Comparative study of in vivo lymphatic sealing capability of the porcine thoracic duct using laparoscopic dissection devices

Incomplete lymphatic sealing around the inferior mesenteric artery is a risk factor for chylous ascites in robotic rectal cancer surgery

INTRODUCTION

Compared with laparoscopic surgery (LS), robotic surgery (RS) is considered to have acceptable outcomes in rectal cancer, but few reports have focused on chylous ascites in RS. The aim of this study was to investigate the incidence and etiology of chylous ascites after RS.

METHODS

This retrospective study included 291 patients with rectal cancer who underwent RS (n = 165) or LS (n = 126) with high ligation of the inferior mesenteric artery (IMA). Propensity score matching (PSM) was performed to compare the two groups.

RESULTS

\Dissection around the IMA was achieved using ultrasonic coagulating shears in most LS cases, and monopolar scissors in most RS cases, sometimes using bipolar vessel sealing device or bipolar forceps. The incidence of chylous ascites was 12.2% in RS and 4.1% in LS after PSM (P = .037). When limited to the RS group, multivariate analysis identified absence of lymphatic sealing at the left side of the IMA and shorter operative time as independent risk factors for chylous ascites. Except for duration of drain placement, no outcomes differed significantly with or without chylous ascites. One patient with chylous ascites developed later infection and required antibiotic treatment.

CONCLUSION

The incidence of chylous ascites is significantly higher in RS than in LS, and RS with incomplete lymphatic sealing around the IMA is a risk factor for chylous ascites in rectal cancer. Although outcomes for patients with chylous ascites were acceptable, adequate lymphatic sealing during dissection around the IMA is crucial to prevent chylous ascites in RS.

Sentinel Lymph Node Biopsy for Melanoma: Comparison of Lymphocele Rates by Surgical Technique

Lymphocele is a common wound complication of sentinel lymph node biopsy (SLNB). The surgical technique may play a key role in lymphocele formation. This study compared rates of postoperative lymphocele formation by different surgical techniques (Harmonic Scalpel [HS], LigaSure [LS], and traditional electrocautery with clips) after SLNB in the groin or axilla for the staging of clinically node-negative cutaneous melanoma. Patients were selected by convenience sample from a single-institution, single-surgeon, prospectively collected melanoma database over a 27-month period. One hundred fifty consecutive patients underwent SLNB, 70 with clips, 37 with HS, and 43 with LS. The median number of nodes removed was two and did not vary significantly between groups. Twenty-three lymphoceles occurred for an overall rate of 15 per cent; rates were 9.9 and 26.5 per cent for the axilla and groin, respectively. Sixteen (70%) were aspirated for size or symptoms; lymphoceles after groin SLNB were significantly (P = 0.03) more likely to require aspiration. Lymphocele rates for the clip, HS, and LS groups were 20.0, 18.9, and 4.7 per cent, respectively. The differences between the LS and other groups were statistically significant. Use of the LS may lead to lower lymphocele rates after groin and axillary SLNB compared with electrocautery and clips.

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.

Development and application of the near-infrared and white-light thoracoscope system for minimally invasive lung cancer surgery

In minimally invasive surgery, the white-light thoracoscope as a standard imaging tool is facing challenges of the low contrast between important anatomical or pathological regions and surrounding tissues. Recently, the near-infrared (NIR) fluorescence imaging shows superior advantages over the conventional white-light observation, which inspires researchers to develop imaging systems to improve overall outcomes of endoscopic imaging. We developed an NIR and white-light dual-channel thoracoscope system, which achieved high-fluorescent signal acquisition efficiency and the simultaneously optimal visualization of the NIR and color dual-channel signals. The system was designed to have fast and accurate image registration and high signal-to-background ratio by optimizing both software algorithms and optical hardware components for better performance in the NIR spectrum band. The system evaluation demonstrated that the minimally detectable concentration of indocyanine green (ICG) was 0.01 ?? ? M , and the spatial resolution was 35 ?? ? m . The in vivo feasibility of our system was verified by the preclinical experiments using six porcine models with the intravenous injection of ICG. Furthermore, the system was successfully applied for guiding the minimally invasive segmentectomy in three lung cancer patients, which revealed that our system held great promise for the clinical translation in lung cancer surgeries.

Microbiological evaluation of infected pelvic lymphocele after robotic prostatectomy: potential predictors for culture positivity and selection of the best empirical antimicrobial therapy

OBJECTIVES

To examine symptomatology and microbiology of infected lymphocele (LC) post-robotic-assisted radical prostatectomy and pelvic lymph node dissection (PLND) and to assess for potential predictors for LC fluid culture positivity. Secondly, to provide general recommendations about use of select antimicrobial therapy.

METHODS

This was a single-center, IRB-approved, retrospective, case series review conducted between October 2008 and October 2014. Data included symptomatology, microbiology of symptomatic LC in men post-robotic prostatectomy and PLND. Those with infected LC were compared to those men with symptomatic LC in the absence of infection.

RESULTS

Symptomatic LC was seen in 7% of men, and among those, infected LC was seen in 42%. Infected LC cultures showed predominance of G+ cocci such as S. aureus, coagulase-negative Staphylococcus species, S. pyogenes, S. fecalis and S. viridans. Monomicrobial infection was seen in 85%. Multivariate logistic regression showed leukocytosis [Odds: 12.3, p = 0.03, 95% CI (1.2-125)] was significant predictor for culture positivity, whereas trend toward significance for factors such CT findings of thickened walls around the LC +/- air.

CONCLUSIONS

LC infection following PLND for prostate cancer is usually monomicrobial and caused by Gram+ cocci. GI tract and skin flora are the main habitat. High index of suspicion of infected LC is undertaken in the presence of leukocytosis, fever and abnormal CT findings. Based upon our local hospital antibiogram, combination of IV ampicillin/sulbactam and vancomycin is suggested as the best initial empiric therapy in treating these patients.

Prospective analysis of the sealing ability of the ENSEAL® G2 Articulating Tissue Sealer and transector on human mesenteric vessels in colorectal surgery

BACKGROUND

The sealing and transection of mesenteric vessels is a crucial step in minimally invasive colorectal surgery. We examined the sealing quality of the ENSEAL^® G2 Articulating Tissue Sealer in three different articulations in mesenteric vessels.

METHODS

This was a prospective experimental study within a tertiary healthcare center, and 30 patients were recruited. Burst pressures for each specimen were measured as the primary outcome. Ten specimens at each of the three articulations were also histologically assessed for the quality of seal.

RESULTS

We evaluated 54 sets of specimens from 30 patients for bursting pressure, all of which were harvested and sealed in the operating room. No statistical difference was seen in burst pressures from seals recorded at no angulation, half-maximal angulation, or maximal angulation (1604, 1507, 1478 mmHg; p = 0.07). Histological analysis showed no statistical differences in the average vessel diameter (p = 0.57), lateral extent of thermal injury (p = 0.48), degree of vascular sclerosis, or the integrity of seal at the three articulations. No cases of intraoperative or postoperative bleeding were observed in any of the patients. Five (16.7%) of the ENSEAL^® devices developed breaks in the black, heat-shrink, polyethylene covering as a result of repeated articulation and disarticulation. Electrical arcing did not appear to have occurred as a result of the break, although this was not formally examined.

CONCLUSIONS

The maximum sustainable pressure in mesenteric vessels sealed with a bipolar electrothermal device is supraphysiological, and consequently, the device can be safely used at various articulations to seal vessels during colorectal surgery.

Experimental study in pulmonary artery sealing with a vessel-sealing device

Background

The development of vessel-sealing devices will facilitate safety in video-assisted thoracoscopic surgery. Our objective was to evaluate the feasibility and safety of sealing pulmonary arteries with the Enseal tissue-sealing device.

Methods

Pulmonary arteries from beagle dogs (mean body weight 13.1 kg, range 10.5–15.4 kg) were divided into 3 groups according to the in-vivo sealing method used (Enseal, ligation, and proximal ligation plus distal Enseal) and extracted to evaluate the pressure tolerance up to 75 mm Hg at the sealed end. A left lower lobectomy was performed to evaluate chronic-phase durability of the sealed stumps in a survival model. Two or three branches of the pulmonary arteries in each dog were allocated to each of the 3 groups. After the scheduled survival period, the pulmonary arteries were sampled.

Results

Pressure tolerance at the sealed end was evaluated in 91 pulmonary artery sections. All sealed ends showed pressure tolerance >75 mm Hg. A left lower lobectomy was performed in 13 dogs in which 35 pulmonary artery sections had been allocated into the 3 groups. No sealing failure was found, and pathological findings showed healing and persistent hemostasis at all sealed ends of the pulmonary arteries after 2 and 4 weeks of the survival period.

Conclusions

Pulmonary arteries sealed in vivo with the Enseal device showed pressure tolerance >75 mm Hg in the acute phase, and persistent hemostasis after 2 or 4 weeks. Pulmonary artery sealing with the Enseal device is feasible and safe in thoracic surgery settings.

A Clinician's Guide to Avoiding and Managing Common Complications During and After Robot-assisted Laparoscopic Radical Prostatectomy

CONTEXT

Robot-assisted radical prostatectomy (RARP) is on the advance globally, and it is essential for surgeons and patients to know the rates of perioperative complications.

OBJECTIVE

To provide evidence-based clinical guidance on avoiding and managing common complications during and after RARP in the context of a comprehensive literature review.

EVIDENCE ACQUISITION

In concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis 2015 statement guidelines, a literature search of the PubMed database from August 1, 2011, to August 31, 2015, using the predefined search terms robot* AND radical prostatectomy, was conducted. The search resulted in 653 unique results that were subsequently uploaded to DistillerSR (Evidence Partners, Ottawa, Canada) for team-based screening and processing of references.

EVIDENCE SYNTHESIS

Overall, 37 studies met the inclusion criteria and were included. Median rate of overall complication was 12.6% (range: 3.1-42%). Most of the complications were minor (Clavien-Dindo grades 1 and 2). Grade 3 complications comprised the bulk of the major complications with a median rate of 2.7%; grade IV and V complications were exceedingly rare in all reports.

CONCLUSIONS

Despite continued adoption of the RARP technique globally, rates of overall complication remain low. Many of the complications experienced during and after RARP can be mitigated and prevented by experience and the implementation of safe techniques.

PATIENT SUMMARY

Despite continued adoption of the robot-assisted radical prostatectomy (RARP) technique globally, rates of overall and major complications remain low at 12.6% and 2.7%, respectively. Complications can be minimized and successfully managed using established techniques. RARP is a safe and reproducible technique.

Chylous Leakage After a Laparoscopic Live-Donor Nephrectomy: Case Report and Literature Review

Laparoscopic donor nephrectomy is an established operation for organ procurement in living-donor transplant. Minimal access approach for organ procurement from living donors ensures early convalescence and improved patient participation. Chylous leakage is a rare complication of laparoscopic living-donor nephrectomy. Chylous leakage is mostly determined by iatrogenic injury of cisterna chyli and its main tributaries. It may lead to malnutrition and immunologic deficits because of protein and lymphocyte depletion. An 18-year-old woman underwent left-hand-assisted laparoscopic donor nephrectomy for living donor transplant. She developed chylosus leakage in third postoperative day. A conservative manage-ment with total parenteral nutrition total paren-teral nutrition and subcutaneous somatostatin was immediately initiated. The patient had an abatement of drainage daily output in 4 days of therapy. Chylous leakage is a potentially insidious and perhaps misdiagnosed complication of laparoscopic donor nephrectomy. Conservative therapy is effective in most donors and should be initially attempted. Surgical ligatures or fibrin sealants may be indicated in case of refractory chylous leakage before the arising of malnutrition and/or relevant immunodeficiency.

A prospective study of in vivo and ex vivo sealing of the human inferior mesenteric artery using an electrothermal bipolar vessel-sealing device

BACKGROUND

Mesenteric vascular ligation is a critical step in minimally invasive colorectal surgery. This study assessed the quality of in vivo and ex vivo sealing of the human inferior mesenteric artery (IMA), as well as the relation of IMA stump and bursting pressure.

PATIENTS AND METHODS

This was a prospective experimental study in a tertiary-care teaching hospital. In total, 25 patients were included in the study. For the main outcome measures, bursting pressures were measured for each specimen. Ten freshly sealed specimens were histologically assessed for seal quality and lateral thermal damage.

RESULTS

We evaluated 54 specimens from 25 patients for bursting pressure, of which 25 were primary sealed vessels (sealed in vivo at surgery) and 29 were secondary sealed vessels (sealed in the laboratory). The mean bursting pressure was 862 mm Hg. The mean diameter was 4 mm (range, 3-5 mm) with a standard deviation of 1 mm. Pearson correlation showed no correlation between diameter and bursting pressure (P=.187) or the length and bursting pressure (P=.247). There was no statistically significant difference in bursting pressures in the four groups of vessels based on length. One calcified vessel had a significantly lower bursting pressure of 89 mm Hg. There was no intraoperative or postoperative bleeding. Ten sealed specimens were sent for histological evaluation, which showed mean lateral thermal damage of 0.57 mm (range, 0-1.75 mm).

CONCLUSIONS

The bursting pressure in IMAs sealed with a bipolar device is significantly higher than physiological pressures; thus, the device can be safely used in sealing the vessel during colorectal surgery. Additionally, the length of the vessel stump does not correlate with the bursting pressures. Care needs to be taken when the vessel is calcified, which can be a potential cause of a weak seal.

How to minimize lymphoceles and treat clinically symptomatic lymphoceles after radical prostatectomy

The development of a lymphocele after pelvic surgery is a well-documented complication, especially where pelvic lymph node dissection (PLND) is part of the operation. However, not all lymphoceles are symptomatic and require treatment. Most lymphoceles spontaneously resolve, and even lymphoceles that become symptomatic may resolve without any intervention. Robotic assisted radical prostatectomy (RARP) is a common operation in urology where PLND is likely to be performed in intermediate and high-risk prostate cancer patients. The rationale for performing a PLND in prostate cancer is for accurate staging and potential therapeutic benefits. However, due to potential intraoperative and postoperative complications there is still a debate regarding the value of PLND in prostate cancer. In this review, we will discuss the potential risk factors to be aware of in pelvic surgery in order to minimize the formation of a lymphocele, along with the management for clinically significant lymphoceles.

Comparison of the value of tissue-sealing devices for thoracoscopic pulmonary lobectomy in small children: a first report

Accurate division and sealing of lung parenchyma particularly in cases of total or near total incomplete fissure are crucial for preventing air leakage following thoracoscopic pulmonary lobectomy (TPL). However, conventional endoscopic stapling devices cannot be used during TPL in small children because of limited space. Consequently, Ligasure (LS) and Enseal (ES) devices are being used instead. We are the first to compare LS and ES for efficacy and efficiency during TPL. Of 26 TPL (6 upper, 3 middle, and 17 lower) performed for congenital adenomatoid malformation (n = 16) and sequestration (n = 10), incomplete fissure was found in 14. TPL (LS = 11; ES = 15) was performed conventionally in the lateral decubitus position with single lung ventilation using four 5 mm trocars. All cases had a chest tube inserted intraoperatively that was left in situ. Patient demographics, location of pathology, incidence of incomplete fissure, mean age/weight at TPL, mean blood loss, and mean operative time were all similar. However, duration of chest tube insertion was significantly shorter in ES because there was less postoperative air leakage (1.3 vs. 3.9 days; p < 0.05). ES would appear to seal lung parenchyma more effectively during TPL based on the shorter duration of chest tube insertion.

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.

Evaluation of EnSeal®, an adaptive bipolar electrosurgical tissue-sealing device

Relatively few, and inconsistent, data are available in the literature about the properties of EnSeal®, an electrosurgical tissue-sealing device. For this reason, we conducted control safety tests on experimental pigs. The mean burst pressure of sealed vessels (2-7 mm in diameter) proved to be 873.89 ± 120.57 mmHg (n = 60). Surface temperature increased to 69.25 ± 0.98 °C in average (n = 22). The mean diameter of the collateral microscopic thermal injury zone was found to be 0.28 ± 0.04 mm, and it did not show significant differences among the groups of tissues studied (n = 183). During our studies, the device worked reliably and met the relevant requirements in all cases. It can be established that EnSeal® enables high-safety clinical interventions at high blood pressure values, in different tissues and even at sites adjacent to heat-sensitive tissues, and thus it paves the way for new operative solutions in both human and veterinary surgery. In our opinion, the discrepancies between data reported in the literature arise from differences in the design of studies and in the designated limit values. To ensure standardisation, we recommend the use of the nitroblue-tetrazolium chloride/lactate dehydrogenase (NBTC/LDH) enzyme histochemical technique for studying thermal injury induced by the different performance levels and application times of devices operating with electromagnetic energy.

Laparoscopic cryptorchidectomy and ovariectomy in standing horses using the EnSeal® tissue-sealing device

In the present series of cases, 8 laparoscopic cryptorchidectomies and 4 laparoscopic ovariectomies were carried out in sedated standing horses. Sedation involved a lesser anaesthesiological risk than does general anaesthesia. As compared to laparotomic exposure, the minimally invasive laparoscopic intervention provided better visualisation, shorter operative time and faster recovery. The blood vessels supplying the testes and ovaries and the suspensory ligaments of the organs were sealed and cut with EnSeal®, an adaptive bipolar electrosurgical blood vessel- and tissue-sealing device. The clinical use of the blood vessel- and tissue-sealing device proved to be successful in all cases. Gradual separation of the intact tissue from the treated, compacted, dehydrated and homogenised tissue areas and occlusion of the lumen of blood vessels treated with the device could be observed in all histological sections. To the best of our knowledge, this is the first report on the use of EnSeal® for laparoscopic cryptorchidectomy and ovariectomy in horses.

Laparoscopic kidney transplantation: an initial experience

Laparoscopic donor nephrectomy has the advantages of less pain, early ambulation and shorter hospitalization compared to open donor nephrectomy. Kidney recipient surgery is, however, traditionally performed by open surgery. Our aim was to study feasibility and safety of laparoscopic kidney transplantation (LKT). After permission from Internal Review Board, LKT was performed in four patients. All kidneys were procured from deceased donors. Left kidney was used for LKT and transplanted in left iliac fossa while right kidney was used for standard open kidney transplantation (OKT). All transplantation procedures were performed successfully. Cold ischemia time varied between 4 h and 14 h. For LKT, mean time for anastomosis was 65 (range 62-72) min, mean operative time was 3.97 (range 3.5-5) h, mean blood loss was 131.25 mL (range 45-350) mL. Mean wound length was 7 cm in LKT group and 18.4 cm in OKT group. Delayed graft function was observed in one patient in each group. One patient was lost in OKT group due to posttransplant bacterial meningitis. At 6 months, both groups have comparable value of serum creatinine. In conclusion, LKT is technically feasible and safe. Long term outcome needs to be evaluated in a larger study.

Safe use of ultrasonically activated devices based on current studies

Ultrasonically activated devices (USADs) are a widely used alternative to suture ligation and clips in open and laparoscopic surgery because of their fast and easy control of bleeding without significant complications. By inducing protein denaturation and forming coaptive coagulation to seal vessels for cutting tissue, USADs result in reduced operating time, blood loss and hospital stay. Recently, various other types of vessel sealers have become available. In this article, we summarize the mechanism, efficacy and the advantages and disadvantages of USADs for appropriate use in surgery.