A sealed bladder cuff technique during laparoscopic nephroureterectomy utilizing the LigaSure electrosurgical device: laboratory and clinical experience

Evaluation of Safety and Feasibility of Using LigaSure During Clipless Single-Incision Laparoscopic Cholecystectomy: A Prospective Clinical Study

Background: Single-incision laparoscopic cholecystectomy (SILC) is a minimally invasive procedure designed to minimize the number and size of the incisions needed for cholecystectomy. Titanium clips are traditionally used to close the cystic duct and artery. Although it is considered safe, dislodgement can result in bleeding and biliary leakage. Using LigaSure for duct sealing is still controversial. The aim of this study was to evaluate the safety and feasibility of using LigaSure to close the cystic duct during SILC. Methods: A prospective study over two years was conducted at the General Surgery Department, Mansoura University Hospital, on 102 patients, 51 in each group. They underwent SILC using LigaSure (Group 1) or titanium clips (Group 2) to control the cystic duct and artery. Results: The data analyzed included demographic data, operative time, intra- and postoperative complications, postoperative pain, and hospital stay. The operative time was significantly shorter in LigaSure group (68.5 ± 9.8 versus 72.9 ± 10.6 minutes in the clips group, P .03). There was no significant difference between the two groups regarding postoperative bile leak or bleeding. However, two cases in Group 1 and four cases in Group 2 were converted to multiple port laparoscopic cholecystectomy; this was statistically nonsignificant. Postoperative pain and hospital stay showed no significant difference between the two groups. Two patients in each group developed port-site incisional hernia. Conclusions: Clipless SILC using LigaSure is a feasible and safe procedure with acceptable morbidity with shorter operative time than SILC using clips. Nevertheless, the risk of port-site incisional hernia should be explained to the patients.

A Systematic Review of Canine Cystectomy: Indications, Techniques, and Outcomes

This review provides a summary of the literature encompassing partial and total cystectomy procedures in dogs and subsequent conclusions that can be drawn. Surgical excision as a component of treatment for lower urinary tract neoplasia in dogs may enhance survival time and result in acceptable quality of life, though risk for surgical complications is substantial, particularly following total cystectomy procedures. However, for dogs with urothelial carcinoma, cystectomy is generally not considered curative and disease progression is common. Appropriate case selection and thorough preoperative discussion with owners regarding potential risks and benefits of cystectomy are imperative for successful outcomes.

Evaluation of the Appropriate LigaSure™ Device to Transect the Appendix-A Comparison between 5 mm and 10 mm Laparoscopic Devices in an Ex Vivo Trial

Background and Objectives: A topic of greatinterest in the surgical field comprises cost and time reduction operative techniques with high efficiency rates. Thus, the aim of this paper is to evaluate whether a transection of the appendix using only a laparoscopic LigaSure™ device is feasible and, if so, which size of the laparoscopic device is optimal. Materials and Methods: Appendectomy specimens were sealed and cut using LigaSure^TM V (5 mm) and LigaSure Atlas^TM (10 mm) devices ex vivo. Analysis criteria included handling, resistance to bursting pressure of the appendicular stump (adequacy), eligibility, durability and airtightness. Results: Twenty sealed areas were measured. While the 5 mm instrument was not able to transect the appendix in one attempt in any of the cases, the 10 mm device could be applied successfully without any handling difficulties. The adequacy of the sealed area was rated as complete and dry in all 10 cases using the 10 mm device and as oozing in 8 of the cases using the 5 mm device. There was no leakage in terms of air and liquid tightness using the 10 mm device, in contrast to six sealed segments with air and liquid leakage when using the 5 mm device. The resistance to bursting pressure was on average 285 mmHg and 60.5 mmHg with the 10 mm and 5 mm devices, respectively. The durability and eligibility of the 10 mm device were rated as very sufficient in 9 of 10 cases (1 perforation) in contrast to the 5 mm device, where the sealing in 9 of 10 cases was not sufficient (9 perforations). Conclusions: Using the 10 mm laparoscopic LigaSure™ device for the transection of the appendix seems to be feasible, safe and resistant to 300 mmHg bursting pressure. The 5 mm LigaSure™ instrument is inadequate to seal the appendix in humans.

Use of a bipolar sealing device to seal partial cystectomy with and without augmentation with a single-layer simple continuous suture pattern in an ex vivo canine model

OBJECTIVE

To evaluate the ability of a bipolar sealing device (BSD) to seal canine bladder tissue and to determine the influence of suture augmentation on resistance to leakage of sealed partial cystectomies.

STUDY DESIGN

Ex vivo, simple randomized study.

SAMPLE POPULATION

Urinary bladders harvested from canine cadavers (n = 23).

METHODS

Partial cystectomy of the cranial third of each bladder was performed with a BSD. This seal was augmented with a simple continuous pattern of 4-0 polydioxanone in half of the specimens. A pressure transducer inserted through the ureter measured intraluminal pressure at initial leakage and catastrophic failure as dyed saline was infused via a catheter inserted through the urethra. Initial leakage pressure and pressure at catastrophic failure were compared between sutured and nonsutured sealed partial cystectomies.

RESULTS

Sutured sealed cystectomies showed initial leakage at lower pressures compared to non-sutured cystectomies (8.6 vs. 17.7 mm Hg; P = .0365) but were able to sustain greater pressures at catastrophic failure (34.3 vs. 21.8 mm Hg; P = .007). Catastrophic failure occurred along the seam of all nonsutured sealed cystectomies and at the suture holes in 10 of the 12 sutured bladders.

CONCLUSION

Partial cystectomies were effectively sealed with a BSD in this canine cadaveric bladder model. Augmentation with a simple continuous suture pattern increased the pressure at which catastrophic leakage occurred but lowered initial leak pressure.

CLINICAL SIGNIFICANCE

This study provides evidence supporting the evaluation of BSD use for partial cystectomy in live animals.

Partial cystectomy with a bipolar sealing device in seven dogs with naturally occurring bladder tumors

OBJECTIVE

To describe the use of a bipolar sealing device (BSD) for partial cystectomy in dogs undergoing excision of bladder tumors.

STUDY DESIGN

Multicenter, prospective, clinical pilot study.

SAMPLE POPULATION

Seven client-owned dogs with nontrigonal urinary bladder lesions.

METHODS

Dogs underwent a sealed partial cystectomy with a BSD, with or without cystoscopic guidance of the resection. The sealed cystectomy site was oversewn with a single-layer simple continuous pattern with monofilament absorbable suture.

RESULTS

Sealed partial cystectomy was successfully performed in all dogs, with a median surgical duration of 69 minutes (range, 50-120). Lesions were located at the apex in six dogs and on the ventral midbody of the bladder in one dog. No urine leakage from the BSD luminal seal was visible prior to suture closure in three dogs, while varying amounts of urine leaked from the sealed site in four dogs. Suture was placed over the seal in grossly normal bladder tissue in six dogs and in the BSD peripheral thermal effect zone in one dog; in this latter dog, revision cystorrhaphy was required 3 days later because of uroabdomen. The other six dogs had no clinical evidence of urinary bladder healing complications.

CONCLUSION

The integrity of the seal generated by the BSD tested here on partial cystectomies varied between dogs and was unpredictable.

CLINICAL SIGNIFICANCE

Sealed partial cystectomy with a BSD may reduce exposure of urinary bladder luminal contents to the surgical site. However, the placement of sutures over the seal and through grossly normal bladder tissue is recommended to prevent postoperative uroabdomen.

Distal Ureter Management During Nephroureterectomy: Evidence from a Systematic Review and Cumulative Analysis

INTRODUCTION AND OBJECTIVES

Standard of care in upper tract urothelial cancer is nephroureterectomy with bladder cuff excision (BCE). However, alternative techniques such as transurethral incision/resection have been used to simplify distal ureterectomy. The optimum strategy is unclear, and current guidelines do not specify a gold standard technique. The objective of this study was to perform a systematic review of the literature, to compare BCE and transurethral distal ureter methods.

MATERIALS AND METHODS

A Cochrane and PRISMA-guided systematic literature search was conducted on English language articles from January 2000 to present, reporting on centers' experience with either BCE or transurethral distal ureterectomy. A cumulative meta-analysis comparison between the two procedures was performed. Primary outcome was intravesical recurrence. Secondary outcomes were local/distant recurrence, surgical margins, and disease-specific mortality (DSM). Groups were compared using chi-square analysis.

RESULTS

In total, 66 studies were included after excluding 1795. BCE and transurethral groups contained 6130 and 1183 patients, respectively. Mean/median age ranged from 57.5 to 75.2 years, and follow-up from 6.1 to 78 months. Level of evidence was low, with high risk of bias and small sample size (<100 patients) in 41 (62%) and 52 (79%) studies, respectively. Baseline cancer demographic analysis identified significantly higher rates of high grade, advanced stage, node-positive and carcinoma in situ disease in the BCE group. However, intravesical recurrence (23.6% vs 28.7%, p = 0.0002) and local/distant recurrence (17.9% vs 21.6%, p = 0.02) were significantly lower than the transurethral group. No difference was seen regarding surgical margins (3.1% vs 2.4%, p = 0.27) or DSM (16.8% vs 14.3%, p = 0.06).

CONCLUSIONS

No prospective, randomized comparisons exist for distal ureterectomy at nephroureterectomy. In this analysis, patients undergoing BCE had more advanced disease burden compared with the transurethral group. Despite this, the BCE group had statistically lower intravesical and local/distant recurrence. Further prospective research should be encouraged to identify gold standard ureter management.

Techniques to resect the distal ureter in robotic/laparoscopic nephroureterectomy

Treatment of clinically-organ confined high grade urothelial carcinoma of the upper tract has historically comprised open nephroureterectomy, with the distal ureter and bladder cuff mobilized through a separate open pelvic incision. To decrease morbidity, urologists have increasingly adopted laparoscopy and robotics in performing nephroureterectomy. In many published series of laparoscopic nephroureterectomy, the distal ureter and bladder cuff are detached from the bladder endoscopically by a variation of the “pluck” technique, with the resulting bladder defect left to heal by prolonged indwelling urethral catheter drainage. While the distal ureter and bladder cuff can be excised laparoscopically, it does require advanced laparoscopic skills. With the wrist articulation and stereoscopic vision in robotic surgery, robotic nephroureterectomy (RNU) and bladder cuff excision can be performed in antegrade fashion to mimic the open technique together with the ability to intracorporeally close the bladder defect in a watertight, mucosa to mucosa fashion after excising the bladder cuff. In this review, we discuss the published minimally invasive techniques in resecting the distal ureter and bladder cuff during laparoscopic and RNU.

Single incision cholecystectomy using a clipless technique with LigaSure in a resource limited environment: The Bahamas experience

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SILC in the third world.

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The addition of LigaSure to enhance procedure.

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Look at feasibility.

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Look at cost different.

Background

Scarless/single-incision laparoscopic cholecystectomy (SILC) is a new procedure. It affords a superior cosmetic outcome when compared to conventional laparoscopic cholecystectomy. We examine the application of this technique using LigaSure via a clipless method. The present study looks at the experience of a single surgeon using this method with initial evaluation of the safety, feasibility, affordability, and benefits of this procedure.

Methods

Twenty-eight patients underwent transumbilical SILC at Doctors Hospital from January to December, 2014. The cohort included both emergency and elective patients. There was no difference in the preoperative work-up as indicated. To perform the operation, a 2–2.5-cm linear incision was made through the umbilicus and the single port platform utilized. A 10 mm 30-degree laparoscope, a 5 mm LigaSure and straight instruments were used to perform the laparoscopic cholecystectomy procedure.

Results

All patients except two were operated on successfully. Conversion was considered the placement of an additional epigastric/Right upper quadrant (RUQ) port. The conversion rate to standard LC was 7%. No patient was converted to open cholecystectomy. In the 28 successfully completed patients, the median duration of the operation was 38.5 min and estimated operative blood loss was 24 ml. Patients were commenced on liquid diet immediately on being fully conscious and after return to the ward with an estimated time of 6 h. The mean postoperative hospital stay was 1.4 days. Follow-up visits were conducted for all patients at 2-weeks intervals and continued for 6 weeks after surgery where possible. Two patients developed wound infections. All patients were satisfied with the good cosmetic effect of the surgery. The total satisfaction rate was 100%.

Conclusions

SILC is a safe and feasible technique for operating with scarless outcomes and reducing perioperative discomfort at the same time. The GelPOINTTM is a safe and feasible platform to be used. The procedure can be accomplished using regular instruments and laparoscope. Curved instruments and a bariatric length laparoscope may make the procedure easier and result in greater time saving. The addition of LigaSure™ decreases the complexity of the operation, decreases operative time and blood loss. The technique is economical in a resource-limited environment.

The Feasibility of LigaSure to Create Intestinal Anastomosis

Objective. To evaluate the feasibility and the effectiveness of LigaSure Forced Triad to create intestinal anastomosis in an ex vivo porcino model. Methods. Colon samples (n = 100) were prospectively randomized into 2 groups: LigaSure group (n = 90) and Stapler group (n = 10). The LigaSure group was divided into 9 subgroups, each of 10 samples, according to the different power levels of the LigaSure system (Bar 1, Bars 2, and Bars 3) and radiofrequency application (1 application, 2 applications, and 3 applications) used. All anastomoses were tested for early burst pressure. The LigaSure subgroup having the highest burst pressure was compared with the Stapler group. Finally, the specimen was reviewed by the same pathologist. Results. The burst pressures of the 9 subgroups of LigaSure segments were the following: 29.7 ± 4.5 (Subgroup a); 27.4 ± 3.1 (Subgroup b); 25.3 ± 4 (Subgroup c); 32.9 ± 2.3 (Subgroup d); 30.7 ± 3.8 (Subgroup e); 25.7 ± 4.8 (Subgroup f); 42 ± 4.7 (Subgroup g); 31.8 ± 3.8 (Subgroup h); and 28.5 ± 3 (Subgroup j). Subgroup g (3 bars-power levels/1 frequency application) had the highest burst pressure ( P < .001; ANOVA test). No significant difference was found between burst pressure of Subgroup g and Stapler group (42 ± 4.7 vs 42 ± 4.3, respectively, P = .9). On histological view, the LigaSure anastomosis was formed by collagen sealed without cavitation defects. Conclusions. Our study seems to confirm the feasibility of creating intestinal anastomosis using LigaSure. However, further researches in in vivo models are mandatory before recommending its clinical usage in such settings.

Oncological impact of endoscopic bladder cuff management during nephroureterectomy varies according to upper urinary tract tumor location

OBJECTIVES

To compare the oncological outcome between extravesical excision and transurethral excision for bladder cuff management in patients undergoing nephroureterectomy with upper urinary tract urothelial cancer.

METHODS

From January 2005 to December 2010, 396 patients were enrolled in the present retrospective study. Nephroureterectomy was carried out either by endoscopic or extravesical bladder cuff excision. The oncological outcome between these two procedures was analyzed in patients with different tumor locations.

RESULTS

The average age of the patients was 66.41 ± 10.52 years, and the median follow-up duration was 40.65 ± 23.84 months. For upper urinary tract urothelial cancer management, extravesical bladder cuff excision was carried out in 240 patients, whereas the endoscopic method was carried out in 156 patients. Previous bladder cancer is still the most independent predictor for bladder recurrence (P < 0.001). In addition, endoscopic bladder cuff management for low ureteral tumor was also independently associated with more bladder tumor recurrence (P = 0.017). Non-organ confined pathological stage still independently predicted metastasis (P < 0.001) and cancer-specific death (P < 0.001).

CONCLUSIONS

There are similar oncological outcomes after nephroureterectomy combined with extravesical or endoscopic bladder cuff management for patients with upper urinary tract urothelial cancer above the low ureter. However, there is a higher incidence of bladder tumor recurrence for the low ureteral tumor after nephroureterectomy with endoscopic bladder cuff excision.

Robotic-assisted laparoscopic nephroureterectomy and bladder cuff excision

BACKGROUND AND OBJECTIVES

Our aim was to show that bladder cuff excision and distal ureterectomy can be safely performed by using the LigaSure device during robotic-assisted laparoscopic nephroureterectomy.

METHODS

A 60-year-old man presented with gross hematuria. He was diagnosed with upper urinary tract transitional cell carcinoma (TCC) on the left side and was scheduled for robot-assisted laparoscopic surgery. Without changing the patient's position, sealing with the LigaSure atlas for bladder cuff excision and distal ureterectomy was performed.

RESULTS

The operating time was 140 minutes from the initial incision to skin closure of all incisions. The estimated blood loss during the surgery was 120 mL. There were no intraoperative or postoperative complications. The Foley drain was removed on day 3 after normal cystographic findings, and the patient was discharged from the hospital on the fourth postoperative day.

CONCLUSION

Robot-assisted nephroureterectomy with distal ureterectomy in the same position using a LigaSure device is a safe alternative for upper tract transitional cell carcinoma.