Hydro-Jet-assisted laparoscopic cholecystectomy: a prospective randomized clinical study

Case report: Minimal tissue damage and low coagulation liver resection for hepatoblastoma using indocyanine green fluorescence and water-jet dissector

Near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) has gained popularity in pediatric surgery as it has in general surgery. In addition, a water-jet dissector (WJD) has been successfully introduced in adult hepatic surgery. Tissue structures are dissected selectively and gently by the WJD. However, there have been no reports of hepatic resection for pediatric patients using a WJD. We applied NIR fluorescence imaging with ICG to visualize the resection line of the liver and used a WJD for liver parenchyma dissection in pediatric hepatoblastoma. The patient was a 3-year-old girl with a large liver tumor. Enhanced computed tomography revealed a liver tumor (maximum diameter: 120 mm) in the right lobe and three small lung metastases. The liver tumor was diagnosed as hepatoblastoma (PRETEXT 2) based on an open biopsy. We performed right hepatectomy after neoadjuvant chemotherapy. The right lobe was mobilized from the diaphragm, and then intraoperative ultrasound was performed to detect the localization of the tumor and its proximity to the vascular structures. We detected the right hepatic artery (RHA), right portal vein (RPV), and right hepatic vein (RHV). The middle hepatic vein was not involved. After ligation of the RHA and RPV to selectively control the right lobe inflow, ICG was administered intravenously and observed by an NIR endoscope. The resection line was clearly visualized by overlaying images in comparison to conventional demarcation line detection. Then, we used a WJD to dissect the parenchyma. Small vessels were divided from parenchymal tissue and were clearly visible. We resected them after clamping with metal clips. Finally, the RHV was transected by a linear stapler, and right hepatectomy was completed with 25 ml of blood loss. There was no postoperative hemorrhage. We performed hepaticojejunostomy because of stricture of the common bile duct on postoperative day 302. The patient was discharged after adjuvant chemotherapy. NIR imaging clearly showed the resection line. The WJD automatically separated, and thus made visible, the more resistant duct and vessel structures from the parenchyma. The combined use of NIR imaging and WJD was useful for pediatric hepatectomy.

Hydrodissection in Laparoscopic Cholecystectomies for Gangrenous Gallbladders

To improve the quality of patient care for cholecystectomies for gangrenous gallbladders, multiple innovations have been introduced including laparoscopic and robotic surgery. However, laparoscopic cholecystectomies for gangrenous gallbladders performed by blunt dissection still represents one of the most technically challenging general surgery procedures, with a high rate of iatrogenic complications and suboptimal measures for key surgical parameters such as length of stay, operating time, and blood loss. For this reason, the novel use of surgical techniques such as hydrodissection, which involves the expulsion of normal saline streams at a predetermined pressure, for cholecystectomies for gangrenous gallbladders are of utmost importance. In this manuscript, we explore the application of hydrodissection in cholecystectomies for gangrenous gallbladders.

Bilateral laparoscopic ureterolysis using hydrodissection in retroperitoneal fibrosis: a new application of an old technique

Objective: To describe our new laparoscopic approach in ureterolysis using the ERBEJET^® 2 device to hydrodissect the ureters in idiopathic retroperitoneal fibrosis.

Methods: Bilateral laparoscopic ureterolysis was done after medical therapy failure (steroids) in a 47 year old patient with retroperitoneal fibrosis. Ureteral stents were placed before surgery. Only five trocars were used for both sides, Toldt’s fascia was opened and the dissection was performed till the psoas muscle. The ureters were completely freed from the fibrotic tissue using the ERBEJET 2 device (pure hydrodissection). An omental wrap was passed behind the colonic flexure at the right and placed around the ureter. At the left, we closed Toldt’s fascia by running sutures back to the freed ureter.

Results: The operating time was 198 mins. The blood loss was 50 cc. The hospital stay was 3 days. The double J stents were removed at 4 weeks postoperatively. After 2 years, the patient is free of symptoms with normal creatinine level and no urinary tract obstructions.

Conclusions: Hydrodissection of the ureter in retroperitoneal fibrosis is a new application in the upper urinary tract laparoscopic approach that has not been described in literature before. It seems to offer excellent midterm outcomes. The use of ERBEJET 2 device seems to simplify the procedure and make it feasible and safe (less trauma to the ureter and more conservation of its blood supply). We believe that comparative studies are needed to assess the role of hydrodissection in ureterolysis for retroperitoneal fibrosis.

Ventricle wall dissection and vascular preservation with the pulsed water jet device: novel tissue dissector for flexible neuroendoscopic surgery

OBJECTIVE

Neuroendoscopic surgery allows minimally invasive surgery, but lacks effective methods to control bleeding. Water jet dissection with continuous flow has been used in liver and kidney surgery since the 1980s, and is effective for tissue manipulation with vascular preservation, but involves some potential risks, such as elevation of intracranial pressure during application in the ventricles. The authors previously reported the efficacy of the actuator-driven pulsed water jet device (ADPJ) to dissect soft tissue with vascular preservation in microscopic neurosurgery. This feasibility study investigated the use of the ADPJ to reduce the amount of water usage, leading to more safety with sustained efficacy.

METHODS

A small-diameter pulsed water jet device was developed for use with the flexible neuroendoscope. To identify the optimal conditions for the water jet, the flow rate, water pressure, and distance between the nozzle and target were analyzed in an in vitro study by using a gelatin brain phantom. A ventricle model was used to monitor the internal pressure and temperature. For ex vivo experiments the porcine brain was harvested and ventricle walls were exposed, and subsequently immersed into physiological saline. For in vivo experiments the cortex was microsurgically resected to make the small cortico-ventricle window, and then the endoscope was introduced to dissect ventricle walls.

RESULTS

In the in vitro experiments, water pressure was approximately 6.5 bar at 0.5 mm from the ADPJ nozzle and was maintained at 1 mm, but dropped rapidly toward 50% at 2 mm, and became 10% at 3.5 mm. The ADPJ required less water to achieve the same dissection depth compared with the continuous-flow water jet. With the ventricle model, the internal pressure and temperature were well controlled at the baseline, with open water drainage. These results indicated that the ADPJ can be safely applied within the ventricles. The ADPJ was introduced into a flexible endoscope and the ventricle walls were dissected in both the ex vivo and in vivo conditions. The ventricle wall was dissected without obscuring the view, and the vascular structures were anatomically preserved under direct application. Histological examination revealed that both the vessels on the ventricle wall and the fine vessels in the parenchyma were preserved.

CONCLUSIONS

The ADPJ can safely and effectively dissect the ventricle wall, with vascular preservation in immersed conditions. To achieve the optimal result of tissue dissection with minimal surgical risk, the ADPJ is a potential device for neuroendoscopic surgery of the ventricles.

Hydro-Jet-assisted laparoscopic partial nephrectomy with no renal arterial clamping: a preliminary study in a single center

OBJECTIVE

To describe our experience with Hydro-Jet-assisted laparoscopic partial nephrectomy (LPN) with no renal arterial clamping in 35 patients with renal cell carcinoma.

METHODS

Hydro-Jet technique was used to incise the renal parenchyma, dissect the intrarenal vessels and collecting system during the LPN procedure in 35 patients with renal cell carcinoma. Patient demographics, tumor characteristics, perioperative data and renal function parameters were collected prospectively. All procedures were performed by a single surgeon.

RESULTS

All LPN procedures were completed without conversion to open surgery or nephrectomy. The mean operation duration was 113.6 min (range 72-202). The mean blood loss was 149.4 ml (range 30-530). No Clavien ≥3 complication was observed in any patient. There was no significant difference between the preoperative GFR of the affected kidney and GFR at 3 months postoperation (54.9 vs. 54.2 ml/min, p = 0.063). Clear cell carcinoma was confirmed histopathologically in 30 patients (85.7%), papillary renal cell carcinoma in four patients (11.4%) and chromophobe renal cell carcinoma in one patient (2.9%), all with negative surgical margins. No tumor recrudescence was observed during the mean follow-up period of 6.32 months (range 3-9 months).

CONCLUSION

The Hydro-Jet-assisted no-clamping LPN technique is safe, feasible and effective in selected cases. It could avoid intraoperative ischemia-reperfusion injury to the kidney. The learning curve should be further discussed, and its feasibility with larger and more complex endophytic tumors should be further explored in future controlled clinical trials with larger samples and long-term follow-up periods.

Water-jet dissector for endoscopic submucosal dissection in an animal study: outcomes of the continuous and pulsed modes

BACKGROUND

Endoscopic submucosal dissection (ESD) allows en bloc resection of early neoplastic lesions of gastrointestinal tract. Lesions are lifted by submucosal fluid injection before circumferential incision and dissection. High-pressure fluid injection using water jet (WJ) technology is already used for lifting and dissection in surgery. The study was designed to assess WJ for ESD submucosal lifting and dissection.

METHODS

An experimental, randomized comparative, "in vivo" nonsurvival animal study on 12 pigs was designed. Stomach mucosal areas were delineated and resected using three ESD techniques: technique A-syringe injection and IT knife dissection; technique B-WJ continuous injection and IT knife dissection; technique C-WJ injection and WJ pulsed dissection. Injection and dissection speeds and complications rates were assessed.

RESULTS

Water jet continuous injection is faster than syringe injection (B faster than A, p = 0.001 and B nonsignificantly faster than C, p = 0.06). IT knife dissection is significantly faster after WJ continuous injection (B faster than A, p = 0.003). WJ pulsed dissection is significantly slower than IT knife dissection (C slower than A and B, both p < 0.001). The overall procedure speed was significantly higher and the immediate bleedings rate was significantly lower for technique B than A and C (overall procedure speed p = 0.001, immediate bleedings p = 0.032 and 0.038 respectively). There were no perforations with any technique.

CONCLUSIONS

Water jet fluid continuous injection speeds up ESD, whereas pulsed WJ dissection does not.

[Histomorphologic findings in the facial nerve after waterjet dissection of the parotid gland. Animal studies in dogs]

BACKGROUND

The postoperative facial nerve palsy is a complication after parotidectomy which one is afraid of. The waterjet seems to be a surgical technic which allows separating different tissues without destroying important structures like vessels and nerves.

MATERIAL AND METHODS

Totally, 106 nerve preparations, done by the waterjet of 14 beagles, were evaluated. According to a defined procedure during parotidectomy by waterjet different cones and pressure were used. After a period time of 21 days the trunk, the frontal branch and both oral branches of the facial nerve of both sides were dissected. The tissue preparation was done using the standard technic for EM-sections.

RESULTS

There are mainly changes due to the preparation like the reduction of nerve fibers and fibrosis depending which cones and pressure has been used.

CONCLUSION

Therefore neither the size of the jet (120 or 150 μm) nor the operating pressure of 40 to 60 or 80 bar plays an important role for the function of the facial nerve. Damage to the nerve is mainly due to the preparation technic and the application time. Using the 200 μm jet there is regularly facial nerve damage.

Pressure-controlled dual irrigation-suction system for microneurosurgery: technical note

OBJECTIVE

We designed a new irrigation-suction system consisting mainly of a pressure-resistant irrigation fluid container, dual irrigation and suction devices, and an intracontainer pressure regulator.

METHODS

The intracontainer pressure can be regulated from 0 to 0.02 MPa. This system is simple and can be operated simultaneously by both an operator and an assistant. It is powered by compressed air, which is available in regular operating rooms of any hospital.

RESULTS

No complications including blood clots in the brain and vascular injuries related to this system were observed.

CONCLUSION

The excellent and safe performance of this dual irrigation-suction system in clearing the operating field by an operator and/or an assistant has been proven in more than 300 neurosurgical operations.

First experimental results with a new waterjet dissector: Erbejet 2

BACKGROUND

Waterjet dissection represents a useful technique for many surgical procedures. In this experimental study, the technical features and dissection qualities of the new Erbejet 2 with its new pump and nozzle applicator system are evaluated for its neurosurgical use compared to the established Helix Hydro-Jet.

METHODS

One hundred twenty-six fresh cadaveric pig brains were simultaneously cut with the Helix Hydro-Jet and Erbejet 2. Different pressure levels were applied to cerebral tissue with and without meninges, cerebellum and brainstem. Additionally, dissection characteristics of various cutting media were investigated.

FINDINGS

There was a nearly equal dissection quality at up to 10 bar of both instruments. In contrast to the Helix Hydro-Jet, Erbejet 2 application at higher pressures resulted in an almost linear increase of dissection depth with a small standard deviation. Smoother cutting margins and less foaming were found. Preserved vessels were observed with both devices. Hydroxyaethyl starch led, in contrast to Ringer's solution and isotonic saline solution, to increased dissection width and more foaming.

CONCLUSIONS

The new Erbejet 2 is more precise, with almost linear correlation of pressure and dissection depth compared to the Helix Hydro-Jet. Less foaming and the possible application of various separating media are a considerable advantage. All things considered, the new Erbejet 2 offers more options to enlarge the field of neurosurgical indications for waterjet dissection.

Development of shock wave assisted therapeutic devices and establishment of shock wave therapy

In order to exploit systems for shock wave therapy, we are working for the development of clinical devices that are based on the concept of shock waves or related phenomena. The paper describes these new therapeutic devices designed for the minimally invasive approach to vascular thromboloysis, selective dissection of tissues, and drug or DNA delivery. To investigate the response of cells to shock loading, a precise method of shock waves generation in space and time has been developed. This method has been studied for application in cardiovascular therapy, cancer treatment, and cranioplasty in close vicinity of the brain. A laser ablation shock wave assisted particle acceleration device has been developed for delivering drug and DNA into soft targets in the human body. The penetration depth of microparticles observed in the experimental targets is believed to be sufficient for pharmacological treatments. In order to achieve an efficient method for rapid revascularization of cerebral thrombosis, a laser induced liquid jet (LILJ) system has been developed. The LILJ has been successfully applied for selective dissection of soft tissue preserving nerve and blood vessels. The system has been further improved by using piezoelectric actuators to drive the liquid jets, as an alternative to pulse laser.

Surgical debridement of mineral pitch and nonviable penile tissue using water-jet power: a preliminary report

OBJECTIVE

To report our experience of debriding genital wounds embedded with mineral pitch (MP) from asphalt, using a water jet-powered surgical tool, the Versajet Hydrosurgery System (VHS, Smith and Nephew, Key Largo, FL) before reconstruction.

PATIENTS AND METHODS

We used the VHS for penile debridement in two patients. The first was 42-year-old Hispanic man involved in a truck-bike accident, who was dragged approximately 60 m after the collision. He presented with 25% body-surface abrasion impregnated with MP. The scrotal soft tissue had been lost and both testicles were exposed and ruptured, with no viable tissue. Moreover, the distal two-thirds of the penile urethra and the ventral glans were completely damaged and his penis entirely degloved. Several procedures were required for surgical debridement and reconstruction, including the skin grafting to 25% of his body surface. All surgical debridement was done with the VHS. A modified Thiersch-Duplay urethroplasty was used over a 16 F Foley catheter to reconstruct the missing urethra. The second patient was a 32-year-old man with no previous medical history, who presented with Fournier's gangrene after a penile abrasion following unprotected sexual intercourse. He required several surgical debridements. The VHS was applied to an 8 x 10 cm area, followed by a free-radial graft to the inferior epigastric.

RESULTS

The clinical follow-up was 9 and 6 months, respectively; both patients had satisfactory granulation tissue and proper wound healing. Neither of the patients had infection after surgical debridement with the VHS, even when used in the case of Fournier's gangrene.

CONCLUSION

The VHS appears to be effective for genital soft-tissue surgical debridement even when the tissue is impregnated with MP or infected, without causing any spread of infection. Larger series and a longer follow-up are needed to validate the effectiveness of the VHS in managing complex genital wounds.

The impact of gallbladder aspiration during elective laparoscopic cholecystectomy: a prospective randomized study

BACKGROUND

The aim of this prospective randomized study was to investigate the effect of gallbladder aspiration during elective laparoscopic cholecystectomy on the operative and postoperative course of patients.

METHODS

Between August 2005 and February 2007, 160 consecutive patients with symptomatic cholelithiasis were randomized into 2 clinically comparable groups. Gallbladders were aspirated before dissection in group A (aspiration, n = 80), and they were not aspirated in group C (control, n = 80). Patients' characteristics and general operative outcomes were compared and analyzed.

RESULTS

The mean dissection time (P = .45), amount of gas used (P = .49), and liver bed bleeding (P = .30) were not significantly different between group A and group C. Similarly, there were no differences between the groups regarding gallbladder perforation (P = .12), spillage of gallstones into the abdominal cavity (P = 1.00), or wound infection (P = 1.00).

CONCLUSIONS

The findings suggest that routine gallbladder aspiration is unnecessary in elective laparoscopic cholecystectomy.

Laparoscopic cholecystectomy without using any energy source

PURPOSE

Laparoscopic cholecystectomy, the gold standard treatment for symptomatic cholecystolithiasis, is still not absolutely safe. Use of energy sources for routine dissection thought to be a facilitator has unfortunately been a cause of significant morbidity. The purpose of this study was to evaluate the feasibility of performing a safe laparoscopic cholecystectomy without using any energy sources.

PATIENTS AND METHODS

From June 2005 to April 2006, 38 consecutive patients of symptomatic cholecystolithiasis without any exclusion criteria underwent laparoscopic cholecystectomy with this technique.

RESULTS

Mean operative time was 33 minutes (25-96). There was no perioperative hemodynamic instability, need for blood transfusion, technical difficulty, need for conversion, or any visceral injury. Majority of patients (34 out of 38) were discharged as day cases. Postoperative follow-up was uneventful.

CONCLUSION

Laparoscopic cholecystectomy can be safely performed without resorting to use of any energy sources.

Hydro-Jet technology in urologic surgery

Hydro-Jet technology utilizes an extremely thin, high-pressure stream of water. This technology has been routinely used in industry as a cutting tool for different materials such as metal, ceramic, wood and glass. Recently, Hydro-Jet technology has been used for dissection and resection during open and laparoscopic surgical procedures. A high-pressure jet of water allows selective dissection and isolation of vital structures such as blood vessels and nerves. This has resulted in improved dissection and decreased complication rate in recent experimental and clinical studies. This technology has been successfully applied during open and laparoscopic partial nephrectomy, cholecystecomy and retroperitoneal lymphadenectomy.

The treatment of intrahepatic calculosis by applying helix hydro-jet lithotripsy under video choledochoscope: a report of 30 cases

BACKGROUND AND AIMS

Intrahepatic lithiasis is a common disease in southeast Asia [Sheen-Chen and Chou, Acta Chir Scand 156:387-390, 1990], and a difficult problem of biliary surgery. There is no established method of treating patients with intrahepatic stones [Uchiyama et al., Arch Surg 137:149-533, 2002]. In recent years, resection of the affected liver lobe or segment is the best therapeutic option to completely remove the source of recurrent infection. The need for endoscopic treatment modalities is evident because hepatic resections are combined with a high morbidity and mortality rate [Andersson et al., HPB Surg 2:145-147, 1990; Adamek et al., Scand J Gastroenterol 34:1157-1161, 1999]. Hepatic resection only fit the cases in which the stones localized in one lobe or segment, while it doesn't fit the cases which have polystones in left and right biliary tract. Duodenoscope can only get the stones in the common bile duct and cannot deal with the intrahepatic lithiasis. The management of intrahepatic lithiasis can only be treated by intraoperative or postoperative choledochoscope. For big stones or compact stones, lithotripsy should be applied. But the laser lithotripsy and the electrohydraulic lithotripsy can cause serious complications such as perforation of bile duct. It needs a safer and more reliable treatment for intrahepatic lithiasis. The aim of our work is to study the lithotrity treatment of intrahepatic lithiasis by using helix hydro-jet under Video Choledochoscope.

MATERIALS AND METHODS

From March 31, 2003 to October 20, 2004, 30 intrahepatic stone patients were treated. Eighteen of them were women and 12 were men, with ages ranging from 35 to 80 years (mean, 58 years). According to B ultrasound and computed tomography (CT) scan report, there were five cases of intrahepatic lithiasis and common bile duct stones, 25 cases of left and right hepatic duct stones, and one case with giant intrahepatic stone (1.5 x 1.5 x 1.2 cm). Intraoperative or postoperative choledochoscopic helix hydro-jet lithotripsy was applied through a video choledochoscope. For the patients to have the intraoperative choledochoscopic helix hydro-jet lithotripsy, they should be diagnosed correctly by B ultrasound or CT scan. The biliary tract reconstruction by spiral CT scan is as helpful as MRCP or ERCP for clinical diagnosis. For the patients to have the postoperative choledochoscopic helix hydro-jet lithotripsy, they should be diagnosed correctly by T-tube cholangiography and BUS and CT scan. All patients should be verified without stones remaining in the bile duct after lithotripsy by choledochoscopic examination and T-tube cholangiography, and should be examined by BUS again after 6 months to 1 year. We decide whether complications occurred by observation of symptoms and signs after choledochoscopy and lithotripsy.

RESULTS

Seventy-five intrahepatic stones with diameter ranging from 0.6 to 1.5 cm were successfully fragmentized in 30 patients using of helix hydro-jet lithotripsy. These fragmentized stones mainly are bilirubin stones. The lithotripsy was carried for 45 times and the procedure needs 1-1.5 h. Helix hydro-jet lithotripsy are used in 16 cases during operation and 12 cases after operation; two cases during operation and after operation. Intrahepatic calculosis was cleaned out completely and verified by postoperative choledochoscope examination and postoperative T-tube cholangiography examination. No complications were observed.

CONCLUSION

Helix hydro-jet lithotripsy under video choledochoscope is a safe and effective method for the removal of intrahepatic stone. No bile duct damnified and perforation was observed. The procedure is without pain and heat, and the pressure can be adjusted easily. The research provides a new way of using the helix hydro-jet, and a new way of curing the intrahepatic lithiasis.

The Versajet??? Water Dissector: A New Tool for Tangential Excision

Goulian and Watson knives work well for tangential burn excision on large flat areas. They do not work well in small areas and in areas with a three-dimensional structure. The Versajet Hydrosurgery System (Smith and Nephew, Key Largo, FL) is a new waterjet-powered surgical tool designed for wound excision. The small size of the cutting nozzle and the ability to easily maneuver the water dissector into small spaces makes it a potentially useful tool for excision of burns of the eyelids, digits and web spaces. The Versajet Hydrosurgery System contains a power console that propels saline through a handheld cutting device. This stream of pressurized saline functions as a knife. We have used the Versajet for burn excision in 44 patients. Although there is a learning curve for both surgeons using and operating room staff setting up the device, the Versajet provides a relatively facile method for excision of challenging aesthetic and functional areas.