A comparative study of ultrasonic scalpel (US) versus conventional metal clips for closure of the cystic duct in laparoscopic cholecystectomy (LC): A meta-analysis

Ultrasonic Technique for Femoral Tunnel Creation in Anterior Cruciate Ligament Reconstruction

Bone tunnel creation in the anatomical location is essential in anterior cruciate ligament (ACL) reconstruction with an autogenous graft and is commonly performed with a drill bit matched to graft diameter. Anatomic rectangular tunnel ACL reconstruction with a bone-patellar tendon-bone autograft has been developed to anatomically create bone tunnels inside the ACL footprints and has been reported to achieve excellent outcomes. To make the rectangular tunnel, the surgeon needs to dilate 2 adjacent bone tunnels after creation of 2 round tunnels with a drill bit, while the tunnel wall occasionally cracks during dilating. An ultrasonic (US) device was developed with improvement of output power and has been implemented with a rectangular shape blade in the field of arthroscopic surgery. This US device can provide a precise and effective bone cut compared to drills. We introduced this device to clinically create a rectangular tunnel during ACL reconstruction. The US device can be useful for rectangular femoral tunnel creation and can create a precise rectangular femoral tunnel in the ACL footprint.

High rate of stone-related complications after stapling the cystic duct during laparoscopic cholecystectomy-an underrecognized risk

BACKGROUND

Laparoscopic staplers (LS) have been suggested as a safe alternative to metal clips in laparoscopic cholecystectomy when the cystic duct is too inflamed or wide for complete clip occlusion. We aimed to evaluate the perioperative outcomes of patients whose cystic ducts were controlled by LS and evaluate the risk factors for complications.

METHODS

Patients who underwent laparoscopic cholecystectomy with LS used to control the cystic duct from 2005 to 2019 were retrospectively identified from an institutional database. Patients were excluded for open cholecystectomy, partial cholecystectomy, or cancer. Potential risk factors for complications were assessed using logistic regression analysis.

RESULTS

Among 262 patients, 191 (72.9%) were stapled for size and 71 (27.1%) for inflammation. In total, 33 (16.3%) patients had Clavien-Dindo grade ≥ 3 complications, with no significant difference when surgeons chose to staple for duct size versus inflammation (p = 0.416). Seven patients had bile duct injury. A large proportion had Clavien-Dindo grade ≥ 3 postoperative complications specifically related to bile duct stones [n = 29 (11.07%)]. Intraoperative cholangiogram was protective against postoperative complications [odds ratio (OR) = 0.18 (p = 0.022)].

CONCLUSION

Whether these high complication rates reflect a technical issue with stapling, more challenging anatomy, or worse disease, findings question whether the use of LS during laparoscopic cholecystectomy is truly a safe alternative to the already accepted methods of cystic duct ligation and transection. Based on these findings, an intraoperative cholangiogram should be performed when considering a linear stapler during laparoscopic cholecystectomy to: (1) ensure the biliary tree is free of stones; (2) prevent inadvertent transection of the infundibulum rather than the cystic duct; and, (3) allow opportunity for safe alternative strategies when an IOC is not able to confirm anatomy. Otherwise, surgeons employing LS devices should be aware that patients are at higher risk for complications.

Harmonic Scalpel Versus Clips for Ligation of Cystic Duct in Laparoscopic Cholecystectomy: A Systematic Review

The gold standard treatment for benign gallbladder disease is laparoscopic cholecystectomy (LC). LC is commonly performed using monopolar diathermy with ligation of the cystic duct and artery with clips. The aim of the current systematic review was to compare harmonic scalpel (HS) with clips in LC. Eligible studies were identified from PubMed, Cochrane library, Embase and Medline and meta-analysis was conducted using Review Manager 5.4. The primary outcome evaluated was bile leak while secondary outcomes evaluated were overall postoperative complications, operative time, conversion to open surgery and gall bladder perforation. Eight randomized control trials met the eligibility criteria which included a total of 1,205 patients. There was no statistically significant difference between the two groups in terms of bile leak (p = 0.56, I²=0%). With respect to the operative time (p = 0.004, I²=97%), conversion to open surgery (p = 0.02, I²=0%) and gall bladder perforation (p = 0.0001, I²=26%) HS was superior to clips. HS is an acceptable alternative to the use of clips when ligating the cystic duct.

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.

Bile leakage and the number of metal clips on the cystic duct during laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVE

The most common way of closing the cystic duct in laparoscopic cholecystectomy is by using metal clips (>80%). Nevertheless, bile leakage occurs in 0.4%-2.0% of cases, and thus causes significant morbidity. However, the optimal number of clips needed to avoid bile leakage has not been determined. The primary aim of this study was to evaluate bile leakage and post-procedural adverse events after laparoscopic cholecystectomy concerning whether two or three clips were used to seal the cystic duct.

METHODS

Using a retrospective observational design, we gathered data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (ERCP) (GallRiks). From 2006 until 2019, 124,818 patients were eligible for inclusion. These were nested to cohorts of 75,322 (60.3%) for uncomplicated gallstone disease and 49,496 (39.7%) with complicated gallstone disease. The cohorts were grouped by the number (i.e. two or three) of metal clips applied to the proximal cystic duct. The main outcome was 30-day bile leakage and post-procedural adverse events.

RESULTS

No significant differences surfaced in the rate of bile leakage (0.8% vs 0.8%; P = .87) or post-procedural adverse events (three clips, 5.7% vs two clips, 5.4%; P = .16) for uncomplicated gallstone disease. However, for complicated disease, bile leakage (1.4% vs 1.0%; P < .001) and post-procedural adverse events (10.2% vs 8.6%; P < .001) significantly increased when the cystic duct was sealed with three clips compared with two.

CONCLUSIONS

Because no differences in the rates of bile leakage or adverse events emerged in uncomplicated gallstone disease when a third clip was applied, a third clip for additional safety is not recommended in such cases. On the contrary, bile leakage and adverse events increased when a third clip was used in patients with complicated gallstone disease. This finding probably indicates a more difficult cholecystectomy rather than being caused by the third clip itself.

Technical note: rectangular femoral tunnel for anterior cruciate ligament reconstruction using a new ultrasonic device: a feasibility study

PURPOSE

The goal of this preliminary report was to show the use of novel Ultrasound (US) technology for anterior cruciate ligament (ACL) reconstruction surgery and evaluate its feasibility for the creation of a rectangular femoral bone tunnel during an arthroscopic procedure in a human cadaver model.

METHODS

Two fresh frozen human cadaver knees were prepared for arthroscopic rectangular femoral tunnel completion using a prototype US device (OLYMPUS EUROPA SE & CO. KG). The desired rectangular femoral tunnel was intended to be located in the femoral anatomical ACL footprint. Its tunnel aperture was planned at 10 × 5 mm and a depth of 20 mm should be achieved. For one knee, the rectangular femoral tunnel was realized without a specific cutting guide and for the other with a 10 × 5 mm guide. One experienced orthopedic surgeon performed the two procedures consecutively. The time for femoral tunnel completion was evaluated. CT scans with subsequent three-dimensional image reconstructions were performed in order to evaluate tunnel placement and configuration.

RESULTS

In the two human cadaver models the two 10 × 5x20mm rectangular femoral tunnels were successfully completed and located in the femoral anatomical ACL footprint without adverse events. The time for femoral tunnel completion was 14 min 35 s for the procedure without the guide and 4 min 20 s with the guide.

CONCLUSION

US technology can be used for the creation of a rectangular femoral bone tunnel during an arthroscopic ACL reconstruction procedure. The use of a specific cutting guide can reduce the time for femoral tunnel completion. Additional experience will further reduce the time of the procedure.

Ultrasonic scalpel combined with internal oxygen assisted sodium nitroprusside in laparoscopic cholecystectomy for elderly patients with acute cholecystitis

To analyze the application value of an ultrasonic scalpel combined with internal oxygen assisted intravenous drip of sodium nitroprusside in laparoscopic cholecystectomy for elderly patients with acute cholecystitis.

METHODS

A total of 76 patients with acute cholecystitis who were admitted to our hospital from January 2017 to December 2018 were included and equally divided into two groups. The control group was treated with ultrasonic scalpel alone, while the study group was treated with ultrasonic scalpel combined with internal oxygen and intravenous drip of sodium nitroprusside. The incidence of postoperative adverse reactions, the recovery of surgical indicators, the quality of life score before and after treatment, and the changes of serum sICAM-1 and IL-6 expression were observed.

RESULTS

The incidence of postoperative adverse reactions in the study group was significantly higher than that in the control group (P < 0.05); and the recovery of surgical indicators in the study group was better than that in the control group (P < 0.05). After treatment, the levels of serum sICAM-1 and IL-6 in the two groups showed a certain degree of decline, and the levels of serum sICAM-1 and IL-6 inflammatory factors in the study group were significantly lower than those in the control group (P < 0.05). After treatment, the scores of psychological state, physical health, independent ability, social relationship, surrounding environment and personal belief of the two groups were significantly higher than those before treatment (P < 0.05). After treatment, the scores of each field in the treatment group were significantly higher than that in the control group (P < 0.05).

CONCLUSION

It is safe and feasible to use an ultrasonic scalpel combined with internal oxygen to assist intravenous drip of sodium nitroprusside in the treatment of elderly patients with acute cholecystitis, but proper operation time and skilled operation are necessary.

Characteristics of ultrasound device: a new technology for bone curettage and excavation

Background

Ultrasonic (US) devices are used in laparoscopic, dental, and spinal surgeries, while it is difficult to use for the joint under irrigation and perfusion solutions due to lack of power. A new US device is developed with greater voltage improvement and has been implemented in the arthroscopic field. The aim is to compare the characteristics of the US devices with the conventional ones in water.

Methods

Twenty bone blocks from the porcine femur were settled in a holder in water. A 4.0 mm diameter abrader burr moved 15 mm along the long axis of the bone block in ten blocks for three times. A 4.3 mm wide curette blade powered by ultrasonic vibration was moved in the same manner in the other ten blocks. The gutter shape, including the gutter depth and the bottom angle of the gutter, and the curetted area ratio of the gutter were assessed.

Forty bones blocks from the porcine femurs were clamped with a holder in water, while the cortical bone surface must be located on the side. A 5 mm diameter drill excavated the bone along the previously-inserted guide wire to the 15 mm depth for twenty blocks. Next, the US excavation probe of 5x4mm rectangular shape was moved to the same depth in the other twenty blocks. Each ten block was cut in half along the bone tunnel and was assessed the surface roughness at three area, while the cross-sectional area (CSA) of the tunnel were measured and the ratio of the measured CSA was calculated based on an expected CSA in the remaining ten blocks for each device.

Results

The depth of curettage and bottom angle were significantly smaller with the US device than with the abrader burr at all planes, while the curetted area ratio created by each device was mostly equal to the other. Surface roughness was similar in two evacuating devices except one area. CSA ratio with the US excavation device was significantly smaller than that with the drill.

Conclusion

US curettage has an advantage to flatly curette bone surfaces, while a bone tunnel can be accurately created with the US device.