Laparoscopic Supracervical Hysterectomy Using EnSeal vs Standard Bipolar Coagulation Technique: Randomized Controlled Trial

Outcomes of conventional and advanced energy devices in laparoscopic surgery: a systematic review

INTRODUCTION

Hemostasis is an important step in all surgical procedures. Mechanical methods of hemostasis have been gradually abandoned in favor of electrosurgery. The aim of this systematic review was to evaluate the effectiveness of electrosurgical instruments utilized in minimally invasive gynecological procedures.

MATERIAL AND METHODS

We performed a systematic review, including randomized controlled trials, prospective and retrospective studies, comparing the outcomes of different energy devices (EDs) used in laparoscopic gynecologic surgeries. We extracted data about blood loss (BL), mean operative time, post-operative pain, hospital stay and complications associated with each electrosurgical device.

RESULTS

We included 30 studies reporting comparative outcomes concerning conventional (bipolar and monopolar) and innovative EDs (Harmonic scalpel, LigaSure, Plasma kinetic gyrus, Thunderbeat, EnSeal, Marseal, Caiman and ALAN). New EDs were found to be more efficient in complex surgeries due to less intraoperative BL and shorter operative time. No significant decrease in hospital stay, post-operative pain or complications was found with the use of new energy instruments.

CONCLUSIONS

Although new electrosurgical devices seem an appealing and safer option, there is still insufficient evidence for one vessel-sealing technology to be considered superior to another. Therefore, monopolar and conventional bipolar (CB) are still widely used in laparoscopic gynecology.

Comparative analysis of peri-operative outcomes following total laparoscopic hysterectomy with conventional bipolar-electrosurgery versus high-pressure pulsed LigaSure use

Objectives:

Materials and Methods:

Results:

Conclusion:

Comparison of surgical outcomes using Gyrus PKS™ vs LigaSure™ in total laparoscopic hysterectomy: A randomised controlled trial

BACKGROUND

Advanced vessel sealing devices are widely used in laparoscopic surgery. However, there remains a lack of adequately powered trials comparing laparoscopic advanced vessel sealing devices in the clinical setting, especially in gynaecology.

AIMS

This single-blinded randomised controlled trial aims to compare the surgical outcomes of total laparoscopic hysterectomy (TLH) using either the Gyrus PKS™ LYONS dissecting forceps or the LigaSure™ Maryland jaw vessel sealer/divider.

MATERIALS AND METHODS

Women who required TLHs for benign indications were randomised to having their surgeries performed using either Gyrus PKS™ or LigaSure™. Time to haemostasis (from initial skin incision to detachment of the uterus with secured haemostasis) was the primary outcome; a 20% difference in time was considered clinically significant. Secondary outcomes measured were intra-operative blood loss, complications, conversions, post-operative analgesia use, and length of stay. This study was registered with the Australia New Zealand Clinical Trials Registry ACTRN12615000639516.

RESULTS

Sixty-four women were included in the study - 33 and 31 in the Gyrus PKS™ and LigaSure™ arms, respectively. TLHs performed by LigaSure™ had statistically significantly shorter time to haemostasis compared to Gyrus PKS™ by 10.6 min (95% CI 1.3-2.0, P = 0.03). There were no differences in any of the other secondary outcomes measured.

CONCLUSIONS

This trial suggests there is no difference between using either device. TLHs performed using LigaSure™ have statistically significantly shorter time to haemostasis than those using Gyrus PKS™; however, the difference is not considered clinically significant as it was only 14.2%. No other differences in surgical outcomes were detected.

[Outpatient hysterectomy: criteria for acceptability and feasibility, survey among 152 surgeons]

OBJECTIVE

The aim of this study is to determine one-day hysterectomy's criteria of acceptability and feasibility.

MATERIALS AND METHODS

We realized an observational descriptive survey based on questionnaires which were sent to gynecologic surgeons. Criteria were defined as major when rate of favorable responses was superior to 70%.

RESULTS

Main major criteria were: definition of an age limit (80.3% of respondents), of a Body Mass Index limit (70%), no history of coronary artery disease (77.6%), no anticoagulant therapy with curative intent (95.4%) or antiplatelet (71.1%), no history of sleep apnea (77.4%), surgery within two hours (85.1%), definition of intraoperative bleeding limit (87.5%), no laparotomy (97.4%), no intra abdominal drainage (77.6%), presence of an accompanying at home (99.3%), pain evaluation (97.4%), absence of nausea before leaving (75.5%) and spontaneous urination (96.7%).

CONCLUSION

Our study determined major criteria to practice one-day hysterectomy. Decision should be based on a personalized benefice-risk balance analysis. Final decision belongs to patient, as her complete engagement is fundamental.

Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations

Background and objectives

Laparoscopic hysterectomy is increasingly performed because it is associated with less postoperative pain and earlier recovery as compared with open abdominal hysterectomy. The aim of this systematic review was to evaluate the available literature regarding the management of pain after laparoscopic hysterectomy.

Strategy and selection criteria

Randomized controlled trials evaluating postoperative pain after laparoscopic hysterectomy published between January 1996 and May 2018 were retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from the EMBASE and MEDLINE databases and the Cochrane Register of Controlled Trials. Efficacy and adverse effects of analgesic techniques were assessed.

Results

Of the 281 studies initially identified, 56 were included. Of these, 31 assessed analgesic or anesthetic interventions and 25 assessed surgical interventions. Acetaminophen, non-steroidal anti-inflammatory drugs, and dexamethasone reduced opioid consumption. Limited evidence hindered recommendations on alpha-2-agonists. Inconsistent evidence was found in the studies investigating pregabalin and transversus abdominis plane block, and no evidence was found for intraperitoneal local anesthetics, port site infiltration, or single-port laparoscopy. Measures to lower peritoneal insufflation pressure or humidify or heat insufflated gas seem to reduce the incidence of shoulder pain, but not abdominal pain.

Conclusions

The baseline analgesic regimen for laparoscopic hysterectomy should include acetaminophen, a non-steroidal anti-inflammatory drug, dexamethasone, and opioids as rescue analgesics.

Comparison of Industry-Leading Energy Devices for Use in Gynecologic Laparoscopy: Articulating ENSEAL versus LigaSure Energy Devices

STUDY OBJECTIVE

To compare 2 laparoscopic bipolar electrosurgical devices used in total laparoscopic hysterectomy (TLH). An articulating advanced bipolar device (ENSEAL G2; Ethicon Endo-Surgery, Cincinnati, OH) and an electrothermal bipolar vessel sealer (LigaSure; Medtronic, Minneapolis, MN) were analyzed for differences in surgeon perception of ease of instrument use and workload using the NASA Raw Task Load Index (RTLX) scale. A second objective was to examine differences in operative time, estimated blood loss (EBL), and perioperative complication rates between the 2 devices.

DESIGN

Single-institution, single-blinded, randomized controlled trial (Canadian Task Force classification I).

SETTING

Division of Minimally Invasive Gynecologic Surgery in a university hospital.

PATIENTS

Eligibility required planned TLH, over age 18 years, and able to give informed consent; exclusions were stage III or IV endometriosis, known gynecologic malignancy, and early decision for conversion to laparotomy. One hundred seventy-eight patients screened, 142 enrolled, 2 withdrew, and 140 completed the study. Patients were followed 1 month postoperatively.

INTERVENTIONS

Preoperative randomization to articulating advanced bipolar device or electrothermal bipolar vessel sealer to be used during TLH.

MEASUREMENTS AND MAIN RESULTS

At the end of each hysterectomy the primary surgeon completed an ergonomic assessment tool, the RTLX. Results were analyzed to detect differences in workload between the 2 devices. For each case the time to ligation of the bilateral uterine arteries, EBL, and complications (including device failure, blood transfusion, or other injury) were recorded. Statistical analysis was performed using the t test for normally distributed data, χ² test for categorical data, and Mann-Whitney U-test for nonparametric data. There were no differences in age, body mass index, parity, prior surgery, uterine weight, race, indication, pathology, and comorbidities between the 2 groups. A statistically significant increase in RTLX scores (p < .0001), device failures (p = .0031), and time to ligation of bilateral uterine arteries (p = .0281) was noted in the articulating device group. No significant differences in EBL or complication rates were noted between the groups.

CONCLUSIONS

The articulating advanced bipolar device was shown to have a statistically significant increase in surgeon-perceived workload and rate of device failure when used in TLH; however, clinical and surgical outcomes were equivalent.

"Energy devices in gynecological laparoscopy - Archaic to modern era"

The introduction of newer vessel sealing systems has revolutionized techniques of hemostasis during laparoscopic surgery. These devices allow for rapid sequential tissue and vessel sealing, coagulation, and transection. Despite of widespread use of newer advanced bipolar and ultrasonic devices, monopolar and conventional bipolar electro-surgery still carry weightage due to wider range of tissue effect, dissection capabilities, cost effectiveness, and ease of availability. Here in we discussed different types of commonly available energy sources in terms of mechanism, efficacy and safety as thorough knowledge is utmost important for surgeon to choose appropriate instrument for surgical procedure.

Hysterectomy for benign disease: clinical practice guidelines from the French College of Obstetrics and Gynecology

OBJECTIVE

The objective of the study was to draw up French College of Obstetrics and Gynecology (CNGOF) clinical practice guidelines based on the best available evidence concerning hysterectomy for benign disease.

METHODS

Each recommendation for practice was allocated a grade, which depends on the level of evidence (clinical practice guidelines).

RESULTS

Hysterectomy should be performed by a high-volume surgeon (>10 hysterectomy procedures per year) (gradeC). Stimulant laxatives taken as a rectal enema are not recommended prior to hysterectomy (gradeC). It is recommended to carry out vaginal disinfection using povidone-iodine solution prior to hysterectomy (grade B). Antibiotic prophylaxis is recommended during hysterectomy, regardless of the surgical approach (grade B). The vaginal or laparoscopic approach is recommended for hysterectomy for benign disease (grade B), even if the uterus is large and/or the patient is obese (gradeC). The choice between these two surgical approaches depends on other parameters, such as the surgeon's experience, the mode of anesthesia, and organizational constraints (duration of surgery and medical economic factors). Vaginal hysterectomy is not contraindicated in nulliparous women (gradeC) or in women with previous cesarean section (gradeC). No specific hemostatic technique is recommended with a view to avoiding urinary tract injury (gradeC). In the absence of ovarian disease and a personal or family history of breast/ovarian carcinoma, the ovaries should be preserved in pre-menopausal women (grade B). Subtotal hysterectomy is not recommended with a view to reducing the risk of peri- or postoperative complications (grade B).

CONCLUSION

The application of these recommendations should minimize risks associated with hysterectomy.

[Urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery on the Fallopian tube: Guidelines]

OBJECTIVES

To provide clinical practice guidelines from the French College of Obstetrics and Gynecology (CNGOF) based on the best evidence available, concerning the urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery including opportunistic salpingectomy and adnexectomy.

MATERIAL AND METHOD

Review of literature using following keywords: benign hysterectomy; urinary injury; bladder injury; ureteral injury; vesicovaginal fistula; infection; bowel injury; salpingectomy.

RESULTS

Urinary catheter should be removed before 24h following uncomplicated hysterectomy (grade B). In case of urinary catheter during hysterectomy, immediate postoperative removal is possible (grade C). No hemostasis technics can be recommended to avoid urinary injury (grade C). There is not any evidence to recommend to perform a window in the broad ligament or an ureterolysis, to put ureteral stent or a uterine manipulator in order to avoid ureteral injury. An antibiotic prophylaxis by a cephalosporin is always recommended (grade B). Mechanical bowel preparation before hysterectomy is not recommended (grade B). If there is no ovarian cyst/disease and no familial or personal history of ovarian/breast cancer, ovarian conservation is recommended in premenopausal women (grade B). In postmenopausal women, informed consent and surgical approach should be taken in account to perform a salpingo-oophorectomy. Since the association salpingectomy and hysterectomy is not assessed in the prevention of ovarian cancer, systematic bilateral salpingectomy is not recommended (expert consensus).

CONCLUSIONS

Practical application of these guidelines should decrease the prevalence of visceral complications associated with benign hysterectomy.

Consistency and sealing of advanced bipolar tissue sealers

Objectives

The aim of this study was to evaluate two commonly used advanced bipolar devices (ENSEAL^® G2 Tissue Sealers and LigaSure™ Blunt Tip) for compression uniformity, vessel sealing strength, and consistency in bench-top analyses.

Methods

Compression analysis was performed with a foam pad/sensor apparatus inserted between closed jaws of the instruments. Average pressures (psi) were recorded across the entire inside surface of the jaws, and over the distal one-third of jaws. To test vessel sealing strength, ex vivo pig carotid arteries were sealed and transected and left and right (sealed) halves of vessels were subjected to burst pressure testing. The maximum bursting pressures of each half of vessels were averaged to obtain single data points for analysis. The absence or presence of tissue sticking to device jaws was noted for each transected vessel.

Results

Statistically higher average compression values were found for ENSEAL^® instruments (curved jaw and straight jaw) compared to LigaSure™, P<0.05. Moreover, the ENSEAL^® devices retained full compression at the distal end of jaws. Significantly higher and more consistent median burst pressures were noted for ENSEAL^® devices relative to LigaSure™ through 52 firings of each device (P<0.05). LigaSure™ showed a significant reduction in median burst pressure for the final three firings (cycles 50–52) versus the first three firings (cycles 1–3), P=0.027. Tissue sticking was noted for 1.39% and 13.3% of vessels transected with ENSEAL^® and LigaSure™, respectively.

Conclusion

In bench-top testing, ENSEAL^® G2 sealers produced more uniform compression, stronger and more consistent vessel sealing, and reduced tissue sticking relative to LigaSure™.

Usefulness of vessel-sealing devices for ≤7 mm diameter vessels: a randomized controlled trial for human thoracoscopic lobectomy in primary lung cancer

OBJECTIVES

Vessel-sealing devices (VSDs) are widely used for various surgical procedures, including thoracoscopic surgery, but very few reports have compared their safety and usefulness with human thoracoscopic lobectomy procedures not employing VSDs.

METHODS

Primary lung cancer patients for whom a thoracoscopic lobectomy involving mediastinal lymph node dissection was planned in our department from April 2011 to March 2013 were recruited for the study. Patients were randomly allocated to a control group (n = 14) or a VSD group (n = 44), which comprised three sub-groups, namely EnSeal (n = 17), LigaSure (n = 15) and Harmonic (n = 12). The control group comprised patients undergoing surgery solely with ligation and conventional electrocautery. EnSeal, LigaSure and Harmonic were chosen because they are the three most popular disposable VSDs used in Japan. In the VSD groups, the proximal side of pulmonary artery stumps (≤7 mm diameter) were ligated and then treated with respective devices. Primary end-points were burst pressure of the pulmonary artery stump (measured using resected specimens), operative time, intraoperative blood loss, instances of endostapler use, intraoperative surgeon stress (assessed by visual analogue scale) and postoperative drainage volume and duration. As a secondary objective, the individual VSD groups were also compared with each other.

RESULTS

The burst pressure of ligation-treated pulmonary artery stumps was higher than that of VSD-treated stumps (P <0.0001). The burst pressure of <5-mm-wide VSD-treated stumps was higher than that of ≥5-mm-wide stumps (P = 0.0421). However, the burst pressure for all groups and all vessel diameters was sufficient to withstand the physiological pulmonary artery pressure. The VSD group demonstrated reduced intraoperative blood loss (P = 0.0241), surgeon stress (P = 0.0002), postoperative drainage volume (P = 0.0358) and shortened postoperative drainage duration (P = 0.0449). Operative time and the instances of endostapler use did not significantly differ. Comparison between each of the VSD groups revealed no significant differences. None of the patients experienced serious perioperative complications or died because of surgery.

CONCLUSION

VSD is simple and safe to use in thoracoscopic lobectomy involving mediastinal lymph node dissection for primary lung cancer. Furthermore, none of the VSDs used in this study presented any observable differences in quality that could lead to clinical problems.

Comparison of the use of LigaSure, HALO PKS cutting forceps, and ENSEAL tissue sealer in total laparoscopic hysterectomy: a randomized trial

STUDY OBJECTIVE

There are many instruments with different energy modalities or with different properties that are available for use in total laparoscopic hysterectomy. The aim of the study was to compare the use of LigaSure (Valleylab, Boulder, CO), HALO PKS cutting forceps (Gyrus-ACMI, Maple Grove, MA), and ENSEAL tissue sealer (SurgRx, Inc. Redwood City, CA) in total laparoscopic hysterectomy with respect to operation time and blood loss as main outcomes. Perioperative complications, return of gastrointestinal activity, and hospitalization time were assessed as secondary outcomes.

DESIGN

Randomized prospective study (Canadian Task Force classification I).

SETTING

Adana Numune Training and Research Hospital.

PATIENTS

Forty-five patients with the indication of hysterectomy were randomized into 3 groups for total laparoscopic hysterectomy. Patients with malignancies, having 3 or more previous abdominal surgeries, a uterus larger than 12 weeks of gestation, and who had to undergo additional surgical procedures during the same operation were excluded.

INTERVENTIONS

Total laparoscopic hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Operations were completed in all 15 patients in the LigaSure and HALO PKS Cutting Forceps groups with the planned instruments. In 2 patients in the ENSEAL group, bleeding could not be controlled with ENSEAL, and additional instruments were used. One patient in the ENSEAL group had bladder injury. The mean operation time and blood loss were 52.4 ± 12.8, 51.86 ± 14.11, and 55.7 ± 15.7 minutes (p > .05) and 138 ± 54.3, 118 ± 63.3, and 218 ± 115.9 mL (p < .05) in the LigaSure, HALO PKS, and ENSEAL groups, respectively. Changes in hemoglobin/hematocrit levels, return of gastrointestinal activity, and hospitalization time did not differ between groups.

CONCLUSION

These 3 novel bipolar platforms had similar results in total laparoscopic hysterectomy. These instruments were not determined to be independent predictors of operating time and amount of blood loss.