± 4 min) patients who received a conventional ligature.

CONCLUSIONS

The application of LigaSure using meticulous surgical technique provides a new option for a safe thyroidectomy. Moreover, the duration of the LigaSure procedure is significantly shorter, and there are fewer complications as compared with the classic surgical thyroidectomy technique.

Collagen-elastin ratio predicts burst pressure of arterial seals created using a bipolar vessel sealing device in a porcine model

BACKGROUND

Bipolar electrosurgical devices are used to generate rapid and efficient hemostasis in a wide range of surgical procedures. Of the factors that influence seal integrity, vessel (artery) diameter has been considered the most important variable. In this study we hypothesized that the relative ratio of the components that form the seal (collagen and elastin) determine the degree of vessel distensibility and play an equally important role in defining seal strength.

METHODS

Porcine carotid, renal, iliac, and femoral arteries were sealed using a bipolar electrosurgical device in vivo. Following removal, arterial diameter was measured and vessels' seals tested for arterial burst pressure (ABPr). Samples were then analyzed histologically and biochemically for collagen and elastin content.

RESULTS

Arteries with the highest collagen-elastin ratio (C/E) (renal) consistently demonstrated significantly higher burst pressures than those arteries with lower C/E ratios (iliac and femoral) independent of artery diameter.

CONCLUSION

Using arteries of distinct anatomical origin and physiological function, we demonstrate that total collagen content, and more specifically C/E ratio, in porcine arteries is a more accurate predictor of ABPr than vessel size alone.

Efficacy and safety of 5-mm-diameter bipolar and ultrasonic shears for cutting carotid arteries of the hybrid pig

BACKGROUND

Experimental data about the efficacy and safety of sealing devices are rare. Therefore, this study investigated these parameters for three commercially available energy-based vascular sealing and cutting systems.

METHODS

In male hybrid pigs, 487 carotid artery segments were sealed and cut using the harmonic scalpel or several bipolar sealing devices. The sealing failure rate, burst pressure, process time, and extent of lateral thermal damage were analyzed.

RESULTS

A regular sealing and cutting process in more than 90% of the carotid arteries was found using the following instruments: LS1520, ACE (level 1), ACE (level 3), CS14C (level 1), WAVE (level 1), and WAVE (level 5). The largest failure rate was found for the CS14C device (level 5: initial sealing failure, 21.5%). The maximal mean burst pressure (1727±453 mmHg) was reached using the ACE device (level 1). Significant differences were found in the size of the lateral thermal damage, which a ranged from 2.5 mm (LS1520) to 1.51 mm (CS14C, level 1). The process time ranged widely from 6.8 s (ACE, level 5) to 31.83 s (WAVE, level 1).

CONCLUSION

The current study demonstrated that all the tested devices are efficacious and safe in sealing and cutting arteries up to 5 mm in diameter. All the devices showed supraphysiologic mean burst pressures. Differences in failure rate, thermal damage, and process time lead to an advised application of the different systems.

A randomized comparison of a new flexible bipolar hemostasis forceps designed principally for NOTES versus a conventional surgical laparoscopic bipolar forceps for intra-abdominal vessel sealing in a porcine model

BACKGROUND

Current devices for hemostasis in flexible endoscopy are inferior to methods used during open or laparoscopic surgery and might be ineffective for natural orifice transluminal endoscopic surgery.

OBJECTIVE

To compare new flexible bipolar forceps (FBF), designed principally for natural orifice transluminal endoscopic surgery, with laparoscopic bipolar forceps (LBF) for hemostasis of intra-abdominal porcine arteries.

SETTING

Surgical laboratories in Europe and the United States.

DESIGN AND INTERVENTIONS

New FBF for hemostasis (3.7-mm diameter), featuring electrode isolation, were compared with rigid 5-mm LBF (ERBE BiClamp LAP forceps) at recommended settings. A porcine model of acute hemostasis was prepared by suturing the uterine horns and cecum to the abdominal wall, exposing uterine arteries, ovarian pedicles, cecal mesenteric bundles, and the inferior mesenteric artery. This allowed access to 10 vessels in each pig by transabdominal laparoscopic devices or a transgastric double-channel gastroscope. Vessels were measured, coagulated at 4 and more points, and transected. Blood pressure was increased to more than 200 mm Hg for 10 minutes by administering phenylephrine. Delayed bleeding was identified.

MAIN OUTCOME MEASUREMENTS

In 7 pigs, a total of 65 vessels (1.5-6.0 mm) were randomly allocated to FBF (n = 32) or LBF (n = 33). Successful hemostasis both before and after blood pressure increase was equivalent between the 2 groups (before: 88% FBF vs 88% LBF, not significant [NS]; after: 97% FBF vs 94% LBF, NS). With FBF, the number of seals per vessel was 4.8 vs 4.4 with LBF (NS). The energy used to create FBF seals was 19.8 J vs 38.2 J for LBF (P < .05).

LIMITATIONS

Results from porcine studies may not reflect patient outcomes.

CONCLUSIONS

In a porcine model, transgastric FBF endoscopic hemostasis was as effective as conventional laparoscopic hemostasis using LBF across a wide range of vessels.

Laparoscopic versus open splenectomy in dogs

In the last few years, the use of laparoscopy in veterinary medicine has expanded and consequently so was the need for studies that establish the advantages, disadvantages and possible complications of each procedure. The purpose of the current study was to describe a laparoscopic splenectomy technique and the alterations due to this access, and compare it to the open procedure in dogs. A total of 15 healthy female mongrel dogs were used, with mean weight of 17.4±2.5kg. The animals were distributed into three groups: Group IA of open splenectomy (laparotomy) using double ligation of the vessels of the splenic hilum with poliglicolic acid, Group IB of open splenectomy (laparotomy) with bipolar electrocoagulation of the splenic hilum, and Group II of laparoscopic access with bipolar electrocoagulation of the splenic hilum. Operative time, blood loss, size of incisions, complications during and after surgery were evaluated. Other parameters included pain scores, white blood cell (WBC) counts and postoperative serum concentrations of alanine aminotransferase (ALT), alkaline phosphatase (ALP), creatine kinase (CK), C-reactive protein (CRP), glucose and cortisol. No differences were found in the evaluation of parameters between both open splenectomy techniques employed. Laparoscopic access presented significant differences (p<0,05) when compared with open surgery: Longer operative time, smaller abdominal access, decrease in blood loss, lower concentrations of CRP, higher levels of CK and ALP, and lower scores in the pain scale. Laparoscopic surgery showed fewer complications of the surgical wound. No significant differences were observed between groups in the postoperative temperature, WBC, ALT, cortisol and glucose concentrations. In conclusion, the laparoscopic technique is useful for splenectomy in dogs, being advantageous in terms of blood loss, surgical stress and surgical wounds. However, it expends more operative time and causes transitory increase in hepatic and muscular enzymes.

Use of Hem-o-lok Clips for Vascular Control During Retroperitoneoscopic Nephrectomy in Children

Aim: To evaluate safety and efficacy of 5-mm Hem-o-lok clips in children undergoing retroperitoneoscopic nephrectomy. Material and Methods: Twenty-four retroperitoneoscopic nephrectomies were performed between September 2004 and August 2007. The indications of nephrectomy were ureteropelvic junction obstruction, reflux nephropathy, ectopic ureteral opening with renal dysplasia, and stone disease with pyonephrosis and primary obstructed megaureter with renal dysplasia. Nine cases were on right side and others on left side. Multiple 5- or 10-mm Hem-o-lok clips were used to control renal artery and vein separately in each case. The specimen was mobilized and removed either by extension of a port site incision or by a separate incision at ipsilateral iliac fossa at the lateral border of the rectus muscle. Results: Hem-o-lok clips were deployed on renal pedicle separately in each case. Two clips were deployed on the body side and one on the specimen side. On the left side lumbar, gonadal and adrenal tributaries were also clipped by 5-mm Hem-o-lok clips. No clip dislodgement was observed in any patient. Mean operative time was 111 (80 ± 47) minutes, and mean blood loss was 25 (10 ± 45) mL. Mean hospital stay was 2.4 (1.9-3.1) days. Conclusion: Five- and 10-mm Hem-o-lok clips are safe and effective for renal pedicle control during retroperitoneoscopic nephrectomy in children.

A review of currently available vessel sealing systems

Laparoscopic surgery is rapidly expanding among urologists as a minimally invasive treatment with surgical procedures becoming increasingly challenging. Accurate haemostatis is of utmost importance in laparoscopy, as bleeding can rapidly impair the working environment conditions. We subsequently reviewed the different haemostatic tools used in laparoscopy with the focus on ultrasonic dissectors and electrothermal bipolar vessel sealer (EBVS). Briefly, there is a wide variety of haemostatic tools currently available in laparoscopy, all with their inherent advantages and limitations. The comparison of ultrasonic dissectors and EBVS shows that both systems are very attractive with similar physical properties concerning thermal spread and bursting pressure of vessels sealed. It has to be noted, however, that EBVS can handle vessels of up to 7 mm. In conclusion, haemostatic tools constitute a rapidly evolving domain with devices being developed which cause less thermal spread, while being more precise and faster. This evolution should finally allow more complex laparoscopic surgical procedures.

The evolutionary state of electrosurgery: where are we now?

PURPOSE OF REVIEW

The purpose of this review is to discuss the evolutionary changes that have taken place in the area of electrosurgery. The distinct differences between devices along with disadvantages and ways of minimizing hazards will be analyzed.

RECENT FINDINGS

Since the first surgical application of electricity in the 1880s, the use of radiofrequency current in surgery has grown. Although monopolar and bipolar energy form the backbone of electrosurgery, various modifications have been made to both the electrosurgical generators and the hand instruments. Much of the driving force behind these modifications has been the goal of minimizing possible complications while improving surgical efficiency. Recently, the ability to obtain vessel sealing has dramatically impacted clinical practice in open, laparoscopic, and vaginal surgery.

SUMMARY

Current evidence demonstrates the effectiveness and safety of electrosurgical devices in gynecologic surgery. Technology has evolved to allow vessel sealing capability through various instruments. Critical to the successful use of these advanced electrosurgical devices is a thorough understanding of their individual differences and nuances in order to obtain the desired tissue effects. Further studies are needed to determine the most appropriate applications and surgical procedures for these devices.

Prospective randomized study of monopolar scissors, bipolar vessel sealer and ultrasonic shears in laparoscopic colorectal surgery

Background

Many instruments are used for laparoscopic dissection, including monopolar electrosurgery scissors (MES), electrothermal bipolar vessel sealers (BVS) and ultrasonically coagulating shears (UCS). These three devices were compared with regard to dissection time, blood loss, safety and costs.

Methods

Sixty-one consecutive patients undergoing laparoscopic left-sided colectomy were randomized to MES, BVS or UCS. The primary endpoint was dissection time.

Results

Patient and operation characteristics did not differ between the groups. Median dissection time was significantly shorter with BVS (105 min) and UCS (90 min) than with MES (137 min) (P &lt; 0·001). With BVS and UCS, significantly fewer additional clips were required (MES 9 versus BVS 0 versus UCS 3; P &lt; 0·001) and there was a trend towards lower blood loss (125 versus 50 versus 50 ml respectively; P = 0·223) and a reduced volume of suction fluid (425 versus 80 versus 110 ml; P = 0·058). Overall satisfaction was similar for the three instruments. Dissection with BVS and UCS was significantly cheaper than with MES, assuming a centre volume of 200 cases per year (P = 0·009).

Conclusion

BVS and UCS shorten dissection time in laparoscopic left-sided colectomy and are cost-effective compared with MES. Registration number: NCT00517608 (http://www.clinicaltrials.com).

Comparison of four energy-based vascular sealing and cutting instruments: A porcine model

AIM

To compare the safety and efficacy of four energy-based vascular sealing and cutting instruments.

METHODS

Blood vessels of various types and diameters were harvested from four pigs using four instruments: Harmonic ACE (Ethicon Endo-Surgery, Cincinnati, OH), LigaSure V and LigaSure Atlas (Valleylab, Inc., Boulder, CO; a division of Tyco Healthcare), and EnSeal vessel fusion system (SurgRx, Inc. Redwood City, CA). The diameters of the vessels, speed and adequacy of the cutting and sealing process, and bursting pressures were compared. An additional set of specimens was sealed and left in situ for up to 4 h after which the vessels were harvested and histopathologically analyzed for the degree of thermal injury.

RESULTS

The bursting pressures were significantly higher with EnSeal compared to all other instruments (p < 0.0001). The sealing process was significantly shorter with Harmonic ACE and significantly longer with LigaSure Atlas (p <0.0001). The mean seal width was larger with the LigaSure Atlas compared to the other instruments, and it was smaller with EnSeal and Harmonic ACE. Less radial adventitial collagen denaturation was present with EnSeal and LigaSure V than with the other two instruments; there were no significant differences in collagen denaturation although proximal thermal injury to the smooth muscle in the media of the vessel wall was less common with LigaSure Atlas than with the other instruments; however, the numbers were too small for statistical analysis.

CONCLUSIONS

The bursting pressures with EnSeal were significantly higher than with all the other instruments. Harmonic ACE was the fastest sealing instrument and LigaSure Atlas was slowest. EnSeal created less radial thermal damage to the adventitial collagen of the vessels and LigaSure Atlas created less thermal damage to the media of the vessels. The clinical significance of these findings is unknown.

[Vaginal hysterectomy using electrofusion: a study of 96 cases]

OBJECTIVE

To compare ligature by electrofusion versus sutures in the practice of vaginal hysterectomy.

STUDY DESIGN

This is a retrospective study on 96 patients completed over a period of 47 months. Patients were allocated into two groups: the electrofusion "suture-free" group (n=54) and the "suture" control group (n=42). Designed-end points were operating time, postoperative pain, duration of postoperative hospitalization and perioperative complications.

RESULTS

In the electrofusion group, the operating time was significantly reduced (51.3+/-22.6 min versus 67.6+/-20.1 min) as well as the reported postoperative pain (based on the visual analog scale - VAS) (1.9+/-2.0 versus 3.5+/-2.3). The average morphine consumption rate and the timing of postoperative morphine administration were lower in the electrofusion group (22.4+/-31.0mg versus 45.4+/-51.3 mg and 22.4+/-13.4 h versus 29.4+/-18.8 h, respectively). Moreover, in the electrofusion group there was less need for additional analgesics (1.9+/-2.0 versus 3.5+/-2.3) and the hospital-stay was shorter (4.2+/-1.3 days versus 5.0+/-1.0 days). There was no significant difference between the two groups in regard to perioperative complications.

CONCLUSION

The use of electrofusion in vaginal hysterectomy appears to be a reliable ligation technique which reduces significantly the operating time, the postoperative pain and the length of postoperative hospitalization.

“Current thoughts” in electrosurgery

The ongoing desire to improve hemostasis and efficiency during surgery is manifested in the rapid development of electrosurgical technology. These changes have brought about a wide variety of devices available to the practicing surgeon during both open and endoscopic cases. Depending on the instrument chosen, various clinical effects ranging from simple coagulation to the sealing of large vascular bundles are obtained. However potential pitfalls or complications also exist. A thorough understanding of the pros and cons of these technological advancements can improve the operative experience for both surgeon and patient.