Utility of a microwave surgical instrument in sealing lymphatic vessels

Extensive Hydrocelectomy Using the Harmonic Scalpel Supersedes Classic Techniques

OBJECTIVE

To present our technique using the harmonic scalpel for scrotal, extensive hydrocelectomy in adolescents and its advantages, compared with the historical techniques. Scrotal hydrocelectomy is an old-timer procedure in-which the Lord plication, the Jaboulay and the bottleneck techniques are the standard of care, up to date. A cumbersome, unpleasant scrotal dressing is commonly used to try to mitigate postoperative edema and hematoma.1 The harmonic scalpel denaturates proteins by ultrasonic vibrations, and provides advantages over conventional electrocautery with respect to bleeding, drain volume, postoperative pain, and the return to normal activity.2-5 MATERIALS: Adolescents with a large hydrocele, and no inguinal hernia were selected for this operation. All tissue layers except the skin were divided by harmonic scalpel Focus (Eticon).

RESULTS

Between 2017 and 2023, 43 adolescents at a median age of 14.3years (range 12-18years), were operated with this technique, using the harmonic scalpel, by a single surgeon. Median operative time was 23 minutes (range 18-35 minutes). No scrotal dressing was used. One patient had a postoperative seroma that was drained spontaneously.

CONCLUSION

The described technique is simple and time-saving, with no postoperative major edema nor hematoma in this series. The only disadvantage is the higher cost of the harmonic scalpel, that may be offset by a short time of recovery. Following our experience, we no longer use other techniques for this surgery.

Video-Assisted Thyroidectomy Using a Surgical Energy Device: Initial Experience in a Japanese Single-Center Cohort

Objective

Video-assisted thyroidectomy (VAT) was approved for coverage under the Japanese public health insurance system in 2016. In our department, we introduced VAT in 2018, and we have since been performing the procedure with the assistance of surgical energy devices. We herein summarize our cases undergoing VAT, including a review of points to consider when introducing the procedure, and characteristics of the surgical energy devices.

Methods

We enrolled 24 patients (14 women and 10 men; age: 24-83 years; mean: 59.0 years) with thyroid/parathyroid tumors who underwent VAT between January 2018 and March 2021 at our department. The medical records of the patients were reviewed, and demographic data, clinical characteristics, histological type, treatment outcomes, and complications were analyzed.

Results

The surgical energy devices used were LigaSure® in the first 4 cases, Acrosurg®. Scissors S17 in the next 13 cases, and Acrosurg®. Revo S15 in the latest 7 cases. The operation time (range: 72-250 min; mean: 147 min), intraoperative blood loss (range: 5-370 mL; mean: 33 mL), indwelling time of wound drain (range: 2-6 days; mean: 3.5 days), and hospitalization period (range: 3-8 days; mean: 5.5 days) were within acceptable ranges. In this study, it is suggested that Acrosurg®. Revo S15 can shorten the indwelling time and the hospitalization period. There were no serious complications, but 1 patient developed transient vocal cord paralysis, which improved 3 months after surgery. It was suggested that the microwave energy devices, Acrosurg®. Scissors S17 and Acrosurg®. Revo S15, may be more effective with respect to sealing/hemostasis/coagulation capacity and controllability than the high-frequency electrosurgical device, LigaSure®.

Conclusion

Based on this initial experience, VAT using surgical energy devices appeared to be a safe, effective, and minimally invasive procedure for the treatment of thyroid/parathyroid tumors. Further studies confirming these early findings are needed.

Novel microwave surgical instrument for use in various lung resection situations

A novel surgical energy device with high sealing ability using microwave technology has been developed. This novel microwave surgical instrument (MSI) is capable of sealing and dissecting a vessel ≤ 5 mm in diameter. The high sealing ability of the MSI enables fine dissection of the lung parenchyma by a scissor-type blade. This device is particularly useful in situations wherein the use of an automatic suturing instrument is difficult. Here, we describe the dissection of the lung parenchyma using this device in three patients (cases 1-3). This device was used for wedge resection of a tumor located close to the pulmonary hilum, for subsegmentectomy, and for dividing incomplete interlobar fissure (cases 1-3, respectively). In all the cases, the postoperative course was uneventful. This MSI is effective for resection of the lung parenchyma, allowing fine tissue dissection and excellent tissue sealing. This technique could assist surgeons in various lung resection cases.

Early experience with a new integrated microwave surgical device, Acrosurg Revo®, for laparoscopic surgery: A case series of two patients

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Early experience with Acrosurg Revo® in laparoscopic surgery has been described.

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Acrosurg Revo® does not cause sparks or tissue scattering.

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A clean surgical field can be maintained during surgery.

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The Acrosurg Revo®︎ may be a useful energy device for laparoscopic surgery.

Introduction

Abdominal surgery uses various energy devices for vessel sealing, tissue dissection, and detachment. Currently, Acrosurg Revo® (Nikkiso Co., Ltd., Tokyo, Japan), a novel energy device using microwaves, has been developed for use in laparoscopic surgery. This report describes the early clinical experience of using this device in two cases of laparoscopic surgery.

Presentation of case

Case 1 was of a 64-year-old woman who underwent laparoscopic abdominal incisional hernia repair. Case 2 was of a 56-year-old man with a diagnosis of ascending and sigmoid colon cancer who underwent laparoscopic right hemicolectomy and sigmoid colectomy with D3 dissection. Each surgery was completed using Acrosurg Revo® and an endoscopic electrosurgical unit. The postoperative course was uneventful, and both patients were discharged from the hospital without any complications.

Discussion

With this new and novel device, vessel sealing, hemostasis, coagulation, tissue dissection, and detachment were all possible. Notably, there was no spark or mist that hindered the surgical field of view. Furthermore, because microwave coagulation did not result in tissue carbonization, there was a considerable decrease in device tip contamination.

Conclusion

The Acrosurg Revo® may be a useful energy device for laparoscopic surgery.

Vessel-Sealing Capability of Novel Microwave Sealer: Experimental Study in Animal Models

Background. Ultrasonically activated dissectors (UADs) and radiofrequency-based devices have been considered excellent surgical devices because of their reliability and flexibility. Meanwhile, microwave-based devices have demonstrated potential with their unique heating mechanism. This study aims to compare the sealing function of a newly invented forceps-like microwave sealer (MS) with that of currently available UADs. Materials and Methods. MS and 2 examples of UADs (Harmonic Focus+ [HF+] and Sonicision [SNC]) were employed to perform mesenterectomies (in vivo) and sealing sizable vessels (ex vivo). Vessel diameter, seal time, burst pressure (BP), sealing completion, and instrument sticking were recorded. The samples underwent histological investigation for thermal damage evaluation. Results. During mesenterectomies, MS required 3 seconds and 30 W to secure a complete seal. The BP achieved by the MS seal was higher than that of HF+ and SNC on arteries (851 ± 203.7 vs 682.4 ± 287.3, P < .05; vs 833.1 ± 251.2 mmHg, P = .4523, respectively) but was not statistically different on veins (324.9 ± 203.5 vs 460.1 ± 320.3 vs 508.3 ± 350.7 mmHg, P = .215). In all trials, MS caused less sticking but exhibited similar heat-induced alterations to UADs. MS's thermal spread was not statistically more extended than that of UADs on either arteries or veins. Conclusions. MS was capable of not only sealing tiny vessels but also achieving high-pressure endurance on sizable vessels. Its forceful grasping and synchronous heating process helped create solid stumps with an acceptable thermal spread.

Safety of a Novel Microwave Surgical Instrument for Lung Parenchyma Dissection During Segmentectomy

BACKGROUND

The choice between electrocautery or automatic suturing instruments for dissection of the lung parenchyma along the intersegmental plane during lung segmentectomy remains controversial. We hypothesized that a novel microwave surgical instrument (MSI) for dissecting the lung parenchyma could have excellent sealing effects. We examined the feasibility and safety of lung parenchymal dissection using a MSI during lung segmentectomy.

METHODS

This was a prospective clinical study of lung segmentectomy involving dissection of the entire intersegmental plane using a MSI. Complications related to sealing of the lung parenchyma were evaluated and perioperative outcomes were compared to those of patients who underwent lung segmentectomy using automatic suturing instruments. Propensity score-matched comparisons were used to assess the potential impact of selection bias.

RESULTS

Lung segmentectomy using a MSI was successfully performed in 30 patients. According to the propensity score matching analysis, intraoperative blood loss, length of hospital stay, and postoperative complications of the microwave group were significantly lesser (P = .019, .003, and .008, respectively) compared to those of the control group (n = 66). Prolonged air leakage was not observed. There were two cases of subcutaneous emphysema after removal of the chest tube, but no other grade 2 or higher complications were observed. No mortality occurred within 30 or 90 days postoperatively.

CONCLUSIONS

The use of a MSI for lung parenchymal dissection was associated with lower blood loss during surgical procedures, reduced air leakage after the operation, and fewer postoperative complications.

Functional Evaluation of a Novel Microwave Surgical Device in a Canine Splenectomy Model

Aim: Partial splenectomy remains a difficult procedure even with the assistance of a sealing system. Recently, a scissor-like microwave energy device (Acrosurg) that provides seamless coagulation and manual cutting has been applied in surgery. The objective of this study is to evaluate the surgical capabilities of Acrosurg in partial splenectomy. Materials and Methods: Acrosurg and Harmonic Focus (HF) were employed for partial splenectomy in dogs without prior ligation of vessels. Cutting time, cutting area, and bleeding were recorded. Lateral thermal injury (LTI), possible complications was observed immediately and after 4 weeks. Results: The manual cutting mechanism of Acrosurg required a longer cutting time compared with the automatic cutting mode of HF (301.5 [243.2-527] vs. 114.5 [106.0-135.0] sec, p < 0.01). There was no statistical difference in cutting area or bleeding cases. Acrosurg achieved complete hemostasis in all cases, whereas the HF group failed to stop bleeding in two of the eight cases. The Acrosurg group exhibited a similar LTI compared with the HF group (3.0 [2.4-3.4] vs. 2.7 [2.3-2.9] mm, p = 0.151), but the LTI of the Acrosurg group tended to shrink more after 4 weeks (1.2 [1.0-1.3] vs. 1.7 [1.3-1.9] mm, p < 0.05). Conclusions: A microwave energy device enabled a partial splenectomy without vessel ligation. The combination of manual cutting and sealing capability helps not only provide an appropriate seal time by adjusting cutting timing adaptively but also potentially stop bleeding by using a microwave heating process unlike other energy devices.

Bipolar Sealing Device Use in Pancreas Graft Preparation: A Novel Tieless Backtable Surgery Technique

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The invention of microwave surgical scissors for seamless coagulation and cutting

PURPOSE

We developed a microwave energy-based scissors device (MWCX) that is capable of performing cutting and coagulation using 2.45 GHz microwave energy. This paper aims to present the concept of the device and assess the basic functions including the hemostasis, cutting, and sealing abilities.

METHODS

Seven beagle dogs were used in our experiments. In six dogs, we measured the coagulation time (CT), lateral thermal injury (LTI), bursting pressure (BP). The dogs were then subjected to re-laparotomy 1 week later to allow us to investigate the results. In one dog, the same factors and the quantities of smoke and mist emitted were compared to those observed when using a Harmonic Focus (HF) device.

RESULTS

At 60 W, the MWCX could cut and seal small (5 s, diameter 1-2 mm) and medium-sized (10 s, 3-4 mm) vessels with complete hemostasis. The liver (length 2 cm) was cut for 30 s. Harvested vessels were sealed for 10 s (artery, 17 times; vein, six times). The mean BP was 887. 8 ± 41.5 mmHg in the medium arteries and 457.2 ± 118.0 mmHg in veins, with a mean diameter of 4.5 ± 1.3 mm. In a comparative study, the MWCX showed similar results to the HF with regard to the CT, BP and LTI, and emitted less smoke and mist.

CONCLUSION

The MWCX showed similar levels of functionality and safety to HF, as well as the advantages offered by the use of microwave energy. Microwave devices might be used in the majority of applications for which traditional energy devices are used.

Modern lymphatic dissection techniques for preventing post renal transplant lymphocele

Background and aims

Development of a lymphocele is a well-known complication following kidney transplant. Among causative factors, recipient iliac lymphatics dissection plays an important role. Electrothermal bipolar sealing devices (LigaSure^TM) have been shown to decrease lymphatic leakage in a number of instances. The aim of this study was to investigate whether the use of this device decreases post-operative lymphatic complications in kidney transplant.

Methods

48 patients admitted for renal transplant were included in the study. They were randomly assigned to either conventional ligation or LigaSure^TM during lymphatic dissection.

Results

One patient in the LigaSure^TM arm and 5 patients in the conventional ligation arm developed lymphocele (p=0.04). Lymphatic drainage volumes were 99.8±39.87 ml in the LigaSure arm and 131.46±54.2 ml in the conventional ligation arm (p=0.02).

Conclusion

Electrothermal bipolar sealing devices exhibit safety and efficiency when used in renal transplant lymphatic dissection. In the present study, this technique proved to be superior to conventional ligation in terms of post-operative lymphatic complications.

Thermal tissue change induced by a microwave surgical instrument in a rat hepatectomy model

BACKGROUND

Microwaves exhibit great potential in tissue heating, which causes effective coagulation. Using this energy, we have developed the microwave coagulation surgical instrument (MWCX) for clinical application. Here, we characterized the impact of MWCX on tissues including heating property, tissue change, and spread of thermal injury.

METHODS

Hepatectomy was performed with MWCX using a rat model. The resections were completed using various energy levels and powers. Tissue temperature during radiation was recorded. Tissue change and lateral thermal injury (LTI) was assessed immediately, 7 days, 3 months, and 6 months after resection.

RESULTS

All cutting and hemostasis procedures were successfully accomplished. Major histologic findings consisted of deformation or destruction of hepatocytes, tissue edema, and peripheral hemorrhage. At various energy levels, 200 to 1000 J, the tissue was heated up to approximately 80°C to 140°C causing 2.7- to 6.5-mm LTI on the 7th day. LTI was then decreased gradually in the following term. At certain energy levels, the application of neither 20 W nor 40 W induced significant difference in both heating and LTI.

CONCLUSIONS

MWCX achieved effective tissue coagulation with relevant tissue injury, and it should be a good candidate for clinical application.

Surgery-induced peritoneal cancer cells in patients who have undergone curative gastrectomy for gastric cancer

BACKGROUND

Some patients who undergo curative gastrectomy with lymph node dissection (LND) for gastric cancer (GC) show subsequent peritoneal metastasis. The source of these metastatic cells remains unclear.

METHODS

Curative gastrectomy with LND was performed in 102 patients with GC. Peritoneal washing was collected before and after gastrectomy. Cytology, reverse transcription-polymerase chain reaction, and cell culture were used to determine the presence of cancer cells. The proliferative potential of tumor cells was evaluated using Ki-67 staining. Tumorigenic capacity was assessed by cell injection into the peritoneal cavity of NOD/ShiJic-scid mice. Peritoneal recurrence-free survival (RFS) and peritoneal recurrence rate (RR) were examined to determine the clinical relevance of detected cancer cells.

RESULTS

Of 102 peritoneal washing samples obtained before gastrectomy, 57 showed no CEA or CK20 mRNA amplification. After gastrectomy, CEA or CK20 mRNA was detected in 35 of these 57 samples, and viable cancer cells were identified in 24. The viable cancer cells in all 24 cases showed Ki-67 positivity, indicating proliferative activity. Cultured viable cancer cells generated peritoneal nodules after spilling over the peritoneal cavity in NOD/ShiJic-scid mice in 4 cases. The peritoneal RFS of patients with CEA or CK20 mRNA amplification after gastrectomy was significantly poorer than that of patients with negative amplification (p < .05). The 24 patients with viable cancer cells in the peritoneal cavity after gastrectomy showed higher peritoneal RR than those without them (p = .033).

CONCLUSIONS

Viable tumorigenic cancer cells spilled into the peritoneal cavity during surgery, indicating that surgery induces peritoneal metastasis.