Evaluation of Stump Pressure in Three Types of Appendectomy: Harmonic Scalpel, LigaSure, and Conventional Technique

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.

Efficacy of LigaSure Versus Harmonic Devices in Laparoscopic Sleeve Gastrectomy: A Systematic Review and Meta-Analysis

Our goal is to conduct a thorough systematic review and meta-analysis of comparative studies to evaluate the efficacy of LigaSure (Valleylab, Boulder, CO) compared with Harmonic (Ethicon Endo-Surgery, Inc., Cincinnati, OH) devices in patients undergoing laparoscopic sleeve gastrectomy (LSG). Our search strategy, from inception until March 1, 2024, involved multiple databases, including the Cochrane Controlled Register of Trials (CENTRAL), Web of Science (WOS), PubMed, Scopus, and Google Scholar. We evaluated randomized clinical trials using the Cochrane Risk of Bias tool for randomized trials (RoB-2) tool and non-randomized studies using the Risk of Bias In Non-randomized Studies for Interventions (ROBINS-I) tool. The primary outcomes assessed were operative time, mean length of hospital stay, and the rates of intraoperative complications such as bleeding, organ injury, leakage, and hematoma formation. Additionally, we collected data on postoperative complications, including bleeding, abscess formation, leakage, fever (>38°C), and reoperation rates. Data were analyzed using random-effects models and reported as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI) using Review Manager software (RevMan, version 5.4 for Windows, The Cochrane Collaboration, 2020). Four studies, comprising two randomized clinical trials (RCTs) and two retrospective cohort studies, involving a total of 692 patients, were included in the analysis. Both the operative time and length of hospital stay did not significantly differ between the LigaSure and Harmonic groups (p>0.05). The pooled analysis also revealed no significant difference between the LigaSure and Harmonic groups in terms of intraoperative and postoperative complications (p>0.05). In conclusion, our systematic review and meta-analysis found no significant statistical or clinical differences between LigaSure and Harmonic devices in terms of operative outcomes and complication rates in patients undergoing LSG.

Energy Devices for Clipless-Sutureless Laparoscopic Appendectomy: A Systematic Review and Meta-Analysis on Utility and Safety

Background and Objectives: While laparoscopic appendectomy is standardized, techniques for appendiceal stump closure and mesoappendix division remain variable. Novel vessel sealing techniques are increasingly utilized ubiquitously. We sought to systematically summarize all relevant data and to define the current evidence on the safety and utility of energy devices for clipless−sutureless laparoscopic appendectomy in this systematic review and meta-analysis. Materials and Methods: This review was conducted following the PRISMA guidelines. PubMed, Embase, Scopus, and Web of Science were systematically searched. Inclusion criteria included studies with laparoscopic appendectomy for appendicitis. The intervention included patients undergoing division of mesoappendix and/or securing of the appendicular base using diathermy (Monopolar or Bipolar or LigaSure Sealing Device) or Harmonic Scalpel (Group A) compared to patients undergoing division of mesoappendix and/or securing of the appendicular base using endoclip or Hem-o-lok or ligature (Group B). The methodological quality of the included studies was assessed using the Downs and Black scale. The outcomes of surgical site infection (SSI) or intra-abdominal collection, postoperative ileus, average operative duration, and length of hospital stay (LHS) were compared. Results: Six comparative studies were included; three were retrospective, two were prospective, and one was ambispective. Meta-analysis revealed a shorter operative duration in Group A with respect to appendicular base ligation (MD −12.34, 95% CI −16.57 to −8.11, p < 0.00001) and mesoappendix division (MD −8.06, 95% CI −14.03 to −2.09, p = 0.008). The pooled risk ratios showed no difference in SSI between groups. Additionally, no difference was observed in LHS. The risk of postoperative ileus was higher in group B regarding mesoappendix division (RR 0.56, 95% CI 0.34 to 0.93, p = 0.02), but no difference was found concerning appendicular base ligation. The included studies showed a moderate-to-high risk of bias. Conclusions: Clipless−sutureless laparoscopic appendectomy is safe and fast. Postoperative ileus seems less common with energy devices for mesoappendix division. However, the studies included have a moderate-to-high risk of bias. Further studies addressing the individual devices with surgeons of similar levels are needed.

Use of a bipolar device (LigaSure) to seal the appendiceal stump in pediatric laparoscopic appendectomy: 10-year Latin-American experience

BACKGROUND

Closure of the appendiceal stump is a critical step during an appendectomy. There is a lack of knowledge about the feasibility of using electrosurgical devices for the occlusion of the appendix. This study aims to determine the safety of this technique in pediatric patients.

METHODS

We performed a cross-sectional analytical study in patients less than 18 years of age treated at Hospital Militar Central Colombia between 2012 and 2021. Our institution's ethics committee approved the study. We analyzed the data using SPSS 22 statistical program. We present frequencies for qualitative variables and measures of central tendency or dispersion for quantitative variables depending on the distribution measured by the Kolmogorov-Smirnov test. In addition, we measured the association of nominal variables with the Chi-square test or Fisher's exact test. For numerical variables, the difference of means with the Student's t-test or the difference of medians with the Mann-Whitney U test.

RESULTS

We treated 209 patients. One hundred sixteen (55.5%) were boys, and the mean age was 9.7 years (SD 3.2). The median intraoperative time was 60 min, and the hospital stay was 2.8 days on average. There were no cases of stump leakage, and only two patients (1%) had an organ-space surgical site infection, which was unrelated to the closure technique. We found no association between procedural complications and appendicular status (p = 0.450).

CONCLUSIONS

Our research suggests that using a bipolar sealing device (Ligasure, Medtronic, USA) for appendiceal stump closure in pediatric patients undergoing laparoscopic appendectomy is feasible and should be further studied.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

A Systematic Review and Meta-Analysis of Harmonic Scalpel Versus Conventional Techniques of Appendiceal Stump Closure in Laparoscopic Appendicectomy

Acute appendicitis is one of the most commonly encountered surgical emergencies worldwide. The laparoscopic approach for managing acute appendicitis is gaining popularity over open appendicectomy in the current surgical practice. The advantages of laparoscopic appendectomy are early recovery, fewer wound complications, less pain and better cosmesis. One of the most critical steps in laparoscopic appendicectomy is a secure appendicular stump closure. Life-threatening postoperative complications are often encountered following the breakdown of appendicular stump closure. There are several methods to achieve appendicular stump closure such as intra-corporeal knotting, endoloops, external corporeal knotting and pushing knot inside, endoscopic linear cutting stapler (endo GIA), and endoclips. A meta-analysis on the technique of appendicular stump closure in laparoscopic appendicectomy failed to demonstrate the superiority of one method over the other. In the last few years, many authors have evaluated the outcome of sutureless appendicectomy performed using devices like a harmonic scalpel. This systematic review and meta-analysis is aimed to summarise the current evidence regarding the utility and safety of harmonic scalpel in sutureless appendicectomy.

This systematic review and meta-analysis was conducted as per the preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. A systematic, detailed search was carried out by the authors in the electronic database, including Medline, Embase, CENTRAL, Scopus, Google scholar and clinical trial registry. Studies were selected and compared based on outcomes such as operative time, hospital stay, postoperative paralytic ileus, wound infection, and total complications. Statistical analysis was performed using the random effect model, fixed-effect model, pooled risk ratio, pooled mean difference and I² heterogeneity.

Four comparative studies with a total of 642 patients (376 male and 266 females) were included in the analysis. There were 359 patients in the conventional technique of appendicular stump closure group and 283 patients in the harmonic scalpel for appendicular stump closure group. Pooled analysis of the outcome measure of total complications showed that the use of harmonic scalpel for closure of appendiceal stump does not result in an increased incidence of complications as compared to the conventional technology of appendiceal stump closure. Pooled analysis of the outcome measure of mean operative time revealed a statistically significant reduction in the operative time in the patients where harmonic scalpel has been used for the management of appendiceal stump as compared to conventional methods (pooled mean difference of -12.96 with 95% CI -15.42, -10.50). Appendiceal stump closure during laparoscopic appendectomy by harmonic scalpel (HS) is comparable with the conventional techniques in terms of hospital stay, wound infection, postoperative paralytic ileus, and total complications. The use of a harmonic scalpel for closure of appendicular stump is associated with a reduction of the mean operative time of laparoscopic appendicectomy.

Ex-Vivo Evaluation of "First Tip Closing" Radiofrequency Vessel Sealing Devices for Swine Small Intestinal Transection

This study compared burst pressure (BP), number of activations, and histological assessment of ex vivo swine small intestine loops transected by stapler, a single fulcrum radiofrequency vessel sealing (RFVS) device, and the newly-developed jaws RFVS. Fifty (n = 50) 20 cm long jejunal loops were randomly assigned to be transected with RFVS devices and linear stapler (Caiman5, Caiman Maryland, Caiman12, Ligasure Atlas, and Stapler group as control respectively). Caiman5, Caiman12 and stapler required only one activation to complete the sealing. The mean BP in Caiman5 and Caiman Maryland groups were significantly lower (p < 0.05) than the S group as control and the other RFVS devices studied. RFVS Caiman12 and Ligasure Atlas produced mean BP values that were close to the Control and did not differ between them. The lumen was totally closed in the Caiman12 and Ligasure Atlas groups. The findings of this investigation were promising; we discovered that Caiman12 and Ligasure Atlas produce comparable mechanical capabilities as well as stapled intestinal closure, however Caiman12 need a single activation to complete the transection.

Comparison of the Electrothermal Bipolar Sealing System (LigaSure) Versus Endoloop in Pediatric Laparoscopic Appendectomy

Background: Laparoscopic appendectomy has long been in the process of replacing open appendectomy owing to a better wound healing, better cosmetic appearance, less pain, and less postoperative adhesion. Although there are many methods for ligating the appendix stump, studies on energy-based coagulation methods have attracted great interest in recent years. In our study, we aimed to compare the use of LigaSure™ appendiceal sealing and ligation of appendiceal stump by endoloop with regard to duration of surgery, length of hospital stay, and complications in laparoscopic appendectomies. Materials and Methods: A total of 174 consecutive patients under the age of 18 who underwent laparoscopic appendectomy in our clinic between September 2016 and February 2021 were retrospectively analyzed. Patients with perforated appendicitis were excluded from the study. The patients were divided into two groups as the appendix stump was ligated with endoloop (Group 1) and sealed with LigaSure (Group 2). Demographic characteristics of the patients, duration of surgery, length of hospital stay, and complications were recorded. Results: Of the 132 patients who were included in the study, Group 1 consisted of patients using endoloop (n = 39) and Group 2 comprised patients that LigaSure was employed (n = 93). There was no significant difference between Groups 1 and 2 in terms of age and length of hospital stay (P = .126 and P = .784, respectively); however, the operation time was found to be significantly shorter in Group 2 (P < .001). Conclusion: The use of LigaSure is a safe and fast method to seal the mesoappendix and appendix stump in pediatric laparoscopic appendectomy. We think that infection complications due to stump leakage and intra-abdominal spillage will less be encountered.

Comparison of Ultrasonic Dissection and Suture Ligation for Mesoappendix in Laparoscopic Appendectomy

Objective

To compare the use of ultrasonic dissector and suture ligation for mesoappendix in laparoscopic appendectomy in terms of mean operative time and per-operative bleed.

Methodology

This was a randomized controlled trial conducted at Surgical Unit II, Holy Family Hospital over a period of six months. All patients with the diagnosis of acute appendicitis who presented in the emergency department of Holy Family Hospital on the call days of Surgical Unit II undergoing laparoscopic appendectomy were included in the study. After taking informed consent about the respective procedure, patients were allocated to two groups using computer-generated random numbers. Group A was operated using harmonic scalpel and in Group B suture ligation was done. Total time required to ligate the mesoappendix or to cauterize it using the harmonic scalpel was measured in minutes. Data was entered and analyzed in SPSS version 21.0 (IBM Corp., Armonk, NY).

Results

A total of 110 patients were enrolled in the study according to the inclusion criteria of the study. Patients were randomly divided into two equal groups. Patients in Group A were operated using harmonic scalpel whereas patients in Group B were operated by suture ligation for dealing the mesoappendix in laparoscopic appendectomy. Mean operative time to ligate the mesoappendix for Group A patients was 1.56 (SD = 0.68) minutes while that of Group B was 21.07 (SD = 2.84) minutes. There was no per-operative bleeding in case of Group A while its incidence was 24% of patients in Group B. Results were statistically significant.

Conclusion

The conclusion of the study is that the use of harmonic scalpel was better than suture ligation for ligating the mesoappendix in laparoscopic appendectomy in terms of mean operative time and per operative bleed, hence it's preferable over the later in laparoscopic appendectomy.

Swine Small Intestine Sealing Performed by Different Vessel Sealing Devices: Ex-Vivo Test

This study aimed to evaluate the sealing quality of swine small intestine using different laparoscopic radiofrequency vessel sealing devices (two 5 mm: RFVS-1 and -2; one 10 mm: RFVS-3) and a harmonic scalpel (HS) compared to golden standard closure technique. The study was divided into two arms. In study arm 1: n = 50 swine intestinal loops (10 per group) were transected with each instrument and the loops in which the devices provided complete sealing, at the gross inspection, were tested for maximum burst pressure (BP) and histological evaluation and compared to an automatic linear stapler. After the BP tests, the devices that achieved significantly lower BP values were excluded from the second arm. The RFVS-1 and -3 provided statistically significant results and were used in study arm 2, to obtain full-thickness biopsies along the antimesenteric border of the loop and were compared with hand-sewn intestinal closure (n = 30; 10 per group). The biopsies were histologically evaluated for thermal injury and diagnostic features, and intestinal loops tested for BP. RFVS-3 achieved comparable results (69.78 ± 4.23 mmHg, interquartile range (IQR) 5.8) to stapler closing technique (71.09 ± 4.22 mmHg, IQR 4.38; p > 0.05), while the RFVS-1 resulted in significantly (p < 0.05) lower BP (45.28 ± 15.23 mmHg, IQR 24.95) but over the physiological range, conversely to RFVS-2 (20.16 ± 7.19 mmHg, IQR 12.02) and HS (not measurable). RFVS-3 resulted not significantly different (p > 0.05) (45.09 ± 8.75 mmHg, IQR 10.48) than Suture (35.71 ± 17.51 mmHg, IQR 23.77); RFVS-1 resulted significantly lower values (23.96 ± 10.63 mmHg, IQR 9.62; p < 0.05). All biopsies were judged diagnostic. Data confirmed that RFVS-1 and -3 devices provided suitable intestinal sealing, with BP pressures over the physiological range. Conversely, the HS and RFVS-2 should not be considered for intestinal sealing. RFVS devices could be employed to obtain small intestine stump closure or full-thickness biopsies. However, further studies should be performed in live animals to assess the role of the healing process.

Sutureless Appendectomy by Using Harmonic Scalpel: Is It Possible?

Introduction: Laparoscopic appendectomy is a commonly performed procedure. The base of appendix is secured by various techniques (suture, LigaSure, endoloop, or hamlock clip). Harmonic scalpel (HS) may be used to seal the base of the appendix. The study was conducted to assess the efficacy of HS in laparoscopic appendectomy for sealing the base of the appendix. Materials and Methods: The patients were divided into two groups: group 1 in which base was secured by endoloop and group 2 in which base of the appendix was sealed by HS in a stepwise manner. We made a record of patients' age and gender, and operative time. The patients were followed for a period of 3 months from the time of discharge. Results: During the study period of 4.5 years, 102 patients were in group 1 and 108 patients in group 2. Both groups were age and gender matched. Mean operating time for group 1 was 43.34 ± 6.7 minutes and that for group 2 was 28.46 ± 7.19 minutes (P < .0001). Complications included postoperative ileus (group 1 = 8, group 2 = 10) and surgical site infection (group 1 = 4, group 2 = 4, P > .05). Conclusion: It appears that use of HS for laparoscopic appendectomy is feasible and safe. Its results appear to be comparable with other methods of laparoscopic appendectomy. Complications are minimal. Further studies at other centers may substantiate our efforts.

Comparison between LigaSure™ and Harmonic® in Laparoscopic Sleeve Gastrectomy: A Single-Center Experience on 422 Patients

BACKGROUND

New laparoscopic devices, such as electrothermal bipolar-activated devices (LigaSure™ (LS)) or ultrasonic systems (Harmonic® scalpel (HS)), have been applied recently to bariatric surgery allowing to reduce blood loss and surgical risks. The aim of this study was to retrospectively compare intraoperative performance of HS and LS, postoperative results, and clinical outcomes in a large cohort of patients undergoing LSG.

METHODS

Data from 422 morbidly obese patients undergoing LSG in our Bariatric Unit at the Advanced Biomedical Sciences Department of the "Federico II" University of Naples (Italy) between January 2009 and December 2017 were retrospectively analyzed. Subjects were divided into two groups (HS and LS), and operative time, intraoperative complications, and postoperative (within 30 days from surgery) complications were compared. Bleeding from the omentum or from the staple line, use of hemostatic clips, and absorbable hemostat were recorded as intraoperative complications; hemorrhages, abscess formation, gastric leaks, fever, and mortality were considered as postoperative complications.

RESULTS

Statistical analysis showed no difference in terms of baseline demographics between the two cohorts. Operative time (48 ± 9 vs 49 ± 6 min, p=0.646) and the rates of intraoperative and postoperative complications did not significantly differ between groups.

CONCLUSION

Harmonic® and LigaSure™ are both useful tools in bariatric surgery, and these two advanced power devices are user-friendly and can facilitate surgeon work; from this point of view, the choice of the energy device should be based on the preference of the surgeon and on the hospital costs policy and availability.