Advances and safe use of energy devices in lung cancer surgery

Examination of resistance of various methods of pulmonary vessel occlusion to hydrostatic pressure

Objective

The aim of this study was to compare pressure resistance of the most common methods of vessel occlusion during thoracic surgical procedures: ligations, clips, and vascular endostaplers.

Methods

Pulmonary vessels were obtained during routine thoracic surgeries. A ball-tipped cannula was inserted through an opening in the side wall and secured with a linen ligature from slipping out. Subsequently, saline was infused into the vessel. We recorded the pressure on which a leakage occurred.

Results

A total of 65 vessels, divided between 3 groups, were enrolled in the study. In the endostaplers group, median bursting pressures were 262.5 mmHg and 300 mmHg for arteries and veins, respectively. In the case of clips, it was over 750 mmHg in both types of the vessels. The same results were observed in the ligation group. Minimal bursting pressures in endostapler occlusion were 187.5 mmHg and 225 mmHg in arteries and veins, respectively. In the case of clips, it was 600 mmHg for arteries and 675 mmHg for veins. A total of 525 mmHg (arteries) and 750 mmHg (veins) were the minimal leaking values observed in vessels occluded with ligations. Comparative analysis showed statistically significant differences in endostapler-clips and endostapler-ligations pairs (p < 0.001). There were no differences between clips and ligations.

Conclusions

The examined methods are capable of occluding pulmonary vessels under physiological conditions. Furthermore, ligations and clips are resistant to pressures highly exceeding physiological values.

Factors affecting insulation failure in reusable surgical devices

The purpose of this study was to investigate the associated factors of insulation failure (IF) in reusable endoscopic instruments. The insulation coating of reusable endoscopic instruments underwent routine visual checks, hand washing to remove visible stains, and mechanized sterilization. We recorded the cleaning number and usage period of all instruments. The instruments were tested for IF using a detector. IF was found in eight of 69 devices (11.6%). Examining by clinical specialty, we found IF in 4 of 28 gastrointestinal (14.3%), 3 of 20 gynecological (15.0%), 1 of 12 urological (8.3%), and none of the nine thoracic devices. The median distance from the tip to the damaged part was 5 cm (3-5 cm). In the IF and the intact groups, the period of use [7 years (6-8) versus 7 years (4-8), P = 0.90] and the number of cleanings [281 (261-323) versus 261 (179-320), P = 0.27] were not significantly different. The IF group included products of three different companies; however, six of the eight (75.0%) were from the same company. Cleaning methods and usage period have a lower impact on IF. The use of reusable forceps as a monopolar device was found to pose a higher risk, requiring regular assessments.

Identification of Factors Related to the Quality of Lymphadenectomy for Lung Cancer: Secondary Analysis of Prospective Randomized Trial Data

The outcomes of non-small cell lung cancer surgery are influenced by the quality of lymphadenectomy. This study aimed to evaluate the impact of different energy devices on lymphadenectomy quality and identify additional influencing factors. This secondary analysis of the prospective randomized trial data (clinicaltrials.gov: NCT03125798) compared patients who underwent thoracoscopic lobectomy with the LigaSure device (study group, n = 96) and monopolar device (control group, n = 94). The primary endpoint was the lobe-specific mediastinal lymphadenectomy. Lobe-specific mediastinal lymphadenectomy criteria were met in 60.4% and 38.3% of patients in the study and control groups, respectively (p = 0.002). In addition, in the study group, the median number of mediastinal lymph node stations removed was higher (4 vs. 3, p = 0.017), and complete resection was more often achieved (91.7% vs. 80.9%, p = 0.030). Logistic regression analysis indicated that lymphadenectomy quality was positively associated with the use of the LigaSure device (OR, 2.729; 95% CI, 1.446 to 5.152; p = 0.002) and female sex (OR, 2.012; 95% CI, 1.058 to 3.829; p = 0.033), but negatively associated with a higher Charlson Comorbidity Index (OR, 0.781; 95% CI, 0.620 to 0.986; p = 0.037), left lower lobectomy (OR, 0.263; 95% CI, 0.096 to 0.726; p = 0.010) and middle lobectomy (OR, 0.136; 95% CI, 0.031 to 0.606, p = 0.009). This study found that using the LigaSure device can improve the quality of lymphadenectomy in lung cancer patients and also identified other factors that affect the quality of lymphadenectomy. These findings contribute to improving lung cancer surgical treatment outcomes and provide valuable insights for clinical practice.

Experiences of novel cotton device for uniportal video-assisted thoracoscopic surgery: CS Two-Way HandleTM

In Japan, cotton is commonly used in thoracic surgery for the gentle handling of organs as well as obtaining a good surgical field. While uniportal video-assisted thoracoscopic surgery is being recognized as a major surgical approach, use of cotton is not noted in this technique. Uniportal video-assisted thoracoscopic surgery needs curved instruments because they are effective in preventing the interference of instruments. Thus, we developed a novel curved cotton instrument, known as the "CS Two-Way HandleTM", for uniportal video-assisted thoracoscopic surgery. The CS Two-Way HandleTM can be used not only as a cotton bar but also as a suction aid. Moreover, surgical smoke can be suctioned with the insertion of cotton. This instrument was introduced in our institution in September 2019, along with some other prototypes. When anatomical lung resection using uniportal video-assisted thoracoscopic surgery was first introduced, there were some instances of conversion to conventional multiportal video-assisted thoracoscopic surgery. However, after the CS Two-Way HandleTM introduction, the procedure has become easy to perform and the need for conversion to conventional methods has reduced. The main uses of the CS Two-Way HandleTM are: (I) exposure of the surgical view, (II) lymph node dissection, (III) bleeding control, (IV) suction, and (V) evacuation of surgical smoke. We present our experiences using the CS Two-Way HandleTM in uniportal video-assisted thoracoscopic surgery.

Comparison of the LigaSure™ bipolar vessel sealer to monopolar electrocoagulation for thoracoscopic lobectomy and lymphadenectomy: a prospective randomized controlled trial

BACKGROUND

High-energy devices allow better vessel sealing compared with monopolar electrocautery and could improve the outcomes of surgical operations. The objective of the study was to compare tissue dissection by the LigaSure™ device with that by monopolar electrocoagulation for thoracoscopic lobectomy and lymphadenectomy.

METHODS

This pragmatic, parallel group, prospective randomized controlled trial was funded by the Medtronic External Research Program (ISR-2016-10,756) and registered at www.

CLINICALTRIALS

gov (NCT03125798). The study included patients aged 18 years or older, who had undergone thoracoscopic lobectomy with lymphadenectomy at the Department of Thoracic Surgery of Poznan University of Medical Sciences between May 3, 2018, and November 4, 2021. Using simple randomization, the patients were assigned to undergo tissue dissection with either the LigaSure device (study group) or monopolar electrocautery (control group). Participants and care givers, except operating surgeons, were blinded to group assignment. The primary outcome was postoperative chest drainage volume. Secondary outcomes were change of the esophageal temperature during subcarinal lymphadenectomy and C-reactive protein level 72 h after surgery.

RESULTS

Study outcomes were analyzed in 107 patients in each group. We found no differences between the study and control groups in terms of chest drainage volume (550 vs. 600 mL, respectively; p = 0.315), changes in esophageal temperature (- 0.1 °C vs. - 0.1 °C, respectively; p = 0.784), and C-reactive protein levels (72.8 vs. 70.8 mg/L, respectively; p = 0.503). The mean numbers of lymph nodes removed were 12.9 (SD: 3.1; 95% CI, 12.4 to 13.5) in the study group and 11.6 (SD: 3.2; 95% CI, 11.0 to 12.2) in the control group (p < 0.001).

CONCLUSIONS

The use of the LigaSure device did not allow to decrease the chest drainage volume, local thermal spread, and systemic inflammatory response. The number of lymph nodes removed was higher in patients operated with the LigaSure device, which indicated better quality of lymphadenectomy.

Adopting a portfolio of ultrasonic and advanced bipolar electrosurgery devices from a single manufacturer compared to currently used ultrasonic and advanced bipolar devices: a probabilistic budget impact analysis from a Spanish hospital perspective

AIMS

Advanced energy devices are commonly used in electrosurgery, including ultrasonic and advanced bipolar (ABP) devices. Smoke evacuation and reusable dispersive electrodes are also utilized during electrosurgery to improve staff and patient safety. This study assessed the budget impact of adopting a portfolio of Ethicon energy devices compared to devices from other manufacturers from a Spanish hospital perspective.

METHODS

The main analysis compared the Ethicon advanced energy device portfolio (ultrasonic and ABP devices) to Non-Ethicon advanced energy devices. It was assumed that 4,000 procedures using one advanced energy device each were performed annually, and the cost impact of operating room time, length of stay, and transfusions were considered. A probabilistic budget impact analysis with 10,000 iterations was conducted for generalizability to other hospitals in Spain and Europe. Secondary analysis assessed whether cost savings from the Ethicon advanced energy device portfolio could offset costs of adopting smoke evacuation and reusable dispersive electrodes (Full Ethicon energy portfolio).

RESULTS

In the main analysis, the annual budget impact of introducing the Ethicon advanced energy device portfolio was cost saving in 79.8% of probabilistic iterations (mean: -€945,214; 95% credible interval [CrI]: -€3,242,710; €1,285,942) with a mean budget impact per procedure of -€236 (95% CrI: -€811; €321). In the secondary analysis, adding smoke evacuation and reusable dispersive electrodes was still cost saving in 75.3% of iterations compared to Non-Ethicon advanced energy devices (mean: -€778,208; 95% CrI: -€3,075,086; €1,464,728) with a mean budget impact per procedure of -€97 (95% CrI: -€384; €183). Savings resulted from differences in operating room time, length of hospital stay, and volume of disposable electrodes.

CONCLUSIONS

Adopting Ethicon advanced energy devices demonstrated economic benefits compared to non-Ethicon devices. Introducing the advanced portfolio may improve surgical care quality and the full portfolio was cost saving while improving OR safety for staff and patients.