Evaluation of the safety, efficacy, and versatility of a new surgical energy device (THUNDERBEAT) in comparison with Harmonic ACE, LigaSure V, and EnSeal devices in a porcine model

Advanced bipolar vessel sealing devices vs conventional bipolar energy in minimally invasive hysterectomy: a systematic review and meta-analysis

PURPOSE

To compare conventional bipolar electrosurgery with advanced bipolar vessel sealing (ABVS) devices for total laparoscopic hysterectomy (TLH).

METHODS

A systematic review was conducted by searching Scopus, PubMed/MEDLINE, ScienceDirect, and Cochrane Library from January 1989 to November 2021. We identified all studies comparing ABVS devices with conventional bipolar electrosurgery in TLH and reporting at least one of the following outcomes: total blood loss, total operative time, hospital stay, perioperative complications, or costs. Meta-analysis was conducted with a random effect model reporting pooled mean differences and odds ratios (ORs) with related 95% confidence intervals (CIs).

RESULTS

Two randomized controlled trials and two retrospective studies encompassing 314 patients were included out of 615 manuscripts. The pooled estimated total blood loss in the ABVS devices group was lower than conventional bipolar electrosurgery of 39 mL (95% CI - 65.8 to - 12.6 mL; p = .004). The use of ABVS devices significantly reduced the total operative time by 8 min (95% CI - 16.7 to - 0.8 min; p = .033). Hospital stay length did not differ between the two groups, and a comparable overall surgical complication rate was observed [OR of 0.9 (95% CI 0.256 - 3.200; p = .878].

CONCLUSIONS

High-quality evidence comparing ABVS devices with conventional bipolar electrosurgery for TLH is lacking. ABVS devices were associated with reduced total blood loss and operative time; however, observed differences seem clinically irrelevant. Further research is required to clarify the advantages of ABVS devices over conventional bipolar electrosurgery and to identify cases that may benefit more from their use.

Comparison of perioperative outcomes between bipolar sealing, ultrasonic shears and a hybrid device during laparoscopic gastrectomy for early gastric cancer: a prospective, multicenter, randomized study

BACKGROUND

Although EBDs are essential for minimally invasive surgery, well-established prospective randomized studies comparing EBDs are scarce. This study aimed to compare the intraoperative inflammatory response and short-term surgical outcomes among different energy-based devices (EBDs) in laparoscopic distal gastrectomy (LDG).

METHODS

Patients with clinical stage I gastric cancer scheduled for LDG at two different medical centers were prospectively randomized into three groups: ultrasonic shears (US), advanced bipolar (BP) and ultrasonic-bipolar hybrid (HB). The C-reactive protein (CRP) level, operation time, intraoperative blood loss (IBL), laboratory tests, cytokines (interleukin (IL)-6 and IL-10), hospital stay, and complication rate were analyzed. A novel semiquantitative measurement method using indocyanine green (ICG) and a near-infrared camera measured the amount of lymphatic leakage.

RESULTS

The primary endpoint, the CRP level, was significantly lower in the BP (n = 60) group than in the US (n = 57) or HB (n = 57) group [9.03 ± 5.55 vs. 11.12 ± 5.02 vs. 12.67 ± 6.14, p = 0.001, on postoperative day (POD) 2 and 7.48 vs. 9.62 vs. 9.48, p = 0.026, on POD 4]. IBL was significantly lower in BP than in US or HB (26.3 ± 25.3 vs. 43.7 ± 42.0 vs. 34.9 ± 37.0, p = 0.032). Jackson-Pratt drainage triglycerides were significantly lower in BP than in US (53.6 ± 33.7 vs. 84.2 ± 59.0, p = 0.11; HB: 71.3 ± 51.4). ICG fluorescence intensity, operation time, laboratory results, cytokines, hospital stay, and complication rate were not significantly different among the 3 groups.

CONCLUSION

BP showed a lower postoperative CRP level and less IBL than US and HB, suggesting less collateral thermal damage and better sealing function. Surgeons may consider this when selecting EBDs for laparoscopic surgery.

Electrocautery, Harmonic, and Thunderbeat Instruments in Parotid Surgery: A Retrospective Comparative Study

The aim of this retrospective study has been to compare the surgical outcomes of patients undergoing superficial parotidectomy with three different instruments: bipolar electrocautery, ultrasound, and mixed energy instruments. The clinical records of 102 patients who had undergone superficial parotidectomy for benign tumors between January 2016 and April 2022 were considered. Based on the tool used during the surgery, the patients were divided into three study groups: classic electrocautery hemostasis group (CH group), ultrasonic instrument group (HA group), and combined energy instrument group (TB group). The duration of surgery, the total post-operative drainage volume, and the intra-operative blood loss were significantly higher in the CH group compared to the HA and the TB group, while the differences were not significant between the latter two groups. Facial nerve weakness was detected in 45.9% of the CH group, 12.5% of the HA group, and 21.2% of the TB group. The rate of facial nerve dysfunction in the CH group was significantly higher than in the HA group (0.011). In the patients who experienced post-operative facial nerve dysfunction, the recovery time was significantly shorter in the HA group compared to the CH and the TB group. The HA and TB groups have demonstrated comparable and significantly better surgical outcomes than bipolar electrocautery. Ultrasound instruments have been shown to cause, in comparison with the other techniques, a lower rate of temporary facial nerve dysfunction and, if this is present, lead to a faster spontaneous recovery time.

A Comparative Study of an Integrated Ultrasonic/Bipolar Sealing Device Versus an Articulating Bipolar Sealing Device for Laparoscopic Liver Surgery

BACKGROUND

Sealing devices (SD) seal and cut tissue through different energy modalities, and are routinely used in laparoscopic liver surgery (LLS). The aim of this study is to compare the outcome of Thunderbeat (TB), an integrated ultrasonic/bipolar SD, versus Enseal (ES), an articulating bipolar SD, in LLS.

METHODS

A retrospective analysis was conducted in a single center from December 2013 to September 2020. The primary endpoint was difference in blood loss (BL) between ES and TB. Secondary endpoints were complications, operative time, hospital stay, and 90-day mortality.

RESULTS

352 patients were identified: TB (n = 105) and ES (n = 247). Median BL was significantly lower with TB (50 mL [20-120]) compared to ES (100 mL [50-250]) (p < 0.0001). Significant differences were identified for median operative time (TB 115 min [45-300]) vs. ES 140 min [40-370]; p = 0.0008) and median hospital stay (TB 2 days [1-4] vs. ES 4 days [3-6]; p < 0.0001). No major differences were encountered for postoperative bleeding (TB 0% vs. ES 1%; p = 0.5574), biliary leak (TB 1% vs. ES 2%; p = 1.0000), and 90-day mortality (TB 0% vs. ES 1%; p = 1.0000).

CONCLUSION

The integrated ultrasonic/bipolar SD is superior to the articulating bipolar SD in LLS for intraoperative BL without an increase in complications.

Feasibility and safety of renal artery closure with advanced bipolar energy device during nephrectomy

Introduction:

Many devices are available to control the renal pedicle during nephrectomy but the gold standard is still a matter of debate. Nanotechnology has evolved to include vessel-sealing systems; companies guarantee an efficacy for vessels until 7 mm. The aim of our study is to evaluate feasibility and safety of closure of the renal artery with radiofrequency energy during nephrectomy.

Methods:

We retrospectively evaluated consecutive patients undergoing nephrectomy between November 2016 and July 2020. Inclusion criteria were: renal artery diameter <7 mm and no significant arterial wall calcification. The EnSeal device was used in all cases for dissection, hemostasis and to secure the renal artery when feasible.

Results:

Overall 101 patients underwent nephrectomy, in 68 cases the radiofrequency alone was used to close the renal artery; in 45 patients during a laparoscopic procedure and in 23 during an open surgery. Conversion to open surgery was never necessary. No patients had major hemorrhagic complications. Mean operative time was 75 min, mean intraoperative blood loss was 85 ml. Overall 11 patients had postoperative complications, according to Clavien-Dindo: five grade I, three grade II, three grade III.

Discussion:

In our experience the closure of the renal artery with a radiofrequency energy device is a feasible and safe procedure. It allows a safe manipulation of the renal hilum, free from clips, which could limit surgeons’ maneuvers and be dislocated. We believe that a deep knowledge of the available technologies is fundamental for the surgeon and guarantees the best achievable results.

A pilot randomized controlled trial comparing THUNDERBEAT to the Maryland LigaSure energy device in laparoscopic left colon surgery

BACKGROUND

The THUNDERBEAT is a multi-functional energy device which delivers both ultrasonic and bipolar energy, but there are no randomized trials which can provide more rigorous evaluation of the clinical performance of THUNDERBEAT compared to other energy-based devices in colorectal surgery. The aim of this study was to compare the clinical performance of THUNDERBEAT energy device to Maryland LigaSure in patients undergoing left laparoscopic colectomy.

METHODS

Prospective randomized trial with two groups: Group 1 THUNDERBEAT and Group 2 LigaSure in a single university hospital. 60 Subjects, male and female, of age 18 years and above undergoing left colectomy for cancer or diverticulitis were included. The primary outcome was dissection time to specimen removal (DTSR) measured in minutes from the start of colon mobilization to specimen removal from the abdominal cavity. Versatility (composite of five variables) was measured by a score system from 1 to 5 (1 being worst and 5 the best), and adjusted/weighted by coefficient of importance with distribution of the importance as follow: hemostasis 0.275, sealing 0.275, cutting 0.2, dissection 0.15, and tissue manipulation 0.1. Other variables were: dryness of surgical field, intraoperative and postoperative complications, and mortality. Follow-up time was 30 days.

RESULTS

60 Patients completed surgery, 31 in Group 1 and 29 in Group 2. There was no difference in the DTSR between the groups, 91 min vs. 77 min (p = 0.214). THUNDERBEAT showed significantly higher score in dissecting and tissue manipulation in segment 3 (omental dissection), and in overall versatility score (p = 0.007) as well as versatility score in Segment 2 (retroperitoneal dissection p = 0.040) and Segment 3 (p = 0.040). No other differences were noted between the groups.

CONCLUSIONS

Both energy devices can be employed effectively and safely in dividing soft tissue and sealing mesenteric blood vessels during laparoscopic left colon surgery, with THUNDERBEAT demonstrating some advantages over LigaSure during omental dissection and tissue manipulation.

CLINICALTRIAL

gov # NCT02628093.

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:

Experimental assessment of three electrosurgical tissue-sealing devices in a porcine model

Three electrosurgical tissue-sealing devices (EnSeal ETSDRC-01, LigaSure LS1500 and Thunderbeat TB-0535PC) were compared regarding sealing time (ST), maximum working temperature (WTmax) and the total (MTZtotal) as well as the collateral microscopic thermal injury zone (MTZcollat) using laparoscopic handpieces 5 mm in diameter on four types of tissue (liver, mesentery, cross striated muscle and spleen) in an in vivo porcine model. LigaSure had the lowest mean ST in spleen, mesentery, muscle and liver, followed by Thunderbeat and EnSeal with significant differences between all types of tissues and devices. The significantly lowest mean WTmax was obtained for EnSeal in mesentery, muscle and liver. LigaSure and EnSeal operated at the lowest temperature in spleen without a significant difference between them. Thunderbeat produced significantly higher temperature peaks in all cases. The lowest mean MTZtotal was caused by LigaSure and EnSeal in spleen, mesentery and muscle without significant differences between them, followed by the significantly higher values of Thunderbeat. Nevertheless, Thunderbeat produced the significantly lowest mean MTZtotal in the liver. EnSeal produced the lowest mean MTZcollat in the liver, followed by LigaSure and Thunderbeat showing significant differences. EnSeal and LigaSure produced the lowest mean MTZcollat in the spleen, mesentery and muscle without significant differences between them, followed by the significantly higher values of Thunderbeat. Based on the results of this study, Thunderbeat seems to be more invasive to tissue integrity (even without the activation of the ultrasonic scissor function) than EnSeal or LigaSure, that operate at lower temperatures and were found to cause negligible collateral thermal damage.

Prospective, Randomized, Comparative, Multicenter Study of the Hybrid Ultrasonic Advanced Bipolar Device and the Ultrasonic Coagulating Shears in Open Thyroidectomy

Background. The hybrid ultrasonic advanced bipolar device (HUB) that integrates ultrasonic energy and advanced bipolar energy was recently developed and applied to thyroid surgery. The purpose of this study was to compare the efficacy and safety of HUB and ultrasonic coagulating shears for open thyroidectomy. Methods. A total of 200 patients were enrolled from April to September 2017 in this prospective, randomized, multicenter study. Patients were randomly assigned to an ultrasonic group (n = 101) or a hybrid group (n = 99). Results. Operation times were similar in the 2 study groups, that is, 54.2 ± 25.2 minutes in the ultrasonic group and 50.2 ± 21.6 minutes in the hybrid group. Postoperative surgical results and morbidities were no different in the 2 groups. However, the total amount of bleeding was significantly less in the hybrid group (13.0 ± 17.7 mg vs 8.6 ± 11.5 mg; P = .042). Conclusions. Our study showed that there was no significant difference between the 2 groups in postoperative surgical results and morbidity. The total bleeding amount was significantly less in the hybrid group. The study shows that HUB is comparable to the ultrasonic coagulating shears in terms of efficacy and safety during thyroid surgery.

Steam induced by the activation of energy devices under a wet condition may cause thermal injury

BACKGROUND

During esophagectomy for esophageal cancer, meticulous attention is needed to prevent thermal injury to the vital organs, such as the recurrent laryngeal nerve (RLN) and tracheobronchus. In order to clarify the novel mechanism behind thermal injury induced by energy devices, we investigated the temperature of steam with the use of two different devices under wet and dry conditions.

METHODS

An ultrasonic device (Sonicision™) and a vessel sealing device (Ligasure™) were studied. We evaluated the temperature at the tip of the devices and the steam when the devices were activated under different grasping ranges, under four different combinations of device and muscle, and under four different wet/dry conditions (dry-dry, dry-wet, wet-dry, and wet-wet).

RESULTS

Although the maximum temperature of the devices was significantly higher with Sonicision™ than with Ligasure™, the maximum temperature of the steam was significantly higher with Ligasure™ than with Sonicision™ in almost all situations. At 1 mm away from Sonicision™, the critical temperature more than 60 °C was observed only when used with one-third grasping range under the wet-dry or the wet-wet conditions. In case of Ligasure™, high-temperature steam was observed when used with one-third grasping under the wet-dry or the wet-wet condition and two-third grasping under the dry-wet, the wet-dry, or the wet-wet condition. Under the wet condition, the emission of steam from the non-grasping part of Ligasure™ caused a spike in temperature that exceeded the critical temperature.

CONCLUSION

We demonstrated that the use of energy devices under a wet condition generates steam from the non-grasping part of the devices. The temperatures of steam from Ligasure™ were significantly higher than that from Sonicision™. To prevent thermal injury to the vital organs, a very attentive and meticulous surgical technique is imperative considering the characteristics of each device.

Safety and effectiveness of a novel generator algorithm for bipolar vessel sealing: a randomised controlled chronic animal study

BACKGROUND

Electrosurgical vessel sealers are gradually replacing conventional techniques such as ligation and clipping. Algorithms that control electrosurgical units (ESU), known as modes, are important for applications in different surgical disciplines. This chronic porcine animal study aimed to evaluate the safety and effectiveness of the novel thermoSEAL electrosurgical vessel sealing mode (TSM). The BiClamp® mode (BCM) of the renowned VIO® 300 D ESU served as control. BCM has been widely available since 2002 and has since been successfully used in many surgical disciplines. The TSM, for the novel VIO® 3 ESU, was developed to reduce sealing time and/or thermal lateral spread adjacent to the seal while maintaining clinical success rates. The primary aim of this study was to investigate the long-term and intraoperative seal quality of TSM.

METHODS

The BiCision® device was used for vessel sealing with TSM and BCM in ten German Landrace pigs which underwent splenectomy and unilateral nephrectomy during the first intervention of the study. The seals were cut with the BiCision® knife. Ninety-nine arteries, veins and vascular bundles were chronically sealed for 5 or 21 days. Thereafter, during the second and terminal intervention of the study, 97 additional arteries and veins were sealed. The carotid arteries were used for histological evaluation of thermal spread.

RESULTS

After each survival period, no long-term complications occurred with either mode. The intraoperative seal failure rates, i.e. vessel leaking or residual blood flow after the first sealing activation, were 2% with TSM versus 6% with BCM (p = 0.28). The sealing time was significantly shorter with TSM (3.5 ± 0.69 s vs. 7.3 ± 1.3 s, p < 0.0001). The thermal spread and burst pressure of arteries sealed with both modes were similar (p = 0.18 and p = 0.61) and corresponded to the histological evaluation. The measured tissue sticking parameter was rare with both modes (p = 0.33). Tissue charring did not occur. Regarding the cut quality, 97% of the seals were severed in the first and 3% in the second attempt (both with TSM and BCM).

CONCLUSIONS

The novel TSM seals blood vessels twice as fast as the BCM while maintaining excellent tissue effect and clinical success rates.

TRIAL REGISTRATION

Not applicable.

Comparison of the efficacy and safety of two advanced vessel sealing technologies in total laparoscopic hysterectomy

AIM

Adequately powered, randomized controlled studies evaluating efficacy and safety of advanced bipolar energy devices in gynecologic laparoscopic surgery are very few. We aimed to compare the two most commonly used devices in total laparoscopic hysterectomy.

METHODS

This randomized controlled trial was carried out in the department of obstetrics and gynecology in an education and research hospital. One hundred thirty-two women who underwent total laparoscopic hysterectomy for benign indications were included. Women with age younger than 18 years, suspected malignancy, stage 3-4 endometriosis and cervical/intraligamentary leiomyoma were excluded. Patients were randomized preoperatively to LigaSure or Articulating Enseal. One experienced surgeon performed all operations.

RESULTS

LigaSure was used in 67 patients and Enseal was used in 65 patients. Primary outcomes of the study were operative time (time from start of sealing and transection of the round ligament until completion of colpotomy) and total operative time (time from skin incision to skin closure). Secondary outcomes were intraoperative blood loss (blood lost during operative time period) and perioperative complications. Operative time was significantly shorter in LigaSure group (P = 0.001). Total operative time, intraoperative blood loss and perioperative complications were similar. When two groups were further classified according to uterine weight taking 300 g as cut-off value, operative time was significantly shorter in LigaSure group in both subgroups (P = 0.003 and P = 0.007).

CONCLUSION

LigaSure use in total laparoscopic hysterectomy shortens operative time when compared with Enseal; without an apparent increase in intraoperative blood loss and perioperative complications. On the other side, total operative time remains unaffected.

Surgical outcomes according to the type of monopolar electrocautery device used in laparoscopic surgery for right colon cancer: a comparison of endo-hook versus endo-shears

BACKGROUND

Although monopolar electrocautery is preferred by many laparoscopic surgeons and is more cost-effective than bipolar or ultrasonic scissors, few studies have compared these outcomes between different monopolar electrocautery devices used in laparoscopic surgery. Therefore, this study compared the surgical outcomes between monopolar endo-hook versus endo-shears during laparoscopic right hemicolectomy for right colon cancer.

METHODS

Using a prospective database of patients treated at our institute, we analyzed the surgical outcomes of 358 consecutive patients with right colon cancer who underwent curative laparoscopic surgery with a monopolar endo-hook (n = 164) or endo-shears (n = 194) between March 2009 and March 2017.

RESULTS

There were no differences in age, sex, body mass index, American Society of Anesthesiologists' grade, previous operative history, or clinical stage between the endo-hook and endo-shears groups. The estimated blood loss was similar between the endo-hook and endo-shears groups (90.9 ± 60.3 vs. 92.0 ± 89.3 mL; P = 0.893). The number of harvested lymph nodes was greater in the endo-hook group (53.5 ± 20.3 vs. 48.1 ± 18.5; P = 0.008). Hospital stay was shorter in the endo-hook group (6.8 ± 2.2 vs. 7.8 ± 4.8 days; P = 0.013). Although chylous ascites was more frequent in the endo-hook group (21.3% vs. 7.7%, P < 0.001), the postoperative morbidity rate was lower in this group (9.8% vs. 18.0%; P = 0.025). All instances of chylous ascites healed spontaneously without intervention.

CONCLUSIONS

This study showed that the use of a monopolar endo-hook during laparoscopic right hemicolectomy might permit more meticulous lymph-node dissection and reduce morbidity compared with the use of monopolar endo-shears. Therefore, we suggest that the outcomes of laparoscopic surgery might be associated with the type of electrocautery device used.

Evaluation and Comparison of Contemporary Energy-Based Surgical Vessel Sealing Devices

Introduction: We evaluated and compared five currently available energy-based vessel sealing devices to assess typical surgical metrics.

Methods: We tested Caiman 5 (C5), Harmonic Scalpel Ace Plus (HA), Harmonic Ace +7 (HA7), LigaSure (LS), and Enseal G2 (ES) on small (2–5 mm), medium (5.1–7 mm), and large (7.1–9 mm) vessels obtained from 15 Yorkshire pigs. Vessels were randomly sealed and transected. We recorded sealing and transection time, charring and carbonization, thermal spread, and bursting pressure (BP). Specimens were sent for histopathologic evaluation of seal quality and thermal spread.

Results: A total of 246 vessels were evaluated: 125 were arteries and 121 were veins. There was no difference in BPs for small size arteries. For medium arteries, C5 provided the highest BP (proximal and distal jaw), followed by HA7, ES, LS, and HA [1740, 1600, 1165, 1165, 981, and 571 mm Hg, respectively, HA<C5-D(<0.001); HA<C5-P(<0.001); HA<ES(0.002); HA<HA7(0.002); HA7<C5-P(0.026); ES<C5-P(0.026); LS<C5-P(0.001); LS<C5-D(0.014)]. For large arteries, C5 and LS provided highest BP followed by HA7, ES, and HA [1676, 530, 467, 467, and 254 mm Hg, respectively, C5<HA(<0.001); C5<HA7(0.006); C5<ES(0.006); C5<LS(0.012)]. There were no bursting pressure failures for C5, HA7, and LS up to 9 mm vessels. For medium and large size arteries, HA had bursting failure of 20% and 40%, respectively. The ES was significantly less efficient with small, medium, and large arteries with bursting failure rates of 10%, 40%, and 80%, respectively.

Conclusions: In this study, C5 outperformed all other devices. However, all of the devices provide a seal that was superphysiologic in that all burst pressures were >250 mm Hg.

Lateral thermal spread induced by energy devices: a porcine model to evaluate the influence on the recurrent laryngeal nerve

BACKGROUND

Recurrent laryngeal nerve (RLN) paralysis is a frequently observed complication after esophagectomy, and thermal injury is considered to be one of the causes. The difference in the lateral thermal spread associated with the grasping range of various energy devices remains unknown.

METHODS

Ultrasonic devices (Harmonic® HD1000i and Sonicision™) and a vessel-sealing device (Ligasure™) were studied. We evaluated the temperature of these devices, the activation time required, and the thermal spread on porcine muscle when the devices were used with different grasping ranges (thermal spread study). In addition, we evaluated the influence of thermal spread by short grasping use of the energy devices on the viability of RLN in a live porcine model (NIM study).

RESULTS

In the thermal spread study, the temperature of the ultrasonic devices lowered as grasping range increased, whereas the highest temperature of Ligasure was observed when used with two-thirds grasping. The activation time of ultrasonic devices became longer as grasping range increased, whereas the grasping range did not influence the activation time of Ligasure. Thermal spreads 1 mm from the energy devices were unaffected by the grasping ranges. Although the temperature of the Ligasure was lower than that of the ultrasonic devices, thermal spread by Ligasure was significantly greater than that induced by the ultrasonic devices. In the NIM study, the activation of the Sonicision with one-third grasping range did not cause EMG changes at distances of up to 1 mm from the RLN, whereas applying Ligasure with a one-third grasping range 1 mm away from the RLN led to a critical result.

CONCLUSIONS

The grasping range did not influence the thermal spread induced by the energy devices. Ultrasonic devices may be safer in terms of lateral thermal spread to the RLN than Ligasure.

Laparoscopic ultrasonic dissectors: technology update by a review of literature

The evolution of minimally invasive surgery has brought forward the appearance of new advances in the course of the most recent couple of years and has introduced energy-based devices. The newest among them today are the ultrasonically activated devices, which are utilized with a great deal of components in-play, including ergonomics and financial aspects amid surgery. The methodology embraced was finding significant investigations through studies from PubMed, Medline and Google Scholar on current ultrasonic dissectors, which are Ethicon’s Harmonic Scalpel (ACE^®), Covidien’s Sonicision™ (SNC), Conmed’s SonoSurg^® (SS) and Olympus’s Thunderbeat^®, to describe their efficacy in terms of vessel sealing speed, vessel burst pressure, visibility, operation time and thermal speed. We found postmarketing evidence to determine which device exhibits the better performance. Animal studies showed that emissivity values and maximum temperatures for coagulation are similar among devices but maximum cutting temperatures are significantly different: ACE = 191.1°C, SNC = 227.1°C, SS = 184.8°C (p < 0.001). Cooling times are significantly different among devices: 35.7 s for ACE, 38.7 s for SNC and 27.4 s for SS (p < 0.001). Cooling times of passive jaws to reach 60°C after activation were also significantly different: 25.4 s for ACE, 5.7 s for SNC, and 15.4 s for SS (p < 0.001). The perfect device would unify brilliant hemostatic outcomes with visual sharpness while permitting none or insignificant thermal damage at the place of use.

Assessment of the Safety of the New Hybrid Pencil Type Energy (NP) Device Used Close to the Recurrent Laryngeal Nerve in a Porcine Model: Comparison With a Conventional Electrosurgical Knife

BACKGROUND

Recurrent laryngeal nerve (RLN) paralysis is mainly associated with esophagectomy, and it may result in not only other morbidities, such as aspiration pneumonia, but also in long-term issues. Therefore, an approach to prevent RLN paralysis is necessary. The present study was designed to determine the technical usability of the new hybrid pencil type energy (NP) device developed by Olympus Corporation (Tokyo, Japan) and compare it with a conventional electrosurgical knife (EK) for resection around the RLN lymph nodes.

METHODS

This nonsurvival (acute) study included 10 pigs (20 RLNs) and investigated the threshold for thermal RLN damage with the NP device and a conventional EK. To obtain basic information for our study, a preliminary experiment for heat spread was performed.

RESULTS

When using the EK device, the amplitude value disappeared at a distance of 1 mm from the RLN, but when using the NP device, the amplitude value was maintained up to a distance of 0.5 mm. There were significant differences at distances of 0 mm, 0.5 mm, and 1 mm between the NP and EK devices. Furthermore, heat spread was lower with the NP device than with the EK device.

CONCLUSIONS

The new energy device developed by Olympus Corporation was found to be technically safe for resection of the RLN lymph nodes in a porcine model. To the best of our knowledge, this is the first study to demonstrate the potential advantages of using this new energy device in a clinical aspect.

Feasibility Study of a Newly Developed Hybrid Energy Device Used During Laparoscopic Liver Resection in a Porcine Model

BACKGROUND

Although various devices have been clinically used for laparoscopic liver resection (LLR), the best device for liver parenchymal transection remains unknown. Olympus Corp (Tokyo, Japan) developed a laparoscopic hybrid pencil (LHP) device, which is the first electric knife to combine ultrasound and electric energy with a monopolar output. We aimed to evaluate the feasibility of using the LHP device and to compare it with the laparoscopic monopolar pencil (LMP) and laparoscopic ultrasonic shears (LUS) devices for LLR in a porcine model.

METHODS

Nine male piglets underwent laparoscopic liver lobe transections using each device. The operative parameters were evaluated in the 3 groups (n = 24 lobes) during the acute study period. The imaging findings from contrast-enhanced computed tomography and histopathological findings of autopsy on postoperative day 7 were compared among groups (n = 6 piglets) during the long-term study.

RESULTS

The transection time was shorter ( P = .001); there was less blood loss ( P = .018); and tip cleaning ( P < .001) and instrument changes were less often required ( P < .001) in the LHP group than in the LMP group. The LHP group had fewer instances of bleeding ( P < .001) and coagulator usage ( P < .001) than did the LUS group. In the long-term study, no postoperative adverse events occurred in the 3 groups. The thermal spread and depth of the LHP device were equivalent to those of the LMP and LUS devices (vs LMP: P = .226 and .159; vs LUS: P = 1.000 and .574).

CONCLUSIONS

The LHP device may be an efficient device for LLR if it can be applied to human surgery.

Evaluation of THUNDERBEAT® in open liver resection- a single-center experience

Background

THUNDERBEAT® (TB) (Olympus Medical Systems Corp., Tokyo, Japan) is a dynamic energy system device that simultaneously delivers ultrasonically generated frictional heat energy and electrically generated bipolar energy. TB is being routinely used in various operative procedures, however, less is known about its utility in liver resection. We, herein, report our early experience of using TB in open liver resection particularly in patients with normal or near-normal liver parenchyma.

Methods

We retrospectively reviewed the clinical characteristics, and evaluated the perioperative outcome of twenty-eight patients who underwent liver resection with TB, and twenty-four patients who underwent liver resection with basic procedure in our institution. The resection type was stratified into: major hepatectomy; resection of 3 or more than 3 Couinauds segments, and minor hepatectomy; resection of less than 3 Couinauds segments.

Results

Liver resection time (mean ± SD) in TB group with major hepatectomy was significantly shorter: 16.7 ± 8.8 compared to 62.8 ± 39.4 min in basic procedure group (P < 0.0001). Accordingly, the liver resection time (mean ± SD) in TB group with minor hepatectomy was also significantly shorter, 8.3 ± 2.9 min compared to 45.2 ± 23.9 min in liver resection with basic procedure (P < 0.001). No significant difference was observed between the groups in terms of intraoperative blood transfusion ratio, postoperative complication and postoperative liver dysfunction.

Conclusion

TB as a new energy device can offer a safe, reliable and substantially rapid liver resection particularly in patients with normal or near-normal liver parenchyma.

A comparison of short-term outcomes of neck dissection for head and neck cancers using Thunderbeat™, LigaSure™ or treatment without an energy-based device: A case controlled study

OBJECTIVE

The aim of this study was to evaluate the efficacy of the new energy-based device Thunderbeat in neck dissection (ND) for head and neck cancer.

MATERIALS AND METHODS

We retrospectively examined 95 consecutive patients who underwent ND for head and neck squamous cell carcinoma between April 2013 and March 2018. The patients were divided into three groups: ND without the energy-based device (control group), ND using the LigaSure Small Jaw (LS group), and ND using the Thunderbeat Open Fine Jaw (TB group). The outcomes were compared among the three groups, as measured by the duration of ND (dissection time), blood loss during ND, and postoperative complications. We also analyzed the factors that may influence dissection time using multivariate analysis.

RESULTS

Compared to the control group, dissection time was found to be significantly shorter in both energy-based device groups (LS group and TB group) (96.4, 71.1, and 66.0 min, respectively, p = 0.0015) by univariate analysis. Blood loss during ND did not differ significantly among the three groups. Multivariate analysis showed that ND using the Thunderbeat as well as elderly patients (70 years and over), less extensive surgery (3 or fewer neck levels), and absence of extracapsular invasion were independently and significantly associated with shorter dissection time (p = 0.0069, 0.0337, <0.0001, and 0.0015, respectively). The incidence of postoperative complications in the LS group (20%) tended to be higher than those in the other groups (5.6% in the control group and 3.4% in the TB group), although the differences were not significant.

CONCLUSION

ND for head and neck cancers using the Thunderbeat is a safe and reliable method in terms of duration of dissection without increasing postoperative complications.

Thermal effects of the Thunderbeat™ device on the recurrent laryngeal nerve during thyroid surgery

PURPOSE

To investigate the safety of the Thunderbeat^™ (TB) device in thyroid surgery by clarifying its thermal effects on the recurrent laryngeal nerve (RLN).

METHODS

We performed thyroidectomy using TB on four female pigs under general anesthesia. TB was applied 0, 1, and 2 mm from the RLN. The effects of incisions made in tissues in the vicinity of the RLN were evaluated by intraoperative neuromonitoring and pathological examination.

RESULTS

The value of the neural integrity monitor (NIM) was unchanged at 2 and 1 mm, but there was loss of signal at 0 mm. The differences between 2 and 0 mm were not clear from the pathological findings.

CONCLUSIONS

When using the TB device during thyroid surgery, it is recommended that it is visually kept from making any contact with the RLN.

Comparison of the Thunderbeat and Other Energy Devices in Laparoscopic Colorectal Resection: A Single-Center Experience

Background: The THUNDERBEAT (TB) is a relatively novel energy device that is used in laparoscopic colorectal resection (LCR), which integrates both ultrasonic and bipolar energy. There are limited data on its use in LCR, compared with bipolar diathermy (LigaSure^™ [LS]) or ultrasonically generated heat (Harmonic ACE [HA]). The aim of this study was to compare outcomes in patients undergoing LCR with TB versus LS or HA, for both benign and malignant colorectal diseases. Methods: This study is a prospective trial using retrospective controls in patients undergoing LCR. The study period was over 6 months from June 2015, during which all elective laparoscopic colonic resections were performed using TB only. The retrospective control population included all consecutive patients who underwent LCR during the preceding 6 months, using either LS or HA. The primary outcome measure was the total operative time. Secondary outcome measures evaluated were rates of postoperative surgical complications, mortality, and length of stay. Results: A total of 114 patients were included in the study. Median operative time was not significantly different between LS/HA and TB arms (246 versus 240 minutes, P = .779). Both arms showed no device failure. There was equivalent rate of intraoperative complications (P = .755) and conversion to open surgery (P = .075). There were no statistically significant differences in postoperative morbidity (P = .938) and mortality (P = .392) observed between the two arms. There was also no difference in the length of stay between LS/HA and TB arms (6 versus 7 days, P = .085). Conclusions: Our dataset has the largest number of cases comparing TB and other energy devices in laparoscopic colorectal cancer surgery. They all appear to be equally safe and effective. Operating the TB device does not require a steep learning curve and utilizes similar techniques transferable from the use of other conventional energy devices.

The invention of microwave surgical scissors for seamless coagulation and cutting

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of a new energy device for parenchymal transection in laparoscopic liver resection

INTRODUCTION

THUNDERBEAT (TB) is a novel device that uses both ultrasonic and advanced bipolar energies for hemostasis. Several recent human studies have proved the safety and efficacy of TB in different surgical procedures, but there have been no similar studies about its efficacy in hepatic parenchymal transection. Therefore, the aim of the study was to assess the safety and efficacy of the TB device in laparoscopic liver resection.

METHODS

This retrospective study compared TB and ultrasonic Harmonic devices in 80 patients who underwent laparoscopic liver resection from 2010 to 2016 in our institution. To reduce the selection bias, the two groups were matched in a 1-to-2 ratio on the basis of propensity scores.

RESULTS

There were no differences in the preoperative patient characteristics between the two groups. The extent of liver resection was comparable between the groups. Although the Harmonic group's intraoperative blood loss and operative time were less than that of the TB group, the differences were not statistically significant (P = 0.08, P = 0.32, respectively). Postoperative complications, mortality within 90 days, and hospital stay were comparable between the two groups.

CONCLUSION

TB is as safe and effective for parenchymal transection in laparoscopic hepatectomy as ultrasonic devices, but it is not a superior alternative.

Total and Subtotal Laparoscopic Gastrectomy for the Treatment of Advanced Gastric Cancer: Morbidity and Oncological Outcomes

BACKGROUND

A debate is still surrounding the use of laparoscopic surgery for advanced gastric cancer (AGC) related to doubts about the requirements to satisfy oncologic criteria. The aim of this study is to analyze the oncological results, the intraoperative complications, and the short- and medium-term morbidity and mortality in patients with AGC who underwent subtotal laparoscopic gastrectomy (SLG) or total laparoscopic gastrectomy (TLG) with extended lymphadenectomy.

MATERIALS AND METHODS

We reviewed medical records of patients who underwent radical gastrectomy for AGC started laparoscopically with the intent of curative surgery, between July 2007 and October 2015. We recruited 74 patients and studied demographics, American Society of Anesthesiologists (ASA) score, pTNM stage, histologic pattern of the tumor, duration of surgery, conversion rate, estimated blood loss, number of resected lymph nodes, type of gastrointestinal reconstruction, postoperative complication, mortality rate, length of stay, time to canalization and resumption of food intake, and overall and disease-free survival rate.

RESULTS

We performed 74 interventions, with a conversion rate of 14.9% (11/74). Sixty-three were performed totally as laparoscopic: 43 (68.25%) SLGs and 20 (31.75%) TLGs, all with an extended lymphadenectomy (D2 or more). Operative time was 150 ± 34 minutes (range 75-225 minutes), the mean number of resected lymph nodes 21.4 ± 6.2, global morbidity rate 25.39%, rate of reoperation 9.52%, and perioperative mortality at 30 days 0%. We performed an average follow-up of 48.7 months (range 18-60), and we observed 5-year overall and disease-free survival, respectively, of 48.6% and 42.7%.

CONCLUSIONS

LG with extended lymphadenectomy for AGC is a feasible procedure with good results in terms of postoperative course, complications, and mortality. Thanks to the use of extremely precise and safe technologies the extended lymphadenectomy can be performed laparoscopically. The laparoscopic approach, when performed by experienced surgeons, ensures a correct oncological treatment in combination with the benefits of the laparoscopic technique.

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.

The THUNDERBEAT system for tissue dissection and vascular control in laparoscopic splenectomy

The advent of new energy sources for hemostasis has greatly facilitated advanced laparoscopic procedures. We describe a straightforward technique of laparoscopic splenectomy (LS) accomplished using the THUNDERBEAT™ system (TS) (Olympus Medical Systems Corp., Tokyo, Japan) as the sole means of tissue dissection and hemostasis in two patients aged 19 and 6 years, respectively. The specimens were removed intact via a Pfannenstiel incision. Total operative time was 165 and 150 min, and length of hospital stay was three and 4 d, respectively. The TS is an appealing and reliable alternative to currently available energy devices, allowing fast dissection and secure hemostasis during laparoscopic splenectomy.

Endoscopic Resection of Skull Base Teratoma in Klippel-Feil Syndrome through Use of Combined Ultrasonic and Bipolar Diathermy Platforms

Klippel-Feil syndrome (KFS) is associated with numerous craniofacial abnormalities but rarely with skull base tumor formation. We report an unusual and dramatic case of a symptomatic, mature skull base teratoma in an adult patient with KFS, with extension through the basisphenoid to obstruct the nasopharynx. This benign lesion was associated with midline palatal and cerebral defects, most notably pituitary and vertebrobasilar arteriolar duplications. A multidisciplinary workup and a complete endoscopic, transnasal surgical approach between otolaryngology and neurosurgery were undertaken. Out of concern for vascular control of the fibrofatty dense tumor stalk at the skull base and need for complete teratoma resection, we successfully employed a tissue resection tool with combined ultrasonic and bipolar diathermy to the tumor pedicle at the sphenoid/clivus junction. No CSF leak or major hemorrhage was noted using this endonasal approach, and no concerning postoperative sequelae were encountered. The patient continues to do well now 3 years after tumor extirpation, with resolution of all preoperative symptoms and absence of teratoma recurrence. KFS, teratoma biology, endocrine gland duplication, and the complex considerations required for successfully addressing this type of advanced skull base pathology are all reviewed herein.

Experience and dissection device are more relevant than patient-related factors for operation time in laparoscopic sigmoid resection-a retrospective 8-year observational study

PURPOSE

Surgical outcome is influenced by multiple patient-specific factors and operative expertise of the surgeon. Clinical relevance of medical technical innovations often remains unclear even though laparoscopic surgical procedures are characterized by continual advancement of various devices. Lately, in dissection and sealing technology, fast-cutting ultrasonic scissors are combined with simultaneous bipolar coagulation (bimodal dissection device (BDD)). We investigated how this new technology, operative expertise, and patient-specific factors (body mass index, age) influence operation time in laparoscopic-assisted sigmoid resection.

METHODS

Between 2008 and 2016, 161 laparoscopic sigmoid resections (52% conventional dissection device (CDD); 48% BDD) performed in a single center were retrospectively evaluated. Biometric patient data, complication rates, and surgery duration, reflecting the learning curve, were analyzed. Operations were performed by experienced surgeons (n = 3) and trainees (n = 4).

RESULTS

Minor postoperative complications (e.g., impaired wound healing, non-revisional secondary bleeding) occurred in 11 cases (6.8%). Major complications (e.g., bleeding requiring revision, anastomotic leakage) were observed in 3.7%. No heat-related coagulation damage was observed. BDD reduced operation time for both experienced (CDD 150 min, BDD 125 min; p < 0.001) and trainee surgeons (CDD 169 min, BDD 135 min; p = 0.036). Reduction of operation time (indicative of a learning curve in progress) was observed for all surgeons. The curve was steeper using BDD.

CONCLUSIONS

Patient-specific factors did not have a significant effect on operation time. Even taking the learning curve into account, a combination of ultrasonic dissection and simultaneous bipolar coagulation reduces operation time of laparoscopic-assisted sigmoid resection, regardless of surgeon's expertise.

Comprehensive guide to laparoscope-assisted graft harvesting in live donors for living-donor liver transplantation: perspective of laparoscopic vision

Background

A living donor (LD) for liver transplantation (LT) is the best target for minimally invasive surgery. Laparoscope-assisted surgery (LAS) for LDs has gradually evolved. A donor safety rate of 100% should be guaranteed.

Methods

We began performing LAS for LDs in June 2012. The aim of this report is to describe the surgical procedures of LAS in detail, discuss various tips and pitfalls, and address the potential for a smooth transition to more advanced LAS.

Results

Preoperative planning based on three-dimensional image analysis is a powerful tool for successful surgery. The combination of liver retraction/countertraction and the pressure produced by pneumoperitoneum widens the dissectible/cuttable layer, increasing the safety of LAS. A flexible laparoscope provides excellent magnified vision in both the horizontal view along the inferior vena cava, under adequate liver retraction, and in the lateral view, to harvest left-sided grafts in critical procedures. Intentional omission of painful incisions is beneficial for LDs. Hepatectomy using a smaller midline incision is safe if a hanging maneuver is used. Safe transition from LAS to a hybrid technique involving a combination of pure laparoscopic surgery and subsequent open surgery seems possible.

Conclusion

LDLT surgeons have a very broad intellectual and technical frontier.

The Thunderbeat and Other Energy Devices in Laparoscopic Colorectal Resections: Analysis of Outcomes and Costs

BACKGROUND

The THUNDERBEAT™ (TB) is a recently developed energy-based device. To date, there are no clinical studies comparing TB and other energy sources, such as standard electrosurgery (ES), ultrasonic coagulating shears (US) and electrothermal bipolar vessel sealers (EBVS) in patients undergoing laparoscopic colorectal resection (LCR). The aim of this study was to compare outcomes and costs in patients undergoing LCR with TB, US, EBVS, or ES for both benign and malignant colorectal diseases.

METHODS

This study is a retrospective analysis of a prospective database of patients undergoing LCR. Unselected consecutive patients who had the laparoscopic dissection conducted by using TB were compared with consecutive patients undergoing LCR with US, EBVS, or ES.

RESULTS

Mean operative time did not significantly differ between the groups (P = .947). Estimated blood loss was significantly higher in the ES group (P < .001). Device-related complications occurred in 2.5% of ES patients, in 2.5% of US patients, and in 5% of EBVS patients, while no complications occurred in TB patients (P = .768). No significant differences were observed in postoperative complication rates between the groups. Mean postoperative hospital stay was similar in the groups. Cost analysis showed no significant differences between US (1519.1 ± 303 €), EBVS (1474.4 ± 372.8 €), and TB (1474.3 ± 176.3 €) (P = .737).

CONCLUSION

This is the first clinical study comparing TB and other energy-based devices in LCR. They all appear to be equally safe and effective. Costs of surgery are very similar. Further large randomized controlled trials are needed to confirm these data.

Comparison between Focus Harmonic scalpel and other hemostatic techniques in open thyroidectomy: A systematic review and meta-analysis

BACKGROUND

The purpose of this review was to compare the efficacy and surgical outcomes of total thyroidectomy between the Focus Harmonic scalpel (Ethicon, Cincinnati, OH) and other hemostatic procedures.

METHODS

An extensive search was conducted using the PubMed and Cochrane databases from January 2008 to October 2014. Operating time, blood loss, pain, complications, and hospital stay were evaluated.

RESULTS

When compared with conventional techniques or LigaSure Precise Vessel Sealing System (Medtronic, Minneapolis, MN), the use of the Focus Harmonic scalpel reduced operative time by 22,428 minutes and blood loss by 13,914 mL. Length of hospital stay was significantly shorter in the Focus Harmonic scalpel group with a mean reduction of 0.410 days.

CONCLUSION

According to our meta-analysis, when comparing the Focus Harmonic scalpel versus conventional techniques, it seems evident that the use of this device in thyroid surgery is associated with a mean reduction in operating time, blood loss, and hospital stay, without any increase in pain and complications. There was no appreciable difference between the Focus Harmonic scalpel and the LigaSure Precise Vessel Sealing System. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1578, 2016.

Sealing of vessels larger than 7 millimeters using Enseal in porcine aorta

Background:

The Enseal (Ethicon Endo-Surgery, Blue Ash, Ohio) tissue-sealing device has proven efficacy for ligation of vessels <7 mm in diameter, even with significant supraphysiologic bursting pressures. We aimed to evaluate the safety of Enseal in porcine vessels >7 mm.

Materials and Methods:

The lumbar aortas of pigs that were euthanized for unrelated procedures were harvested. A 5- to 6-cm segment of aorta was sealed using the Enseal device. The opposite end was attached to a pressure-testing device to measure pressures at leak or bursting. The bivariate Pearson correlation was used to determine the relationship between diameter and bursting pressure. One-way analysis of variance was used to determine differences between the groups of vessels on the basis of their diameter.

Results:

Ninety samples of 5-cm aorta segments were used to assess bursting pressure. The median diameter was 14 mm (range, 7–18) and bursting pressure was 85 mm Hg (range, 24–650). The Pearson test showed a negative correlation between vessel diameter and bursting pressure (P = .25). One-way analysis of variance did not show any significant difference between vessel diameters grouped by size (P = .517), and neither did the Scheffe post hoc test when comparing diameter with bursting pressure; 31% of specimens failed to seal.

Conclusions:

Bursting pressures are low and inconsistent after tissue sealing with the Enseal device in porcine vessels >7 mm. These vessels also demonstrated a higher rate of failure to seal. The histologic results of the aorta segments (ie, a low collagen-elastin ratio) may be the cause of the low bursting pressures.

Does reduced-port laparoscopic surgery for medically uncontrolled ulcerative colitis do more harm than good?

INTRODUCTION

Reduced-port laparoscopic surgery is a novel minimally invasive surgery. However, reduced-port surgery for ulcerative colitis (UC) remains controversial. Here, we describe the clinical outcomes of single-incision plus one port laparoscopic surgery (SILS + 1) for medically uncontrolled UC.

METHODS

Between May 2011 and September 2014, 10 UC patients underwent SILS + 1 port surgery. All procedures were performed with the use of a SILS port and either a 5-mm or a 12-mm port placed at the planned ileostomy site.

RESULTS

The median age of patients was 32 years (range, 22-53 years). Six patients underwent two-stage SILS + 1 port restorative proctocolectomy with ileal pouch-anal anastomosis, two patients underwent SILS + 1 total proctocolectomy, and the remaining two patients underwent SILS + 1 subtotal colectomy with subsequent three-stage SILS + 1 ileal pouch-anal anastomosis. The median operative time was 363.1 min (range, 253-465 min) and the median estimated blood loss was 29 mL (range, 0-100 mL). There were no conversions or additional ports required. Two patients previously underwent SILS + 1 subtotal colectomy, and in one of those patients, SILS + 1 ileal pouch-anal anastomosis was performed successfully 6 months after the previous surgery. There were no intra-abdominal adhesions, and no extra wounds were necessary because the previous stoma site had been used to access the SILS port. The median postoperative period was 24 months, during which five patients had their ileostomies closed. No patients reported occasional minor daily soiling or the need to wear a pad.

CONCLUSION

Reduced-port laparoscopic surgery for medically uncontrolled UC is a feasible and safe procedure when performed by skilled surgeons.

Strategies to increase the resectability of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is best treated by liver transplantation, but the applicability of transplantation is greatly limited. Tumor resection in partial hepatectomy is hence resorted to. However, in most parts of the world, only 20%-30% of HCCs are resectable. The main reason for such a low resectability is a future liver remnant too small to be sufficient for the patient. To allow more HCC patients to undergo curative hepatectomy, a variety of ways have been developed to increase the resectability of HCC, mainly ways to increase the future liver remnants in patients through hypertrophy. They include portal vein embolization, sequential transarterial chemoembolization and portal vein embolization, staged hepatectomy, two-staged hepatectomy with portal vein ligation, and Associating Liver Partition and Portal Vein Ligation in Staged Hepatectomy. Herein we review, describe and evaluate these different ways, ways that can be life-saving.

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.