Evaluation of a vessel sealing system, bipolar electrosurgery, harmonic scalpel, titanium clips, endoscopic gastrointestinal anastomosis vascular staples and sutures for arterial and venous ligation in a porcine model

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.

LigaSure versus the standard technique (Hem-o-lok clips) for robot-assisted radical prostatectomy: a propensity score-matched study

The aim of the study is to compare the utility and efficacy of the LigaSure system and standard surgical clips for robot-assisted radical prostatectomy. The medical records of 473 patients who underwent robot-assisted radical prostatectomy between May 2011 and 2018 were retrospectively reviewed and analyzed. The patients were divided into the LigaSure (n = 125) and Hem-o-lok (n = 348) groups, based on the device used to ligate the vascular pedicle. Owing to differences in the patient characteristics, a 1:2 propensity score matching was performed. In the final matched cohort, 375 patients were included for analysis. The median initial prostate-specific antigen level was not significantly different between the two groups. The median surgical and console times were significantly shorter for the LigaSure group than for the Hem-o-lok group (p < 0.001 and 0.003, respectively). The number of specimens with positive surgical margins was significantly lower in the LigaSure group than in the Hem-o-lok group (24.8 vs 40.8%, p = 0.002). The number of specimens with positive surgical margins for pathological stage T2 cases was also significantly lower in the LigaSure group than in the Hem-o-lok group (17.0 vs 37.5%, p < 0.001). However, non-focal positive surgical margins and biochemical recurrence-free survival rates at 1 year postoperatively were not significantly different (11.2 vs 18.4%, p = 0.075 and 91.2 vs 92.8%, p = 0.565, respectively). The LigaSure system was associated with fewer positive surgical margins and shorter operation time, indicating that it could be a useful alternative to Hem-o-lok clips for controlling the prostatic pedicle in robot-assisted radical prostatectomy, despite its high costs.

Optical coherence tomography for use in infrared laser sealing of blood vessels

Infrared lasers may provide faster sealing of vascular tissues with less collateral thermal damage and lower device temperatures than radiofrequency and ultrasonic devices currently used for surgery. Optical coherence tomography is tested to image native and thermally coagulated blood vessels, as a potential feedback system.

Robotic assisted nephrectomy for living kidney donation (RANLD) with use of multiple locking clips or ligatures for renal vascular closure

Background

Robotic assisted nephrectomy for living donation (RANLD) is a rapid emerging surgical technique competing for supremacy with totally laparoscopic and laparoscopic hand assisted techniques. Opinions about the safety of specific techniques of vascular closure in minimally invasive living kidney donation are heterogeneous and may be different for laparoscopic and robotic assisted surgical techniques.

Methods

We retrospectively analyzed perioperative and short-term outcomes of our first (n=40) RANLD performed with the da Vinci Si surgical platform. Vascular closure of renal vessels was performed by either double clipping or a combination of clips and non-transfixing suture ligatures.

Results

RANLD almost quintupled in our center for the observed time period. A total of n=21 (52.5%) left and n=19 (47.5%) right kidneys were procured. Renal vessel sealing with two locking clips was performed in 18 cases (45%) Both, clips and non-transfixing ligatures were used in 22 cases (55%). Mean donor age was 53.075±11.68 years (range, 28–70). The average total operative time was 150.75±27.30 min. Right donor nephrectomy (139±22 min) was performed significantly faster than left (160.95±27.93 min, P=0.01). Warm ischemia time was similar for both vascular sealing techniques and did not differ between left and right nephrectomies. No conversion was necessary. Clavien-Dindo Grade ≤IIIb complications occurred in (n=5) 12.5%. Grade IV and V complications did not develop. In particular no hemorrhage occurred using multiple locking clips or suture ligatures for renal vascular closure. Mortality was 0%. Thirteen kidneys (32.5%) were transplanted across the AB0 barrier.

Conclusions

RANLD is an emerging minimally invasive surgical technique which facilitates excellent perioperative and short-term outcomes also when using multiple locking clips or suture ligatures for renal vascular closure.

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.

Thermal damage width and hemostatic effect of bipolar electrocoagulation, LigaSure, and Ultracision techniques on goat mesenteric vessels and optimal power for bipolar electrocoagulation

BACKGROUND

We aimed to determine the optimal bipolar electrocoagulation power for laparoscopic surgery and to investigate which method, bipolar electrocoagulation, advanced bipolar, or ultrasonic technique was more reliable.

METHODS

Goat mesenteric vessels (210 in vivo samples) with diameters of 3.03-5.44 mm were selected. Bipolar electrocoagulation with 80 W, 75 W, 70 W, 65 W, 60 W, 55 W, and 50 W, and advanced bipolar and ultrasonic techniques were performed on mesenteric vessels. The thermal damage width, hemostatic effect, and burst pressure of these tissues were recorded. SPSS version 13.0 was used for all data analysis.

RESULTS

The results showed that 60 W was the optimal for bipolar electrocoagulation based on the thermal damage width, hemostatic effect, and burst pressure. In contrast, the thermal damage width of advanced bipolar and ultrasonic techniques was smaller than that of bipolar electrocoagulation, and advanced bipolartechnique had the highest successful rate for hemostasis and highest burst pressure.

CONCLUSIONS

Bipolar electrocoagulation was optimally performed with 60 W of power. Compared with ultrasonic and bipolar electrocoagulation techniques, advanced bipolar use was more reliable for mesenteric vessels in laparoscopic surgery; however, bipolar electrocoagulation with optimal power can be used for its simplicity of operation and low cost.

Multifunctional Biomedical Adhesives

Currently available biomedical adhesives are mainly engineered to have one function (i.e., providing mechanical support for the repaired tissue). To improve the performance of existing bioadhesives and broaden their applications in medicine, numerous multifunctional bioadhesives are reported in the literature. These adhesives can be categorized as passive or active by design. Passive multifunctional bioadhesives contain inherent compositions and structural designs that can carry out additional functions without added external influences. These adhesives exhibit new functionalities such as antimicrobial properties, self-healing abilities, the ability to promote cellular ingrowth, and the ability to be reshaped. Conversely, active multifunctional bioadhesives respond to environmental changes (e.g., pH, temperature, electricity, light, and biomolecule concentration), which initiate a change in the adhesive to release encapsulated drugs or to activate or deactivate the bioadhesive for interfacial binding. This review article highlights recent advances in multifunctional bioadhesives.

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.

The methods and techniques of identifying renal pedicle vessels during retroperitoneal laparoscopic radical and partial nephrectomy

Background

Retroperitoneal laparoscopic radical and partial nephrectomy (RLRN and RLPN) have become the preferred modes of management for renal malignancy. One of the most critical steps in the RLRN and RLPN process is to seek and control the renal pedicle. The current study focuses on introducing methods and techniques that can help quickly and accurately identify the renal pedicle vessels during RLRN and RLPN.

Methods

RLRNs and RLPNs were performed for 292 cases in our hospital from November 2014 to January 2017. Different measures were adopted to seek and manage bilateral renal pedicle vessels. All operation procedures were performed by the following three steps: dissection, opening, and clamping. For the left lateral, after the perirenal fat in the dorsal and lateral side was fully dissected, the kidney was pushed toward the ventral side. The renal artery was visible when opening the dense bulging connective tissue, which was located in the middle of the dorsal interior of the kidney. Then, the renal artery was clamped with a Hem-o-lok or the Bulldog clamp. For the right kidney pedicles, the inferior vena cava was first identified and then dissipated upward. When the inferior vena cava was not visible, it was often the location of the right renal artery. The treatment for the artery was the same as for the left renal artery. Relevant clinical characteristics of patients, such as operative time, intraoperative blood loss, and duration of postoperative drainage, were analyzed retrospectively. The three-step method of identifying renal pedicle vessels during retroperitoneal laparoscopic radical and partial nephrectomy was evaluated.

Results

All operations were successfully accomplished with satisfying results, during which the artery could be controlled quickly, and no cases were converted to open surgery due to severe bleeding of renal pedicle vessels. There were no complications involving renal vessels during the entire study. The mean operative times were (81.9 ± 19.71) min and (88.2 ± 21.28) min for RLRN and RLPN, with an average intraoperative blood loss of (91.7 ± 47.10) ml and (62.4 ± 47.45) ml, respectively. The warm ischemia time for RLPN was (19.3 ± 5.6) min. The postoperative drainage-tube was removed within (4.5 ± 1.29) d (RLRN) and (4.6 ± 1.98) d (RLPN); the mean postoperative hospital stay times were (7.0 ± 2.4) d and (5.9 ± 1.98) d, respectively.

Conclusion

The three-step method of identifying renal pedicle vessels during RLRN and RLPN is direct and feasible, and it may help simplify the operating procedure and improve the safety of the surgery. It may be of great practical application value in the clinical field.

Electronic supplementary material

The online version of this article (10.1186/s12957-019-1580-1) contains supplementary material, which is available to authorized users.

Effect of LigaSure™, Monopolar Cautery, and Bipolar Cautery on Surgical Margins in Breast-Conserving Surgery

Background

We compared the differences in thermal damage at the surgical margin between monopolar cautery, bipolar cautery, and LigaSure™ in breast cancer lumpectomy specimens and assessed the effect of these techniques on the evaluation of the surgical margins.

Methods

30 patients scheduled for breast-conserving surgery for breast cancer were included in this study. During lumpectomy, each of the superior, inferior, lateral, and medial borders of the tumour was excised using one of the following: a scalpel, monopolar cautery, bipolar cautery, and LigaSure technology. The surgical margins of frozen and paraffin-embedded tissue sections of the lumpectomy specimen were evaluated. Thermal damage was defined as the maximum depth of thermal damage (in mm) from the surgical margin, and the level was categorized as none, low (≤1 mm), or high (>1 mm).

Results

There was no statistically significant difference between monopolar cautery, bipolar cautery, and LigaSure in terms of thermal damage. There was no thermal damage at the surgical margin in tissues dissected by scalpel.

Conclusion

Thermal damage due to the excision method may cause false-negative and false-positive results in the surgical margin evaluation of lumpectomy specimens. More research is needed on the effects of different energy modalities on surgical margin evaluation in breast-conserving surgery.

Stapleless Laparoscopic Sleeve Gastrectomy: Reasoning and Technical Insights

Background

Laparoscopic sleeve gastrectomy (LSG) with staple line reinforcement (SLR) is a popular and safe treatment option for morbid obesity. We have developed, devised, and described our own method of stapleless laparoscopic sleeve gastrectomy, which in our limited study appeared safe, efficacious, and potentially cost-effective.

Methods

We analyzed the outcome of our modified LSG in a case series of three middle-aged women (median age 42 years old). Our main modification was sutured closure of the stomach rather than the commonly utilized technique of stapled closure. Our primary measure of success was the occurrence of post-operative leak. Secondary measures were (a) length of operation, (b) duration of inpatient stay, and (c) percentage of weight loss at 6 and 12 months post operation.

Results

Median operative time = 132 min (120–195 min), and median inpatient stays were 2 days. No post-operative leaks were recorded. The median excess weight loss at 6 months was 39% of initial weight loss and 57.7% at 12 months.

Conclusions

Stapleless LSG has the potential to be an affordable alternative to the traditional LSG. High-powered studies and a formal cost analysis are required.

Staplers or clips?: A systematic review and meta-analysis of vessel controlling devices for renal pedicle ligation in laparoscopic live donor nephrectomy

BACKGROUND

Controlling of the renal vessels is a critical step in live donor nephrectomy (LDN). Currently, mainly 2 devices, Hem-o-Lok clips and staplers, are utilized to control vessels during LDN. Both of them have advantages and disadvantages.

METHODS

This systematic review and meta-analysis was aimed to compare the safety and the efficacy of the 2 devices and to identify the better one in LDN. A systematic search for related publications in the databases of PubMed, Medline, Embase, the Cochrane Library, and Web of Science through February 2018 was performed. Eight studies were selected and evaluated with the Newcastle-Ottawa Scale (NOS).

RESULTS

The meta-analysis result showed that utilization of Hem-o-Lok clips resulted in greater amount of estimated blood loss (mean differences [MD]: 40.10; 95% confidence interval [CI] 4.37-75.84) and longer time of warm ischemia (WIT) (MD: 55.61; 95% CI 36.79-74.43) than using staplers. Residual vascular length of grafts in clip group was longer than that in stapler group (MD: 2.51; 95% CI 0.78-4.24). However, the differences in primary outcomes such as device failure rate, death rate, and severe hemorrhage rate, were not significant between these 2 groups. In addition, utilization of Hem-o-Lok clips costed approximate $400 lower than staplers per patient.

CONCLUSION

This study revealed that Hem-o-Lok clips and staplers have the similar function in LDN renal ligation, regarding the device failure rate, death rate, and severe hemorrhage rate. However, the surgeons would benefit from the clips in terms of the residue length of vessels, these outstanding features provide operation convenience and flexibility, such as right-sided donor nephrectomies, early vascular bifurcation, and rare vascular variation. In addition, the clips have potential economic advantages. In some developing countries, it would reduce the healthcare expenditure.

Bipolar Vessel Sealing System Versus Suture Ligation in Selective Neck Dissection

Aim

To evaluate whether the use of electrothermal bipolar vessel sealing system reduces the blood loss and operating time, with lesser complications as compared to suture ligation in selective neck dissection in patients with oral cancer.

Materials and Methods

The study was conducted in the Department of Oral and Maxillofacial Surgery of our institute from January 2015 to December 2016. The sample consisted of 60 patients, divided into Groups I and II with 30 subjects in each. In Group I electrothermal bipolar vessel sealer and in Group II suture ligation were used. The outcome measures recorded were: blood loss, operating time, quality of surgical field, postoperative pain on days 1, 2, and 3, drainage volume at 24, 48, and 72 h, edema, complications, and duration of hospital stay.

Results

There were 36 males and 24 females with a mean age of 50.76 ± 12.6 years. Blood loss was significantly less for Group I than for Group II (p = 0.001); the operating time was significantly less in Group I than in Group II (p = 0.001); Group I had better quality of surgical field (p = 0.001); less pain on postoperative evening, day 2 and day 3 (p < 0.05); and less drainage volume at 24 and 48 h (p < 0.05). Postoperative edema, complications, need for perioperative blood transfusion, and duration of hospital stay postsurgery were similar in both groups.

Conclusion

The electrothermal bipolar vessel sealer was efficacious in terms of reducing blood loss and operating time while providing a better surgical field and patient compliance without increasing the perioperative morbidity.

Effective thermal destruction of residual tubal epithelium using an advanced sealing device in opportunistic salpingectomy: A randomized trial

Objective:

To examine the effectiveness of proximal tube destruction at the uterine cornu by additional application of a sealing device.

Methods:

A single-center randomized trial was conducted on 40 patients receiving a laparo-endoscopic single-site hysterectomy with opportunistic salpingectomy. We randomized patients into two groups at the time of admission to determine the laterality of additional thermal cauterization. Additional thermal cauterization for 10 seconds was applied on the right cornu in one group and on the left cornu in the other group. Three pieces of cornual tissue from each cornu were biopsied. One gynecological pathologist examined the cornual tissue to determine the residual tubal epithelium (TE) and thermal destruction of the specimens.

Results:

Of the 40 patients enrolled in this study between September 2012 and July 2014, samples of 26 patients were subjected to tissue analysis. Residual TE was found in the cornu in 73.1% (19/26) and 65.4 % (17/26) of tissues from the side of no additional cauterization (NO) and the side of additional cauterization (AD), respectively (p < 0.001). Residual TE was detected in 5.3% (1/19) and 94.1% (16/17) of the specimens from the NO and AD groups, respectively.

Conclusion:

We observed that a high incidence of residual TE and efficacious cauterization-induced thermal destruction was achieved following 10 seconds of additional cauterization. These results suggest that additional cauterization of the uterine cornu using the sealing device effectively destroys residual TE after salpingectomy.

A Moldable Nanocomposite Hydrogel Composed of a Mussel-Inspired Polymer and a Nanosilicate as a Fit-to-Shape Tissue Sealant

The engineering of bioadhesives to bind and conform to the complex contour of tissue surfaces remains a challenge. We have developed a novel moldable nanocomposite hydrogel by combining dopamine-modified poly(ethylene glycol) and the nanosilicate Laponite, without the use of cytotoxic oxidants. The hydrogel transitioned from a reversibly cross-linked network formed by dopamine-Laponite interfacial interactions to a covalently cross-linked network through the slow autoxidation and cross-linking of catechol moieties. Initially, the hydrogel could be remolded to different shapes, could recover from large strain deformation, and could be injected through a syringe to adhere to the convex contour of a tissue surface. With time, the hydrogel solidified to adopt the new shape and sealed defects on the tissue. This fit-to-shape sealant has potential in sealing tissues with non-flat geometries, such as a sutured anastomosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Vessel sealing comparison: old school is still hip

BACKGROUND

Ligation with either absorbable or non-absorbable sutures has been the traditional state of the art, but a proliferation of technology now offers a host of methods to close and divide vessels. Only limited data are available that objectively compare different vessel sealing methods. The objective of this study was to compare a broad variety of methods of surgical vessel closure in a reproducible, independent, standardized test-to-failure ex vivo pressure challenge.

METHODS

Ten of the most common surgical sealing devices were represented in this study, including both mechanical and energy devices. Unfixed porcine carotid arteries were selected for testing. They were connected to a pump, and automated controlled infusion was initiated. Upon identification of a leak at the source of sealing, the maximum pressure in mmHg was logged.

RESULTS

There were a total of 184 trials conducted using the 10 vessel sealing methods. The average burst pressure across all trials was 1100 mmHg with a range of 51.3-5171 mmHg. Suture-based methods displayed the highest average pressure until failure. Stapling methods showed the lowest burst pressures. All methods showed mean burst pressures above the "physiologically relevant" level of 250 mmHg.

CONCLUSIONS

This study presents an independent, reproducible, ex vivo comparison of multiple methods of surgical arterial closure. In these laboratory conditions, tests to failure demonstrated widely varying sealing strength, highly dependent on method. All hemostatic modalities tested are capable of securing vessels safely and well above physiologic blood pressures, while suture-based methods were significantly stronger than other mechanical methods or modern energy devices.

Update on Surgical Principles and Equipment

The diversity implicit in exotic animal surgery requires a tailored approach to optimize successful outcomes. Outlined is information on patient preparation, instrumentation, hemostatic techniques, and magnification as it pertains to the exotic animal. Application of topical antiseptic solutions and judicious removal of pelage and feathers will decrease bacterial load during patient preparation. The use of specific barrier protection ensures proper aseptic technique and enables optimal patient monitoring. Magnification combined with a focal light source enhances visual acuity, allowing for better use of delicate instrumentation and identification of anatomic structures.

Comparison of two laparoscopic splenectomy plus pericardial devascularization techniques for management of portal hypertension and hypersplenism

OBJECTIVE

Our research was conducted to analyze the outcomes of two laparoscopic splenectomy plus pericardial devascularization (LSPD) techniques in the management of portal hypertension (PTH) and hypersplenism.

METHODS

Between May 2012 and May 2013, 41 patients with PTH and hypersplenism undergoing LSPD were retrospectively analyzed. Of them, 29 patients received LSPD by LigaSure Vessel Sealing System (LVSS) and Endo-GIA universal endoscopic vascular linear staplers (Endo-GIA) (EG Group) and 12 patients received LSPD by LVSS and Hem-o-Lock (HL Group). Operating time, intraoperative blood loss, postoperative course, and hospitalization costs were compared between the two LSPD combination techniques.

RESULTS

There were no significant differences in preoperative patient characteristics of the two groups. Significantly less operating time, intraoperative blood loss, and postoperative complications were observed in EG Group. The incidence of portal vein thrombosis was lower in the EG Group (3.4 vs. 8.3%), as well as the incidence of pancreatic fistula (0 vs. 8.3%). Upper gastrointestinal hemorrhage was not observed in either group. Uncontrolled bleeding warranted conversion to open surgery in one case in EG Group (conversion rate 3.4%) and in two cases in HL Group (conversion rate 16.7%). Two patients (16.7%) in HL Group underwent successful emergency exploratory laparotomy due to uncontrolled intraabdominal bleeding postoperatively. No re-operation was needed in EG Group. Two patients experienced liver failure after surgery in each group. Of those, three patients were managed successfully and one patient refused further therapy. While the overall complication rate was significantly lower in EG Group (17.2 vs. 58.3%, P < 0.05), overall hospitalization costs remained significantly higher for EG Group.

CONCLUSION

The results suggest that the modified Endo-GIA and LVSS technique is a safe and effective combination approach to LSPD with shorter operative time, less intraoperative blood loss, lower conversion rate to laparotomy, shorter hospital stay, better recovery, and lower postoperative complication rate compared with the Hem-o-Lock and LVSS approach. Higher hospitalization expenses associated with the Endo-GIA and LVSS approach.

Large bowel injuries during gynecological laparoscopy

Laparoscopy is one of the most frequently preferred surgical options in gynecological surgery and has advantages over laparotomy, including smaller surgical scars, faster recovery, less pain and earlier return of bowel functions. Generally, it is also accepted as safe and effective and patients tolerate it well. However, it is still an intra-abdominal procedure and has the similar potential risks of laparotomy, including injury of a vital structure, bleeding and infection. Besides the well-known risks of open surgery, laparoscopy also has its own unique risks related to abdominal access methods, pneumoperitoneum created to provide adequate operative space and the energy modalities used during the procedures. Bowel, bladder or major blood vessel injuries and passage of gas into the intravascular space may result from laparoscopic surgical technique. In addition, the risks of aspiration, respiratory dysfunction and cardiovascular dysfunction increase during laparoscopy. Large bowel injuries during laparoscopy are serious complications because 50% of bowel injuries and 60% of visceral injuries are undiagnosed at the time of primary surgery. A missed or delayed diagnosis increases the risk of bowel perforation and consequently sepsis and even death. In this paper, we aim to focus on large bowel injuries that happen during gynecological laparoscopy and review their diagnostic and management options.

Sealing vessels up to 7 mm in diameter solely with ultrasonic technology

Introduction

Ultrasonic energy is a mainstay in the armamentarium of surgeons, providing multifunctionality, precision, and control when dissecting and sealing vessels up to 5 mm in diameter. Historically, the inability to seal vessels in the 5–7 mm range has been perceived as an inherent limitation of ultrasonic technology. The purpose of this study was to evaluate sealing of vessels up to 7 mm in diameter with an ultrasonic device that modulates energy delivery during the sealing period.

Methods

In ex vivo benchtop and in vivo acute and survival preclinical models, a new ultrasonic device, Harmonic ACE^®+7 Shears (Harmonic 7), was compared with advanced bipolar devices in sealing vessels 1–7 mm in diameter with respect of burst pressure, seal reliability, and seal durability. Lateral thermal damage and transection time were also evaluated.

Results

Ex vivo tests of Harmonic 7 demonstrated significantly greater median burst pressures than an advanced bipolar device both for vessels <5 mm in diameter (1,078 mmHg and 836 mmHg, respectively, P=0.046) and for those in the range of 5–7 mm (1,419 mmHg and 591 mmHg, P<0.001). In vivo tests in porcine and caprine models demonstrated similar rates of hemostasis between Harmonic 7 and advanced bipolar devices, with high success rates at initial transection and seal durability of 100% after a 30-day survival period.

Conclusion

Sealing 5–7 mm vessels is not a limitation of the type of energy used but of how energy is delivered to tissue. These studies document the ability of ultrasonic energy alone to reliably seal large vessels 5–7 mm in diameter, with significantly greater burst pressure observed in in vitro studies than those observed with an advanced bipolar technology when energy delivery is modulated during the sealing cycle. Furthermore, the seals created in 5–7 mm vessels are shown to be reliable and durable in in vivo preclinical studies.

Pathophysiological mechanisms of high-intensity focused ultrasound-mediated vascular occlusion and relevance to non-invasive fetal surgery

High-intensity focused ultrasound (HIFU) is a non-invasive technology, which can be used occlude blood vessels in the body. Both the theory underlying and practical process of blood vessel occlusion are still under development and relatively sparse in vivo experimental and therapeutic data exist. HIFU would however provide an alternative to surgery, particularly in circumstances where serious complications inherent to surgery outweigh the potential benefits. Accordingly, the HIFU technique would be of particular utility for fetal and placental interventions, where open or endoscopic surgery is fraught with difficulty and likelihood of complications including premature delivery. This assumes that HIFU could be shown to safely and effectively occlude blood vessels in utero. To understand these mechanisms more fully, we present a review of relevant cross-specialty literature on the topic of vascular HIFU and suggest an integrative mechanism taking into account clinical, physical and engineering considerations through which HIFU may produce vascular occlusion. This model may aid in the design of HIFU protocols to further develop this area, and might be adapted to provide a non-invasive therapy for conditions in fetal medicine where vascular occlusion is beneficial.

Harmonic scalpel versus conventional haemostasis in neck dissection: a prospective randomized study

PURPOSE

The aim of this prospective randomized trial was to compare operative factors, postoperative outcomes, and surgical complications of neck dissection (ND) when using the harmonic scalpel (HS) versus conventional haemostasis (CH) (classic technique of tying and knots, resorbable ligature, and bipolar diathermy).

MATERIALS AND METHODS

Sixty-one patients who underwent ND with primary head and neck cancer (HNSCC) resection were enrolled in this study and were randomized into two homogeneous groups: CH (conventional haemostasis with classic technique of tying and knots, resorbable ligature, and bipolar diathermy) and HS (haemostasis with harmonic scalpel). Outcomes of the study included operative time, intraoperative blood loss, drainage volume, postoperative pain, hospital stay, and incidence of intraoperative and postoperative complications.

RESULTS

The use of the HS reduced significantly the operating time, the intraoperative blood loss, the postoperative pain, and the volume of drainage. No significant difference was observed in mean hospital stay and perioperative, and postoperative complications.

CONCLUSION

The HS is a reliable and safe tool for reducing intraoperative blood loss, operative time, volume of drainage and postoperative pain in patients undergoing ND for HNSCC. Multicenter randomized studies need to be done to confirm the advantages of this technique and to evaluate the cost-benefit ratio.

Radiofrequency-induced small bowel thermofusion: an ex vivo study of intestinal seal adequacy using mechanical and imaging modalities

BACKGROUND

Bipolar radiofrequency (RF) induced tissue fusion is believed to have the potential to seal and anastomose intestinal tissue thereby providing an alternative to current techniques which are associated with technical and functional complications. This study examines the mechanical and cellular effects of RF energy and varying compressive pressures when applied to create ex vivo intestinal seals.

METHODS

A total of 299 mucosa-to-mucosa fusions were formed on ex vivo porcine small bowel segments using a prototype bipolar RF device powered by a closed-loop, feedback-controlled RF generator. Compressive pressures were increased at 0.05 MPa intervals from 0.00 to 0.49 MPa and RF energy was applied for a set time period to achieve bowel tissue fusion. Seal strength was subsequently assessed using burst pressure and tensile strength testing, whilst morphological changes were determined through light microscopy. To further identify the subcellular tissue changes that occur as a result of RF energy application, the collagen matrix in the fused area of a single bowel segment sealed at an optimal pressure was examined using transmission electron microscopy (TEM).

RESULTS

An optimal applied compressive pressure range was observed between 0.10 and 0.25 MPa. Light microscopy demonstrated a step change between fused and unfused tissues but was ineffective in distinguishing between pressure levels once tissues were sealed. Non uniform collagen damage was observed in the sealed tissue area using TEM, with some areas showing complete collagen denaturation and others showing none, despite the seal being complete. This finding has not been described previously in RF-fused tissue and may have implications for in vivo healing.

CONCLUSIONS

This study shows that both bipolar RF energy and optimal compressive pressures are needed to create strong intestinal seals. This finding suggests that RF fusion technology can be effectively applied for bowel sealing and may lead to the development of novel anastomosis tools.

Use of a vessel sealing system versus conventional electrocautery for lung parenchymal resection: a comparison of the clinicopathological outcomes in porcine lungs

PURPOSE

LigaSure, a vessel sealing system, has been shown to have excellent hemostatic properties; however, its use for lung parenchymal resection has been limited. We herein examined the hemostatic properties and potential for inducing histological lung injury of the LigaSure system in non-anatomic pulmonary resection to estimate the feasibility of its clinical application.

METHODS

Non-anatomic pulmonary wedge resections of the right cranial, middle, and caudal lobes were performed in four pigs using the LigaSure system (Group A) or electrocautery (Group B). In each resection, the resection time, blood loss, and weight of the resected lung were measured. The thermal effect on the lung tissue was examined by means of intraoperative thermography and histology.

RESULTS

A total of 12 lung wedge resections were performed in each group. For an equivalent length of operation and weight of the resected lung parenchyma, Group A showed significantly lower blood loss and lower maximum and minimum temperatures of the lung tissue, as assessed by thermography, than Group B. The degree of thermal injury as estimated by a histological examination was lower in Group A than in Group B.

CONCLUSION

Our study suggests that the LigaSure system may be superior to conventional electrocautery, indicating its clinical usefulness for non-anatomic pulmonary resection.

A multicenter, randomized, controlled clinical trial of LigaSure small jaw vessel sealing system versus conventional technique in thyroidectomy

The objective of this work was to compare efficacy and adverse effects between vessel sealing system thyroid lobectomy (VSSL) with the new LigaSure™ Small Jaw Instrument and conventional thyroid lobectomy (CTL). This is a multicenter, randomized and controlled study, conducted in the Department of Otolaryngology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Faculty of Medicine, Chulalongkorn University, Bangkok and Division of Otolaryngology, Sukhothai General Hospital, Sukhothai, Thailand. Forty subjects with solitary thyroid nodule planned for thyroid lobectomy were enrolled consecutively in both centers. Intervention was randomized by block randomization into two groups (VSSL, CTL). Primary outcomes were operative time and intraoperative blood loss. Secondary outcomes were postoperative blood loss and recurrent laryngeal nerve paralysis. There was clinically significant less operative time (VSSL/CTL = 62.4 ± 15.9/83.3 ± 16.1 min, p < 0.001) and less intraoperative blood loss (VSSL/CTL = 40.5 ± 19.1/63.3 ± 22.4 mL, p = 0.001) in VSSL group compared with CTL group. There was no significant difference of postoperative blood loss (VSSL/CTL = 58.8 ± 30.6/76.0 ± 36.9 mL, p = 0.116) between both the groups. There was one case of permanent recurrent laryngeal nerve injury found in both groups. VSSL with the new LigaSure™ Small Jaw Instrument was better than conventional technique in terms of shortening operative time. It was also better in reducing intraoperative hemorrhage, but this effect did not exceed clinically significant levels. Postoperative blood loss and recurrent laryngeal nerve injury were not significantly different between both the groups.

Perioperative outcomes using LigaSure™ compared to conventional bipolar instruments in laparoscopic salpingo-oophorectomy: a randomized controlled trial

BACKGROUND

The aim of this study was to compare the effects of LigaSure™ versus conventional bipolar techniques on operating time and blood loss during laparoscopic salpingo-oophorectomy in a randomized controlled trial.

METHODS

In three teaching hospitals, 100 women undergoing a laparoscopic salpingo-oophorectomy were randomized for LigaSure or conventional bipolar instruments. Primary outcome was operating time (from initial skin incision to removal of the specimen). Secondary outcome measures were total operating time (from initial skin incision to skin closure), time to dissect the ovarian and infundibulopelvic ligaments, intraoperative blood loss, and subjective judgment of the instrument used.

RESULTS

There were no differences in operating time and total operating time using LigaSure versus conventional bipolar instruments: 41.0 vs. 39.2 min (p = 0.78; 95 % CI = -10.9 to 14.5) and 54.6 vs. 58.6 min (p = 0.46; 95 % CI = -14.8 to 6.8), respectively. The mean blood loss using LigaSure versus conventional bipolar instruments was 38 vs. 33 mL (p = 0.73; 95 % CI = -22.7 to 32.2). Various subjective efficacy and instrument handling parameters of the two instruments varied among participating centers.

CONCLUSION

There were no significant differences in operating time and blood loss with the use of LigaSure compared to conventional bipolar instruments during laparoscopic salpingo-oophorectomy, even after correction for potential confounders.

Effectiveness of electrothermal bipolar vessel-sealing devices versus other electrothermal and ultrasonic devices for abdominal surgical hemostasis: a systematic review

BACKGROUND

Adequate hemostatic techniques are essential for optimal intra- and postoperative results. A number of different hemostatic techniques and devices have been developed over the past few years, but which device should be preferred during laparoscopic and open abdominal procedures?

METHODS

We conducted a systematic search for randomized controlled trials (RCTs) that compared the effectiveness and costs of vessel-sealing devices with those of other electrothermal or ultrasonic devices in abdominal surgical procedures.

RESULTS

Seven RCTs that included 554 patients met the inclusion criteria. Various procedures that used a vessel-sealing device (LigaSure™) (n = 264) were compared to ultrasonic devices (n = 139) and mono- (n = 20) or bipolar devices (n = 130). LigaSure was favored in two studies with respect to less blood loss, shorter operating time, and lower costs. However, no differences were observed in the other studies. Considering the relatively low number of complications, all hemostatic devices used may be considered relatively safe. None of the studies reported on quality of life or cost effectiveness.

CONCLUSIONS

Vessel-sealing devices may be considered safe and their use may reduce costs due to reduced blood loss and shorter operating time in some abdominal surgical procedures compared to mono- or bipolar electrothermal devices. Wider-ranging RCTs of sufficient quality that assess (cost) effectiveness are required to make firm conclusions.

Laparoscopic versus robotic subtotal splenectomy in hereditary spherocytosis. Potential advantages and limits of an expensive approach

BACKGROUND

This study was designed to compare the laparoscopic subtotal splenectomy with the robotic approach in patients with hereditary spherocytosis.

METHODS

Thirty-two consecutive subtotal splenectomies by minimal approach in patients with hereditary spherocytosis were analyzed (10 robotic vs. 22 laparoscopic subtotal splenectomies).

RESULTS

A significant difference was found for the robotic approach regarding blood loss, vascular dissection duration, and splenic remnant size. Follow-up for 4-103 months was available.

CONCLUSIONS

Subtotal splenectomy seems to be a suitable candidate for robotic surgery, requiring a delicate dissection of the splenic vessels and a correct intraoperative evaluation of the splenic remnant. Robotic subtotal splenectomy is comparable to laparoscopy in terms of hospital stay and complication. The main benefits are lower blood loss rate, vascular dissection time, and a better evaluation of the splenic remnant volume.

Focus harmonic scalpel compared to conventional haemostasis in open total thyroidectomy: a prospective randomized trial

The aim of this prospective randomized trial was to compare operative factors, postoperative outcomes and surgical complications of open total thyroidectomy when using the Harmonic Scalpel (HS) versus Conventional Haemostasis (CH). Methods. 100 consecutive patients underwent open total thyroidectomy were randomized into two groups: group CH (Conventional Haemostasis) and group HS (Harmonic Scalpel). We recorded the following: age, sex, pathology, thyroid volume, haemostatic technique, operative time, drainage volume, thyroid weight, postoperative pain, postoperative complications, and hospital stay. The results were analyzed using the Student's t test and χ² test. Results. No significant difference was found between the two groups concerning mean thyroid weight and mean hospital stay. The mean operative time was significantly shorter in the HS group. The total drainage fluid volume was lower in HS group. Two (4%) transient recurrent laryngeal nerve palsies were observed in CH group and no one (0%) in the HS group. Postoperative transient hypocalcemia occurred more frequently in the CH group. HS group experienced significantly less postoperative pain at 24 and 48 hours. Conclusions. In patients undergoing thyroidectomy, HS is a reliable and safe tool. Comparing with CH techniques, its use reduces operative times, postoperative pain, drainage volume and transient hypocalcemia.

Design of a factorial experiment with randomization restrictions to assess medical device performance on vascular tissue

Background

Energy-based surgical scalpels are designed to efficiently transect and seal blood vessels using thermal energy to promote protein denaturation and coagulation. Assessment and design improvement of ultrasonic scalpel performance relies on both in vivo and ex vivo testing. The objective of this work was to design and implement a robust, experimental test matrix with randomization restrictions and predictive statistical power, which allowed for identification of those experimental variables that may affect the quality of the seal obtained ex vivo.

Methods

The design of the experiment included three factors: temperature (two levels); the type of solution used to perfuse the artery during transection (three types); and artery type (two types) resulting in a total of twelve possible treatment combinations. Burst pressures of porcine carotid and renal arteries sealed ex vivo were assigned as the response variable.

Results

The experimental test matrix was designed and carried out as a split-plot experiment in order to assess the contributions of several variables and their interactions while accounting for randomization restrictions present in the experimental setup. The statistical software package SAS was utilized and PROC MIXED was used to account for the randomization restrictions in the split-plot design. The combination of temperature, solution, and vessel type had a statistically significant impact on seal quality.

Conclusions

The design and implementation of a split-plot experimental test-matrix provided a mechanism for addressing the existing technical randomization restrictions of ex vivo ultrasonic scalpel performance testing, while preserving the ability to examine the potential effects of independent factors or variables. This method for generating the experimental design and the statistical analyses of the resulting data are adaptable to a wide variety of experimental problems involving large-scale tissue-based studies of medical or experimental device efficacy and performance.

Infrared thermographic profiles of vessel sealing devices on thyroid parenchyma

BACKGROUND

During thyroid lobectomy, division of the thyroid parenchyma has traditionally been accomplished using suture ligation. Development of hemostatic techniques in the forms of ultrasonic dissection (UD) and electronic vessel sealing (EVS) have increased the usage of these devices during thyroid operations. We sought to characterize the thermal profile of each of these devices when used to divide the parenchyma of the thyroid gland.

METHODS

Using a porcine model, the parenchyma of the gland was sealed by alternating application of the UD and EVS devices. In each case, the thermal activity was recorded using infrared thermal imaging. We performed multiple seals with each instrument and then compared the thermal profiles.

RESULTS

There was no significant difference in lateral thermal spread of EVS and UD above 39, 40 or 60°C (2.30 ± 0.31 mm versus 2.53 ± 0.47 mm, P = 0.26; 2.22 ± 0.27 mm versus 2.47 ± 0.47 mm, P = 0.22, and 1.37 ± 0.27 mm versus 1.54 ± 0.26 mm, P = 0.22). There was no significant difference in mean time above 39 or 40°C (35.1 ± 8.7 s versus 31.7 ± 9.3 s, P = 0.47 and 29.9 ± 8.1 s versus 27.3 ± 6.7 s, P = 0.50). UD reached a greater maximum temperature (179.12 ± 0.0008C versus 96.52 ± 5.6C, P ≤ 0.001) and stayed over 60°C for longer than EVS (9.5 ± 1.8 s versus 5.3 ± 0.97 , P ≤ 0.001).

CONCLUSIONS

The amount of lateral spread of thermal energy was not significantly different between the UD and EVS devices. However, the use of UD produced a higher maximum temperature during thyroid parenchyma sealing and remained above 60°C longer than EVS. This may translate into greater thermal injury to thyroid and surrounding tissues during division.

Efficacy and safety of 5-mm-diameter bipolar and ultrasonic shears for cutting carotid arteries of the hybrid pig

BACKGROUND

Experimental data about the efficacy and safety of sealing devices are rare. Therefore, this study investigated these parameters for three commercially available energy-based vascular sealing and cutting systems.

METHODS

In male hybrid pigs, 487 carotid artery segments were sealed and cut using the harmonic scalpel or several bipolar sealing devices. The sealing failure rate, burst pressure, process time, and extent of lateral thermal damage were analyzed.

RESULTS

A regular sealing and cutting process in more than 90% of the carotid arteries was found using the following instruments: LS1520, ACE (level 1), ACE (level 3), CS14C (level 1), WAVE (level 1), and WAVE (level 5). The largest failure rate was found for the CS14C device (level 5: initial sealing failure, 21.5%). The maximal mean burst pressure (1727±453 mmHg) was reached using the ACE device (level 1). Significant differences were found in the size of the lateral thermal damage, which a ranged from 2.5 mm (LS1520) to 1.51 mm (CS14C, level 1). The process time ranged widely from 6.8 s (ACE, level 5) to 31.83 s (WAVE, level 1).

CONCLUSION

The current study demonstrated that all the tested devices are efficacious and safe in sealing and cutting arteries up to 5 mm in diameter. All the devices showed supraphysiologic mean burst pressures. Differences in failure rate, thermal damage, and process time lead to an advised application of the different systems.

Ureteral injury due to a Harmonic scalpel during laparoscopic salpingo-oophorectomy

This report highlights the need for vigilance when using laparoscopic energy sources and suggests surgeons who use the Harmonic scalpel pay close attention to application times during tissue dissection.

We present an unusual complication of a ureteral injury occurring during a bilateral laparoscopic salpingo-oophorectomy with the Harmonic scalpel (HS). The case illustrates in the same patient the versatility of the HS as a laparoscopic surgical instrument and energy source while at the same time demonstrating the potential for adverse, unexpected complications.

Application of the Hem-o-lok ligation system in laparoscopic nephrectomy

BACKGROUND

The Hem-o-lok polymer clip has become the preferred method to control large vessels during operation. We explored the advantages of application of the Hem-o-lok ligation system in laparoscopic nephrectomy.

METHODS

From January 2004 to May 2009, 116 laparoscopic nephrectomies were performed using Hem-o-lok clips to control renal artery and vein, including 22 simple nephrectomies, 63 radical nephrectomies, and 31 nephroureterectomies. Operative time, estimated intraoperative blood loss, recovery time of intestinal function, postoperative hospital day, as well as complication rate were recorded and studied retrospectively. The number and cost of Hem-o-lok clips were analyzed.

RESULTS

All 116 laparoscopic nephrectomies using Hem-o-lok clips for renal pedicle control were accomplished successfully without conversion to open surgery. No intra/postoperative vascular complications or other clip-related complications occurred. Laparoscopic operating time was 14-275 min (average 146.5 min). Estimated blood loss was 25-600 ml (average 159.2 ml). Mean recovery time of intestinal function was 30.4 h (range 16-72 h). Postoperative hospital stay was 4-22 days, with an average of 7.3 days. The mean number of Hem-o-lok clip used per operation was 5.3 (range 4-8).

CONCLUSIONS

Use of the Hem-o-lok ligation system to control renal pedicle is safe and reliable for laparoscopic simple/radical nephrectomy.

Laparoscopic and open splenectomy and azygoportal disconnection for portal hypertension

AIM: To compare the outcomes of laparoscopic and open splenectomy and azygoportal devascularization for portal hypertension.

METHODS: From June 2006 to March 2009, laparoscopic splenectomy and azygoportal disconnection (LSD) were performed on 28 patients with cirrhosis, bleeding due to portal hypertension, and secondary hypersplenism. Success was achieved in 26 patients. Demographic, intraoperative, and postoperative variables of the patients were compared.

RESULTS: Success of laparoscopic splenectomy and azygoportal disconnection was achieved in all but two patients (7.14%) who required open splenectomy and azygoportal devascularization (OSD). The operation time was significantly longer in patients undergoing LSD than in those undergoing OSD (235 ± 36 min vs 178 ± 47 min, P < 0.05). The estimated intraoperative blood loss was much more in patients receiving OSD than in those receiving LSD (420 ± 50 mL vs 200 ± 30 mL, P < 0.01). The proportion of patients undergoing laparoscopic and open splenectomy and azygoportal disconnection who received transfusion of packed red blood cells during or after the operation was 23.08% and 38.46%, respectively (P < 0.05). The time of first oral intake was faster in patients after LSD than in those after OSD (1.5 ± 0.7 d vs 3.5 ± 1.6 d, P < 0.05). The hospital stay of patients after LSD was shorter than that of patients after OSD (6.5 ± 2.3 d vs 11.7 ± 4.5 d, P < 0.05). The pain requiring medication was less severe in patients after LSD than in those after OSD (7.69% vs 73.08%, P < 0.001). The overall complication rate was lower in patients after LSD than in those after OSD (19.23% vs 42.31%, P < 0.05).

CONCLUSION: Laparoscopic splenectomy and azygoportal disconnection are the feasible, effective, and safe surgical procedure, and are advantageous over minimally invasive surgery for bleeding portal hypertension and hypersplenism.

Comparison of blood vessel sealing among new electrosurgical and ultrasonic devices

BACKGROUND

Bipolar electrosurgical devices and ultrasonic devices are routinely used in open and advanced laparoscopic surgery for hemostasis. New electrosurgical and ultrasonic instruments demonstrate improved quality and efficiency in blood vessel sealing.

METHODS

The 5-mm laparoscopic Gyrus PKS Cutting Forceps (PK), Gyrus Plasma Trissector (GP), Harmonic Scalpel (HS), EnSeal Tissue Sealing and Hemostasis System (RX), LigaSure V with LigaSure Vessel Sealing Generator (LS), LigaSure V with Force Triad Generator (FT), and Ligamax 5 Endoscopic Multiple Clip Applier (LM) were tested to compare burst pressure, sealing time, and failure rate. Each device was used to seal 13 small (2-3 mm diameter), 13 medium (4-5 mm diameter), and 13 large (6-7 mm diameter) arteries from euthanized pigs. A p value <0.05 was considered statistically significant.

RESULTS

Mean burst pressures were not statistically different for 2-3 mm or 6-7 mm vessels. For 4-5 mm vessels, LS had the highest mean burst pressure recorded. Mean seal times were shorter for every vessel size when FT was compared with LS (p < 0.05). The shortest sealing times for 2-3 mm vessels were recorded for GP. The shortest sealing times for medium and large vessels were observed with FT. The highest percentage failure rate for each vessel size occurred with GP. For 4-5 mm diameter vessels, the failure rate was 48% for GP, 41% for PK, and 22% for HS. For 6-7 mm diameter vessels, the failure rate was 92% for GP, 41% for PK, and 8% for HS. LM and FT had no recorded failures.

CONCLUSION

Among the new 5-mm laparoscopic electrosurgical and ultrasonic instruments available for testing, RX, LS, and FT produced the highest mean burst pressures. FT had the shortest mean seal times for medium and large vessels. Minimal or no seal failures occurred with HS, RX, LS, LM, and FT.

Bipolar sealing increases mesenteric reach during bowel transection compared with stapled division: clinical evidence and laboratory support in a porcine model

BACKGROUND

The ideal technique for mesenteric division to create tension-free anastomoses has not been defined. For patients undergoing Roux-en-Y gastric bypass (RYGB), the mesenteric division technique was changed from stapler to bipolar sealing using LigaSure for cost reasons. This study aimed objectively to assess the impact of the mesenteric division method on mobilization length of the Roux limb in an animal model. Clinical complications related to Roux limb tension also were analyzed in the authors' population of RYGB patients.

METHODS

Bowel and mesenteric divisions were performed in a porcine model. Four pigs received six to eight mesenteric divisions each. Steady force was applied for 1 min. The distances between the divided limbs of bowel were compared. To assess the clinical impact with RYGB patients, anastomotic complications were analyzed before and after incorporation of bipolar sealing in the authors' practice.

RESULTS

In the porcine model, the length of mesenteric stretch averaged 93.7 mm with stapled division and 109 mm with bipolar sealing (p = 0.021). From a laparoscopic RYGB population, 160 patients with stapled division were included, all of whom were at least 1 year beyond their surgery. The study analyzed 792 patients with bipolar sealing for leak or bleeding and included 479 bipolar sealed patients more than 1 year beyond their surgery for analysis of their strictures. No difference in bleeding or leaks was found between these groups. The stricture rate was significantly different, with seven strictures after stapled division (4.37%) compared with one stricture after bipolar sealing (0.2%; p = 0.001).

CONCLUSIONS

Bipolar sealing for mesenteric division is superior to stapling for optimization of enteric limb length at constant tension in a laboratory model. Clinical evidence supports this hypothesis with patients undergoing RYGB surgery by a decrease in the complications that can arise from Roux limb tension.

Comparison of four energy-based vascular sealing and cutting instruments: A porcine model

AIM

To compare the safety and efficacy of four energy-based vascular sealing and cutting instruments.

METHODS

Blood vessels of various types and diameters were harvested from four pigs using four instruments: Harmonic ACE (Ethicon Endo-Surgery, Cincinnati, OH), LigaSure V and LigaSure Atlas (Valleylab, Inc., Boulder, CO; a division of Tyco Healthcare), and EnSeal vessel fusion system (SurgRx, Inc. Redwood City, CA). The diameters of the vessels, speed and adequacy of the cutting and sealing process, and bursting pressures were compared. An additional set of specimens was sealed and left in situ for up to 4 h after which the vessels were harvested and histopathologically analyzed for the degree of thermal injury.

RESULTS

The bursting pressures were significantly higher with EnSeal compared to all other instruments (p < 0.0001). The sealing process was significantly shorter with Harmonic ACE and significantly longer with LigaSure Atlas (p <0.0001). The mean seal width was larger with the LigaSure Atlas compared to the other instruments, and it was smaller with EnSeal and Harmonic ACE. Less radial adventitial collagen denaturation was present with EnSeal and LigaSure V than with the other two instruments; there were no significant differences in collagen denaturation although proximal thermal injury to the smooth muscle in the media of the vessel wall was less common with LigaSure Atlas than with the other instruments; however, the numbers were too small for statistical analysis.

CONCLUSIONS

The bursting pressures with EnSeal were significantly higher than with all the other instruments. Harmonic ACE was the fastest sealing instrument and LigaSure Atlas was slowest. EnSeal created less radial thermal damage to the adventitial collagen of the vessels and LigaSure Atlas created less thermal damage to the media of the vessels. The clinical significance of these findings is unknown.

New-model ultrasonically activated shears for hemostatic sectioning during video-assisted thoracic surgery

During video-assisted-thoracic surgery (VATS), bleeding limits the field of view and requires frequent exchange of surgical instruments through ports, complicating the surgical procedure. The poor video view also increases the risk of vessel injury. Attention must be paid to hemostasis to achieve safe, smooth VATS. The Harmonic Scalpel (HS) is able to grasp and divide tissues while sealing small vessels, which often cause bleeding during electrocautery, and lymphatic vessels. We obtained experience using a new model of HS, which appears effective for separating membranous or streak adhesions, cutting pulmonary parenchyma, and dividing lymphatic tissues. Compared to previous models, it allows superior handling during VATS. Tissue holding with this HS is greatly improved.

Temperature safety profile of laparoscopic devices: Harmonic ACE (ACE), Ligasure V (LV), and plasma trisector (PT)

BACKGROUND

Reports of iatrogenic thermal injuries during laparoscopic surgery using new generation vessel-sealing devices, as well as anecdotal reports of hand burn injuries during hand-assisted surgeries, have evoked questions about the temperature safety profile and the cooling properties of these instruments.

METHODS

This study involved video recording of temperatures generated by different instruments (Harmonic ACE [ACE], Ligasure V [LV], and plasma trisector [PT]) applied according the manufacturers' pre-set settings (ACE setting 3; LV 3 bars, and the PT TR2 50W). The video camera used was the infrared Flex Cam Pro directed to three different types of swine tissue: (1) peritoneum (P), (2) mesenteric vessels (MV), and (3) liver (L). Activation and cooling temperature and time were measured for each instrument.

RESULTS

The ACE device produced the highest temperatures (195.9 degrees +/- 14.5 degrees C) when applied against the peritoneum, and they were significantly higher than the other instruments (LV = 96.4 degrees +/- 4.1 degrees C, and PT = 87 degrees +/- 2.2 degrees C). The LV and PT consistently yielded temperatures that were < 100 degrees C independent of type of tissue or "on"/ "off" mode. Conversely, the ACE reached temperatures higher than 200 degrees C, with a surprising surge after the instrument was deactivated. Moreover, temperatures were lower when the ACE was applied against thicker tissue (liver). The LV and PT cooling times were virtually equivalent, but the ACE required almost twice as long to cool.

CONCLUSIONS

The ACE increased the peak temperature after deactivation when applied against thick tissue (liver), and the other instruments inconsistently increased peak temperatures after they were turned off, requiring few seconds to cool down. Moreover, the ACE generated very high temperatures (234.5 degrees C) that could harm adjacent tissue or the surgeon's hand on contact immediately after deactivation. With judicious use, burn injury from these instruments can be prevented during laparoscopic procedures. Because of the high temperatures generated by the ACE device, particular care should be taken when it is used during laparoscopy.

To knot or not to knot? Sutureless haemostasis compared to the surgeon's knot

INTRODUCTION

The aim of this study was to carry out an independent evaluation of the efficacy and security of a number of vessel ligation devices and ligatures.

MATERIALS AND METHODS

A vascular ligation model was devised using fresh, ex vivo porcine internal carotid arteries of varying external diameters. Coloured normal saline was infused via a pressure/monitor device through the artery. The end lumen was occluded by five different techniques: (i) braided suture in a surgeon's knot; (ii) a monofilament suture in a granny knot; (iii) a metallic clip (Ligaclip, Johnson and Johnson); (iv) a bipolar diathermy system (Ligasure, ValleyLab); and (v) an ultrasonically activated scalpel (Harmonic Scalpel, Johnson and Johnson). The vessels were subjected to supraphysiological pressures. Loss of haemostasis was evident by leakage of coloured perfusion fluid.

RESULTS

Secure haemostasis was obtained with all the techniques in all vessels below 5 mm in diameter. In vessels over 5 mm, secure haemostasis was obtained with all modalities except harmonic scalpel. With the harmonic scalpel, leaks occurred in 3/27 (11%) vessels between 5-6 mm and 3/5 (60%) vessels over 6 mm, confirming the manufacturer's instructions.

CONCLUSIONS

In this first, independent, randomised study comparing vessel ligation devices and ligatures, the manufacturer's claims for each of the haemostatic methods were accurate. We find that all the modalities tested perform as well as the traditional surgeon's knot in vessels of 5 mm and below.

The use of LigaSure in patients with hyperthyroidism

BACKGROUND

Thyroidectomies of hyperthyroidic patients are known to be more blood-spattered than the operations performed for euthyroid nodular diseases and require careful hemostasis. Our purpose was to evaluate the efficacy of the use of LigaSure in patients with hyperthyroidism.

MATERIALS AND METHODS

Between January 2004 and October 2005, 100 patients underwent total or near-total thyroidectomy. Bipolar vessel ligation system (LigaSure) was the choice of modality for hemostasis in half of these patients, and the conventional suture ligation technique was used for the rest. The following data were evaluated non-randomized and prospectively in this study: patients demographics, thyroid pathology, operative duration, presence of complications, and the duration of the hospital stay. Comparisons of the data were evaluated by the Wilcoxon and chi-square tests.

RESULTS

Among the patients of the LigaSure group, 14 patients were detected to have hyperthyroidism (seven patients with Graves' disease and another seven patients with multinodular toxic goiter), while 36 patients were found to be euthyroidic. The durations of the operation time and of the hospital stay of the patients in the LigaSure group were significantly lower than the conventional thyroidectomy group (p<0.05). The complication rates of the LigaSure and conventional thyroidectomy groups were 4 and 6%, respectively (p>0.05).

CONCLUSIONS

The use of LigaSure as an operative technique in the treatment of Graves' disease and toxic goiter is a safe and effective modality that provides a shorter hospital stay and a shorter operation time as well.

Effect of Endo-GIA vascular staple size on laparoscopic vessel sealing in a porcine model

BACKGROUND

Two sizes of endoscopic gastrointestinal anastomosis (Endo-GIA) staples are currently available for vascular control. The purpose of this study was to compare the Endo-GIA 30-2.0 mm with the Endo-GIA 30-2.5 mm vascular staple.

METHODS

The renal blood vessels, aorta, and vena cava were divided laparoscopically using the Endo-GIA 30-2.0 and 30-2.5 mm in four pigs, respectively. The arterial and venous segments were harvested en bloc for ex vivo burst pressure studies.

RESULTS

Both 2.0-mm and 2.5-mm staples achieved vessel sealing at supraphysiologic mean burst pressures (> or =310 mmHg). There were no statistical differences between mean burst pressures of vessels stapled by 2.0-mm compared to 2.5-mm staples. Both staples sealed arteries up to 17 mm and veins up to 22 mm in diameter.

CONCLUSION

Endo-GIA 30-2.0 mm and 30-2.5 mm vascular staples are equivalent in sealing vessels at supraphysiologic mean burst pressures.