Lateral temperature spread of monopolar, bipolar and ultrasonic instruments for robot-assisted laparoscopic surgery

Design and validation of a method for evaluating medical device cleanliness by recovering and quantifying residual proteins on stainless plates

We recently reported a method for recovering and quantifying residual proteins bound to surfaces of various medical instruments via thermal coagulation under neutral pH and room temperature. The method effectively recovered and solubilised coagulated proteins at high temperatures in dry and humid conditions, with a protein recovery rate of > 90%. This study validated the previous method by comparing residual protein recovery from test samples using a conventional extraction solution (1% SDS, [pH 11.0]) and proposed solution (1% SDS, 10 mM TCEP, and 10 mM HEPES [pH 7.0]). To mimic soiled medical equipment, pseudo-blood-contaminated stainless steel plates were prepared. Residual protein was recovered using conventional and proposed solutions under varying temperature and humidity conditions. Quantitative protein recovery limits were determined at nine facilities. Compared with the conventional solution, the proposed solution recovered proteins more effectively from samples processed at temperatures > 60 °C. However, low recovery rates were observed for samples processed at 95 °C, possibly owing to differences in protein adhesion due to sample and plate-surface properties. Our findings present a method for quantifying residual proteins on medical instruments exposed to high temperatures during use or disinfection. Further studies should standardise test soiling conditions, materials, and solutions to evaluate cleaning methods.

Comparing adverse events associated with LigaSure and Harmonic devices in head and neck surgery

OBJECTIVE

To characterize adverse events, provide a safety profile, and understand patient outcomes after complications arising from LigaSure and Harmonic use in the head and neck region.

METHODS

Retrospective analysis of adverse events from the Manufacturer and User Facility Device Experience (MAUDE) between January 2013 and 2023.

RESULTS

A total of 158 LigaSure and 159 Harmonic events were extracted. There were significantly more reports of Harmonic device overheating (6.9% vs. 0.6%, p = 0.003) and spontaneous self-activation (4.4% vs. 0%, p = 0.032). Although intra-operative and post-operative complications were similar among both groups, there were significantly more intra-operative bleeding events for LigaSure as compared to Harmonic (8.2% vs. 0.0%, p = 0.001).

CONCLUSION

Understanding technical complications and adverse events attributable to LigaSure and Harmonic devices enables the development of clinically relevant risk mitigation strategies. Surgeons should avoid improper use by remaining vigilant of device functionality and temperature changes.

Energy devices versus electrocoagulation in video-assisted thoracoscopic lobectomy: a propensity-match cohort study

BACKGROUND

The aim of the study was to compare the effect on perioperative outcome of intraoperative use of different devices for tissue dissection (electrocoagulation [EC] or energy devices [ED]) in patients who underwent video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer.

METHODS

We retrospectively reviewed 191 consecutive patients who underwent VATS lobectomy, divided into two cohorts: ED (117 patients), and EC (74 patients); after propensity score matching, 148 patients were extracted, 74 for each cohort. The primary endpoints considered were complication rate and 30-day mortality rate. The secondary endpoints considered were length of stay (LOS) and the number of lymph nodes harvested.

RESULTS

The complication rate did not differ between the two cohorts (16.22% EC group, 19.66% ED group, P=0.549), before and after propensity matching (16.22% for both EC and ED group, P=1.000). The 30-day mortality rate was 1 in the overall population. Median LOS was 5 days for both groups, before and after propensity match, with the same interquartile range, (IQR: 4-8). ED group had a significantly higher median number of lymph nodes harvested (ED median: 18, IQR: 12-24; EC median: 10, IQR: 5-19; P=0.0002). The difference was confirmed after the propensity score matching (ED median: 17, IQR: 13-23; EC median: 10, IQR: 5-19; P=0.0008).

CONCLUSIONS

ED dissection during VATS lobectomy did not lead to different complication rates, mortality rates, and LOS compared to EC tissue dissection. ED use led to a significantly higher number of intraoperative lymph nodes harvested compared to EC use.

Efficacy of using Maryland forceps versus electrocoagulation hooks in da Vinci robot-assisted thoracoscopic mediastinal tumor resection

BACKGROUND

To compare the difference of short-term curative effect between the use of Maryland forceps (MF) and electrocoagulation hooks (EH) in da Vinci robot-assisted thoracoscopic mediastinal tumor resection.

METHODS

Retrospectively analyze 84 patients with mediastinal tumors who underwent robot-assisted thoracoscopic surgery (RATS) at the Department of Thoracic Surgery in Gansu Provincial Hospital from February 2019 to February 2023. Two groups were divided according to the intraoperative use of energy devices, including 41 cases in the MF group and 43 cases in the EH group. Perioperative clinical data was gathered to compare the short-term efficacy of patients in both groups.

RESULTS

There were no significant differences in baseline characteristics such as sex (P = 0.685), age (P = 0.165), and tumor size (P = 0.339) between the two groups. Compared with the EH group, patients in the MF group have shorter operative time (P = 0.030), less intraoperative bleeding (P = 0.010), less total postoperative drainage volume (P = 0.001), shorter postoperative drainage time (P = 0.022), shorter hospital stay (P = 0.019), and lower levels of interleukin-6 (IL-6), interleukin-8 (IL-8), tumor necrosis factor-alpha (TNF-α), and cortisol. No statistically significant differences were found between the two groups in terms of total hospitalization costs (P = 0.123), postoperative visual analog scale (VAS) pain scores (P = 0.064), and postoperative complications (P = 0.431).

CONCLUSION

Using MF in RATS for mediastinal tumor is safe and effective, which can reduce the amount of bleeding, reduce the degree of inflammatory reaction, and conducive to the quick recovery of patients.

Measuring thermal spread during bipolar cauterizing using an experimental pneumoperitoneum and thermal sensors

Objective

During nerve-sparing robot-assisted radical prostatectomy (RARP) bipolar electrocoagulation is often used but its use is controversial for the possible thermal damage of neurovascular bundles. Aim of the study was to evaluate the spatial-temporal thermal distribution in the tissue and the correlation with the electrosurgery-induced tissue damage in a controlled, CO2-rich environment modelling the laparoscopy conditions..

Methods

We manufactured a sealed plexiglass chamber (SPC) equipped with sensors to reproduce experimentally the environmental conditions of pneumoperitoneum during RARP. We evaluated in 64 pig musculofascial tissues (PMTs) of approximately 3 cm³ × 3 cm³ × 2 cm³ the spatial-temporal thermal distribution in the tissue and the correlation with the electrosurgery-induced tissue damage in a controlled CO2-rich environment modeling the laparoscopy conditions. Critical heat spread of bipolar cauterizing during surgical procedure was assessed by the employment of a compact thermal camera (C2) with a small core sensor (60 × 80 microbolometer array in the range 7-14 μm).

Results

Bipolar instruments used at 30 W showed a thermal spread area of 18 mm² when applied for 2 s and 28 mm² when applied for 4 s. At 60 W, bipolar instruments showed a mean thermal spread and 19 mm² when applied for 2 s; and 21 mm² when applied for 4 s. Finally, histopathological analysis showed that thermal damage is distributed predominantly on the surface rather than in depth.

Conclusions

The application of these results is very interesting for the definition of an accurate use of bipolar cautery during nerve-sparing RARP. It demonstrates the feasibility of using miniaturized thermal sensors, thus addressing the potential for next developments regarding the design of thermal endoscopic devices for robotic use.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Clipless Robotic-assisted Radical Prostatectomy and Impact on Outcomes

BACKGROUND

The use of surgical clips for athermal dissection of the lateral prostatic pedicles and ligation during pelvic lymph node dissection (PLND) while performing robotic-assisted radical prostatectomy (RARP) has been the gold standard. Clips are used to prevent thermal injury of the unmyelinated nerve fibers and lymphceles, respectively.

OBJECTIVE

To compare oncological and functional outcomes of a new technique of clipless, lateral pedicle control and PLND with RARP with bipolar energy (RARP-bi) versus the standard RARP technique with clips (RARP-c).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective study was conducted among 338 men who underwent RARP between July 2018 and March 2020.

SURGICAL PROCEDURE

RARP-c versus RARP-bi.

MEASUREMENTS

We prospectively collected data and retrospectively compared demographic, clinicopathological, and functional outcome data. Urinary as well as sexual function was assessed using the Expanded Prostate Cancer Index for Clinical Practice, and complications were assessed using Clavien-Dindo grading. Multivariable regression modeling was used to examine whether the technical approach of RARP-bi versus RARP-c was associated with positive surgical margins (PSMs) or sexual and urinary function scores.

RESULTS AND LIMITATIONS

A total of 144 (43%) and 194 (57%) men underwent RARP-bi and RARP-c, respectively. Overall, there were no differences in functional and oncological outcomes between the two approaches. On multivariable regression analysis, the RARP-bi technique was not associated with significant differences in PSMs (odds ratio [OR] = 1.04, 95% confidence interval [CI] 0.6-1.8; p = 0.9), sexual function (OR = 0.4, 95% CI 0.1-1.5; p = 0.8), or urinary function (OR = 0.5, 95% CI 0.2-1.4; p = 0.2). The overall 30-d complication rates (12% vs 16%, p = 0.5) and bladder neck contracture rates (2.1% vs 3.6%, p = 0.5) were similar between the two groups. There was no difference in lymphocele complications (1.4% vs 0.52%, p = 0.58). All complications were of Clavien-Dindo grade I-II.

CONCLUSIONS

Despite the concerns for an increased risk of nerve injury secondary to the use of bipolar energy for prostatic pedicle dissection, we demonstrate that this technique is oncologically and functionally similar to the standard approach with surgical clips. There was no difference in complications or lymphocele formation for techniques with versus without clips.

PATIENT SUMMARY

We describe a modified technique for prostatic pedicle dissection during robotic-assisted radical prostatectomy, which utilizes bipolar energy and is associated with shorter operative time, without compromising functional or oncological outcomes.

Quantifying the magnitude of local tendon injury from electrosurgical transection

BACKGROUND

Electrocautery is a common surgical technique and is often used during shoulder arthroplasty to elevate or transect the subscapularis tendon. The relative amount of tissue damage caused by cautery as opposed to sharp transection is not currently known. The purpose of this study was to examine local tissue damage resulting from electrocautery vs. sharp transection with a scalpel. We hypothesized that the electrosurgical unit would cause higher collateral tissue damage and cell death compared with sharp transection.

METHODS

Twelve cadaveric ovine shoulders were randomized to either the electrosurgical or sharp transection group. The infraspinatus tendon was isolated, and a partial-thickness transection was made using either a monopolar electrosurgical device (Bovie) or No. 10 scalpel blade. Tendon explants were then visualized with confocal microscopy to evaluate tissue architecture. A live/dead assay was performed using microscopy imaging analysis software. Comparisons between Bovie and scalpel transection were made using the Mann-Whitney U test, and the cell death percentage at standardized distances from the transection site was compared between groups using a mixed-model analysis. Significance was defined at P < .05.

RESULTS

The cellular and tendon fibril architecture was well maintained beyond the scalpel transection site, whereas Bovie transection disrupted the architecture beyond its transection path. The percentage of dead cells in the Bovie group (74.9% ± 31.2%) was significantly higher than that in the scalpel group (27.6% ± 29.9%, P = .0004). Compared with the transection site, the cell death percentage after Bovie transection significantly declined at 2.5 mm whereas that after scalpel transection significantly declined at 1 mm from the transection site.

CONCLUSION

There was a significantly higher dead cell percentage in the Bovie transection group, indicating extensive damage beyond the local incision site, compared with sharp transection. Electrosurgical transection of the ovine infraspinatus tendon ex vivo caused higher cell death and greater tissue architecture disruption compared with sharp scalpel transection.

A multimodal concept for vaginal cuff closure by modification of the Bakay technique in total laparoscopic hysterectomy: a randomized clinical study

Background

The aim of this study was to compare the outcomes of modified Bakay technique (MT) to standard colpotomy (ST) and cuff closure in total laparoscopic hysterectomy (TLH).

Methods

This two-centre, randomized-controlled study included a total of 160 patients who were scheduled for TLH for benign diseases (ClinicalTrials.gov Identifier is NCT05080114 and the first posted date was 15/10/2021). The patients were allocated into two groups by a computer-based randomization programme as ST group and MT group. Total operative time, cuff closure time, length of hospital stay, intra- and postoperative complications according to the Clavien-Dindo classification, pre- and postoperative vaginal length, and patient satisfaction according to the Patient Global Impression of Improvement (PGI-I) questionnaire were assessed.

Results

Seventy-seven patients in the ST group and 80 patients in the MT group underwent TLH. The total operative time was significantly shorter in the MT compared to the ST (55.5 vs. 59 min, respectively; p = 0.001). The median total operative time for colpotomy, extraction of uterus, and vaginal cuff closure steps was 9 (range 6–12 in MT vs. 6 to 11 in ST) min in both groups. The median hospital stay was 2 (range 1–4) days in both groups. Intraoperative blood loss was not significantly different between the groups (90 mL in ST vs. 80 mL in MT; p = 0.456). The mean uterine weight for the ST group and MT group was comparable (258.6 ± 88.6 g vs. 232.9 ± 102.5 g, respectively; p = 0.107). The preoperative vaginal length was not significantly different between the groups (p = 0.502). The median postoperative vaginal length was significantly higher in the MT group compared to the ST group on Day 90 (8 cm vs. 7,5 cm, respectively; p = 0.001). The PGI-I questionnaire score on Day 90 postoperatively was 2 (range 1–5) in both groups (p = 0.636). The complication rates were similar between the groups (p = 0.230).

Conclusion

The MT can be safely performed in most of the cases requiring TLH with the advantages of vaginal cuff closure before the alteration of pelvic anatomy, support to primary healing of the vaginal cuff, and routine concomitant apical support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01591-z.

The current role of robotic surgery in endometriosis management

INTRODUCTION

Endometriosis is a chronic inflammatory disease that affects approximately 10%-15% of women of childbearing age. Laparoscopic surgery is the preferred surgical approach. Recently, robotic surgery has been used for benign gynecologic surgery, but its role in the treatment of endometriosis is still unknown.

AREAS COVERED

We included studies that evaluated the outcomes of robotic surgery for endometriosis. Using the keywords 'endometriosis' and 'robotics', a comprehensive literature search on PubMed, Embase, and the Cochrane Library was performed in July 2021.

EXPERT OPINION

Robotic surgery for endometriosis has similar outcomes as conventional laparoscopy, with no evidence of increased complication rates. Despite the non-inferiority of the surgical route, the associated costs of robotic surgery limit its availability. Rapid development of robot-assisted surgery necessitates long-term prospective randomized controlled trials. However, the limitations of robotic surgery should not be overlooked. If robotic surgery can facilitate the spread of minimally invasive surgery, it will be necessary to evaluate the cost, availability, complexity of the lesions, and most importantly, the results of patient satisfaction and values of value-based medicine.

Cerenkov Luminescence Imaging in Prostate Cancer: Not the Only Light That Shines

Cerenkov luminescence imaging (CLI) is a novel imaging technology that might have the ability to assess surgical margins intraoperatively during prostatectomy using 68Ga-prostate-specific membrane antigen (68Ga-PSMA-11). This study evaluated the accuracy of CLI compared with histopathology and, as an exploratory objective, investigated the characteristics of the identified chemiluminescence signal. Methods: After intravenous injection of a mean 68Ga-PSMA-11 activity of 69 MBq intraoperatively, all excised specimens were imaged with CLI. Areas of increased signal were marked for histopathologic comparison and scored for the likelihood of being a positive surgical margin (PSM) using a 5-point Likert scale. In addition, the chemiluminescence signal was investigated in 3 radioactive and 3 nonradioactive specimens using CLI. Results: In 15 patients, the agreement between CLI and histopathology was 60%; this improved to 83% when including close surgical margins (≤1 mm). In 6 hot spots, CLI correctly identified PSMs on histopathology, located at the apex and mid prostate. In all 15 patients, an increased signal at the prostate base was observed, without the presence of the primary tumor in this area in 8 patients. This chemiluminescence signal was also observed in nonradioactive prostate specimens, with a half-life of 48 ± 11 min. The chemiluminescence hampered the visual interpretation of 4 PSMs at the base. Conclusion: CLI was able to correctly identify margin status, including close margins, in 83% of the cases. The presence of a diathermy-induced chemiluminescent signal hampered image interpretation, especially at the base of the prostate. In the current form, CLI is most applicable to detect PSMs and close margins in the apex and mid prostate.

Harmonic scalpels compared with electrocautery in reconstructive flap harvesting: A meta-analysis

BACKGROUND

Numerous studies have compared electrical devices used for flap surgery, but the results are inconsistent. This research was performed to evaluate the efficacy of two different types of electric devices: electrocautery and ultrasonic shears.

METHODS

The PubMed, Embase, and Scopus databases were searched systematically. A total of 505 cases were included in this study, including 209 electrocautery and 296 harmonic scalpel cases. The following information was retrieved from the included studies: the first author of the article, publication year, flap type, flap harvest time, drain volume, bleeding volume and postoperative complications. Hematoma, infection, flap necrosis and wound dehiscence were considered postoperative complications. The Q statistic for heterogeneity and the I² index were calculated. If I²  < 50%, we used a fixed-effects model; if I²  > 50%, we employed a random-effects model in our meta-analysis.

RESULTS

A total of eight studies which met the inclusion criteria were included and reviewed systematically for a meta-analysis. The harmonic scalpel yielded a statistically significantly more favorable flap harvest time and drain volume than did electrocautery. The Harmonic scalpel led to a shorter flap harvest time by 26.29 min (95% CI = -39.38 to -13.2; p < .00001) and smaller drain volume by 58.76 ml (95% CI = -105.27 to -12.25; p = .01) on average. However, there were no significant differences in the bleeding volume or incidence rates of infection, flap necrosis and wound dehiscence.

CONCLUSION

The Harmonic scalpel method yields better outcomes in terms of the flap harvest time and drain volume than does the conventional electrocautery method. Therefore, the Harmonic scalpel is a better option for cauterization and dissection in flap surgery.

Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review

Almost all gynecological and general-surgical operations are - or can be - performed laparoscopically. In comparison to an abdominal approach, the minimally invasive access offers several advantages; however, laparoscopy (both conventional and robotic-assisted) can be associated with a number of approach-specific complications. Although the majority of them are related to the laparoscopic entry, adverse events may also occur due to the presence of pneumoperitoneum or the use of laparoscopic instruments. Unfortunately, a high proportion of complications (especially affecting the bowel and ureter) remain unrecognized during surgery. This narrative review provides comprehensive up-to-date information about definitions, classifications, risk factors and incidence of surgical complications in conventional and robotic-assisted laparoscopy, with a special focus on gynecology. The topic is discussed from various perspectives, e.g. in the context of stage of surgery, injured organs, involved instruments, and in relation to malpractice claims.

Infant Robot-assisted Laparoscopic Pyeloplasty: Outcomes at a Single Institution, and Tips for Safety and Success

BACKGROUND

Since its first description, multiple reports proved efficacy and safety of the robotic platform. Further progress has been made allowing for the application of robotic surgery to smaller patients, including infants. Despite the early favorable results, the use of robot surgery in infants is still controversial and more studies are needed to confirm its benefits.

OBJECTIVE

To our knowledge, we present the largest single-institution case series of robot-assisted laparoscopic pyeloplasty (RAL-P) in infants, aiming to contribute to the current literature with a guide for key technical steps and safety tips for infant RAL-P.

DESIGN, SETTING, AND PARTICIPANTS

We performed a retrospective review of a prospectively maintained database. The study protocol was approved by the institutional review board.

SURGICAL PROCEDURE

Only infants (≤12 mo of age) with a diagnosis of congenital ureteropelvic junction obstruction (UPJO) undergoing primary robotic dismembered pyeloplasty were included in the study.

MEASUREMENTS

We critically reviewed the clinical outcomes, described the main steps of the operation, and shared tips for a safe approach.

RESULTS AND LIMITATIONS

From January 2012 to August 2019, 44 infants underwent RAL-P for UPJO--33 (75%) males and 11 (25%) females. All robotic cases were completed successfully, with no laparotomic conversions. The median age and weight were 4 (1-12) mo and 6.8 (3.8-10.5) kg, respectively. The mean operative time was 142 (±25) min. The mean estimated blood loss was 7 (±3.6) ml, and no intraoperative complications occurred. The mean length of hospital stay (LOS) was 1.4 (±0.7) d. Seven (15.6%) patients had postoperative complications-one (2%) ileus (Clavien-Dindo grade [CDG] I), four (9%) urinary tract infections (CDG II), and two (4.5%) port-site hernias (CDG III). At a median follow-up of 19 mo, the success rate was 100%.

CONCLUSIONS

Given the successful outcomes, benefits of decreased LOS, and improved cosmesis, RAL-P is an appealing management option for UPJO in infants. Market release of new systems, further miniaturization of instruments, and more affordable costs will hopefully be shedding light on more complex applications.

PATIENT SUMMARY

Infants (≤12 mo of age) diagnosed with ureteropelvic junction obstruction undergoing primary robotic dismembered pyeloplasty were selected and included in this study. No intraoperative complications or conversion to an open approach occurred. Seven patients (16%) developed postoperative complications-one (2%) postoperative ileus, four (9%) urinary tract infections, and two (4.5%) port-site hernias. At a median follow-up of 19 (7-66) mo, the success rate was 100%.

The Micro Hand S vs. da Vinci Surgical Robot-Assisted Surgery on Total Mesorectal Excision: Short-Term Outcomes Using Propensity Score Matching Analysis

Objective: To compare the operation mode and clinical short-term outcomes of the Micro Hand S and the da Vinci surgical robot, we chose total mesorectal excision (TME) as the standard procedure for its good reflection of robot-assisted surgery advantages.

Methods: We collected a total of 54 consecutive patients who underwent robot-assisted TME by two surgical robots from January 2016 to October 2020. We used propensity score matching (PSM) to create balanced cohorts of Micro Hand S group (n = 14) and da Vinci group (n = 14). Robotic installation and operation time, hospital and surgery costs, and intraoperative and postoperative clinical outcomes were compared.

Results: In terms of robotic installation time, the Micro Hand S robot took longer than the da Vinci robot (24.2 ± 9.4 min vs. 17.1 ± 5.1 min, P < 0.05). As for the costs, the Micro Hand S group had lower total hospital costs (87,040.1 ± 24,676.9 yuan vs. 125,292.3 ± 17,706.7 yuan, P < 0.05) and surgery costs (25,772.3 ± 4,117.0 yuan vs. 46,940.9 ± 10,199.7 yuan, P < 0.05) than the da Vinci group. There were no statistically significant differences (P > 0.05) in other indicators, including total operation time, robotic operation time, blood loss, time to first liquid diet, time of getting out of bed, and hospital stay.

Conclusion: The Micro Hand S enables patients with rectal cancer to enjoy lower medical costs of robotic surgery.

Clinical Trial Registration:ClinicalTrials.gov [NCT02752698]

Modified enhanced recovery after surgery protocol in patients with acute cholecystitis: efficacy, safety and feasibility. Multicenter randomized control study

Laparoscopic cholecystectomy (LC) is a common surgical procedure in acute cholecystitis (AC). Patients often suffer from considerable postoperative pain and indigestion, which prolongs in-hospital stay. The enhanced recovery after surgery (ERAS) program has proven its efficacy in elective surgery and could hypothetically improve outcomes of emergency LC. Currently, there is no ERAS program for LC in patients with AC. A modified ERAS (mERAS) protocol was studied in a prospective, randomized non-blinded clinical trial (NCT03754751). The mERAS group consisted of 88 patients the control group of 101 patients. The modified protocol included a patient information brochure; minimizing drain use; local anesthesia; low-pressure pneumoperitoneum; PONV prophylaxis, early mobilization and oral diet. The primary outcome was postoperative length of stay (pLOS). The postoperative length of stay in the mERAS group was shorter (24 (21-45.5) h) than in the control (45 (41-68) h) (p < 0.0001). One re-admission in the mERAS group was reported (p = 0.466). There difference in complications was insignificant (mERAS 6.8% vs 5% p = 0.757). Post-operative pain intensity was significantly lower in the mERAS group immediately after awaking (3.7 ± 1.8 vs 5.4 ± 1.3 p < 0.0001), 2 h (3.3 ± 1.7 vs 4.9 ± 1.6 p =  0.0006), 6 h (2.9 ± 1.5 vs 4.2 ± 1.2 p  < 0.0001), 12 h (2.7 ± 0.9 vs 4.1 ± 1.2 p = 0.0001) and 24 h after surgery (2.1 ± 1.2 vs 3 ± 1.2 p <  0.0001). The incidence of shoulder and neck pain was lower in mERAS group (13.6% vs 34.7% p = 0.0009). Peristalsis recovery was similar in both groups. The proposed protocol improved postoperative recovery and reduced hospital stay in patients with AC without increasing the rate of complications or re-admissions.

Energy devices safety and impact on video-assisted thoracoscopic lung lobectomy postoperative course: monopolar electrocautery versus ultrasonic dissector

Background

This study aims to compare safety and impact of monopolar electrocautery and ultrasonic dissector (Harmonic ACE Plus®) on postoperative short-term outcomes after video-assisted thoracoscopic (VATS) lobectomy and lymphadenectomy for lung cancer.

Methods

We analyzed the prospectively collected data of 140 consecutive patients [59% male; median age: 71(IQR:62–76) years] undergoing VATS lobectomy and lymphadenectomy in our institution between October 2016 and November 2019. Patients were divided in two groups based on device used: monopolar electric hook in 79 cases (Group A); ultrasonic dissector in 61(Group B). Energy instrument-related intraoperative accidents, hemothorax/chylothorax incidence, total pleural effusion volume at 48 postoperative hours and chest tube duration were compared between groups. Multivariable analysis was performed to test energy device as possible independent risk factor either for increased pleural effusion volume or for prolonged chest tube duration.

Results

No intraoperative accidents due to energy device occurred. No hemothorax was recorded. Postoperative chylothorax incidence was slightly higher in Group A (2.5% vs 0%; p-value = 0.21). Total pleural effusion volume at 48 h was significantly higher in Group B: 400 (285–500) vs 255 (150–459) ml (p-value = 0.005). Chest tube duration was similar in the two groups: 5 (3–9) vs 5 (3–8) days (p-value = 0.77). At multivariable analysis the energy device used was not associated with increased pleural effusion volume (p-value = 0.43) nor with prolonged chest tube duration (p-value = 0.28).

Conclusions

Monopolar electrocautery and Harmonic ACE Plus® were safe and had a similar impact on short-term outcomes after VATS lobectomy and lymphadenectomy, suggesting that energy devices choice could be left to surgeon’s preference.

The effect of laparoscopic excisional and ablative surgery on ovarian reserve in patients with endometriomas: A retrospective study

This study investigates the effect of 2 laparoscopic methods on ovarian reserve in patients of reproductive age with endometriomas.This was a retrospective study performed at a tertiary medical center from Jan 1st to Dec 31st, 2016. Laparoscopic cystectomy (group 1, 46 patients) and laparoscopic ovarian drainage and ablation with bipolar coagulation at low power (group 2, 30 patients) were performed to treat endometriomas larger than 3 cm. Anti-Müllerian hormone was used to assess ovarian reserve before and after surgery.There were no statistically significant differences in patients' baseline clinical characteristics, endometriotic stage, operative time, and follow-up time between the groups. The mean serum anti-Müllerian hormone concentration decreased significantly from 4.25 ng/ml to 3.40 ng/ml in group 1 compared with 4.47 ng/ml to 3.95 ng/ml in group 2 (P  = .04). Pregnancy rates were 71.05% in group 1 and 73.08% in group 2, with a mean follow-up of 30.40 months and 32.35 months (P  > .99), respectively. Although there was no statistical significance, the recurrence rate in group 1 was lower than that in group 2 (4.35% vs 16.67%, respectively; P = .11). The mean diameter of recurrent cysts was 1.75 cm in group 1 and 1.54 cm in group 2 (P = .13).Appropriate laparoscopic electrocautery of the endometrioma wall with a bipolar instrument may be a valid alternative to traditional laparoscopic cystectomy, with less effects on ovarian reserve.

Presacral Anatomy in Women With a Horseshoe Kidney

OBJECTIVE

Horseshoe kidney (HSK) is the most common renal fusion defect that can alter vascular and upper urinary tract anatomy. Anatomic variations in the presacral space can make surgical dissection very challenging. The aim of this study was to characterize presacral anatomy in women with HSK.

METHODS

Large academic centers' database was queried to identify imaging studies in adult women with HSK. Available multiplanar computed tomography and magnetic resonance imaging images were reviewed, and relevant vascular and upper urinary tract anatomy was measured and compared with published normal values. Study population was compared with the normal controls using Student t test, χ test, or Fisher exact test as appropriate.

RESULTS

One hundred seventy-eight women were identified initially, and 20 confirmed to have HSK on imaging. The mean ± SD age was 54.5 ± 16.9 years, and body mass index was 27.3 ± 7.5 kg/m. Women with HSK had a narrower angle of aortic bifurcation (39.1 ± 18.7 degrees vs 55.6 ± 4.5 degrees, P = 0.014); the right ureter was closer to midline (22.9 ± 8.8 mm vs 32.3 ± 1.2 mm, P < 0.001) when compared with normal controls anatomy. In 40% of women with HSK, the bifurcation of the vena cava was below the level of L5 in contrast to the 8% in the normal population (P < 0.001). In 60% of women with HSK, the inferior pole of the kidney was at or below L5.

CONCLUSIONS

Ureteral, renal, and vascular anatomic alterations in women with HSK may make presacral surgical anatomy challenging by obscuring the anterior longitudinal ligament anchoring point. Preoperative imaging is warranted to determine the feasibility of female pelvic reconstructive surgery in HSK patients.

A new method using a vessel-sealing system provides coagulation effects to various types of bleeding with less thermal damage

BACKGROUND

Hemostasis is very important for a safe surgery, particularly in endoscopic surgery. Accordingly, in the last decade, vessel-sealing systems became popular as hemostatic devices. However, their use is limited due to thermal damage to organs, such as intestines and nerves. We developed a new method for safe coagulation using a vessel-sealing system, termed flat coagulation (FC). This study aimed to evaluate the efficacy of this new FC method compared to conventional coagulation methods.

METHODS

We evaluated the thermal damage caused by various energy devices, such as the vessel-sealing system (FC method using LigaSure™), ultrasonic scissors (Sonicision™), and monopolar electrosurgery (cut/coagulation/spray/soft coagulation (SC) mode), on porcine organs, including the small intestine and liver. Furthermore, we compared the hemostasis time between the FC method and conventional methods in the superficial bleeding model using porcine mesentery.

RESULTS

FC caused less thermal damage than monopolar electrosurgery's SC mode in the porcine liver and small intestine (liver: mean depth of thermal damage, 1.91 ± 0.35 vs 3.37 ± 0.28 mm; p = 0.0015). In the superficial bleeding model, the hemostasis time of FC was significantly shorter than that of electrosurgery's SC mode (mean, 19.54 ± 22.51 s vs 44.99 ± 21.18 s; p = 0.0046).

CONCLUSION

This study showed that the FC method caused less thermal damage to porcine small intestine and liver than conventional methods. This FC method could provide easier and faster coagulation of superficial bleeds compared to that achieved by electrosurgery's SC mode. Therefore, this study motivates for the use of this new method to achieve hemostasis with various types of bleeds involving internal organs during endoscopic surgeries.

Vessel-Sealing Capability of Novel Microwave Sealer: Experimental Study in Animal Models

Background. Ultrasonically activated dissectors (UADs) and radiofrequency-based devices have been considered excellent surgical devices because of their reliability and flexibility. Meanwhile, microwave-based devices have demonstrated potential with their unique heating mechanism. This study aims to compare the sealing function of a newly invented forceps-like microwave sealer (MS) with that of currently available UADs. Materials and Methods. MS and 2 examples of UADs (Harmonic Focus+ [HF+] and Sonicision [SNC]) were employed to perform mesenterectomies (in vivo) and sealing sizable vessels (ex vivo). Vessel diameter, seal time, burst pressure (BP), sealing completion, and instrument sticking were recorded. The samples underwent histological investigation for thermal damage evaluation. Results. During mesenterectomies, MS required 3 seconds and 30 W to secure a complete seal. The BP achieved by the MS seal was higher than that of HF+ and SNC on arteries (851 ± 203.7 vs 682.4 ± 287.3, P < .05; vs 833.1 ± 251.2 mmHg, P = .4523, respectively) but was not statistically different on veins (324.9 ± 203.5 vs 460.1 ± 320.3 vs 508.3 ± 350.7 mmHg, P = .215). In all trials, MS caused less sticking but exhibited similar heat-induced alterations to UADs. MS's thermal spread was not statistically more extended than that of UADs on either arteries or veins. Conclusions. MS was capable of not only sealing tiny vessels but also achieving high-pressure endurance on sizable vessels. Its forceful grasping and synchronous heating process helped create solid stumps with an acceptable thermal spread.

Stray energy transfer in single-incision robotic surgery

INTRODUCTION

Stray energy transfer from surgical monopolar radiofrequency energy instruments can cause unintended thermal injuries during laparoscopic surgery. Single-incision laparoscopic surgery transfers more stray energy than traditional laparoscopic surgery. There is paucity of published data concerning stray energy during single-incision robotic surgery. The purpose of this study was to quantify stray energy transfer during traditional, multiport robotic surgery (TRS) compared to single-incision robotic surgery (SIRS).

METHODS

An in vivo porcine model was used to simulate a multiport or single-incision robotic cholecystectomy (DaVinci Si, Intuitive Surgical, Sunnyvale, CA). A 5 s, open air activation of the monopolar scissors was done on 30 W and 60 W coag mode (ForceTriad, Covidien-Medtronic, Boulder, CO) and Swift Coag effect 3, max power 180 W (VIO 300D, ERBE USA, Marietta, GA). Temperature of the tissue (°C) adjacent to the tip of the assistant grasper or the camera was measured with a thermal camera (E95, FLIR Systems, Wilsonville, OR) to quantify stray energy transfer.

RESULTS

Stray energy transfer was greater in the SIRS setup compared to TRS setup at the assistant grasper (11.6 ± 3.3 °C vs. 8.4 ± 1.6 °C, p = 0.013). Reducing power from 60 to 30 W significantly reduced stray energy transfer in SIRS (15.3 ± 3.4 °C vs. 11.6 ± 3.3 °C, p = 0.023), but not significantly for TRS (9.4 ± 2.5 °C vs. 8.4 ± 1.6 °C, p = 0.278). The use of a constant voltage regulating generator also minimized stray energy transfer for both SIRS (0.7 ± 0.4 °C, p < 0.001) and TRS (0.7 ± 0.4 °C, p < 0.001).

CONCLUSIONS

More stray energy transfer occurs during single-incision robotic surgery than multiport robotic surgery. Utilizing a constant voltage regulating generator minimized stray energy transfer for both setups. These data can be used to guide robotic surgeons in their use of safe, surgical energy.

Thermal effects of monopolar electrosurgery detected by real-time infrared thermography: an experimental appendectomy study

Background

Monopolar energy (ME) is routinely used in appendectomy. This study aimed to investigate the degree of lateral thermal spread generated by ME and to evaluate the thermal injury sustained by the close-lying tissues.

Methods

Appendectomy with a monopolar Maryland dissector was performed in 8 rabbits (at 30 and 60 W power settings). A high-resolution infrared camera was used to record tissue heating during the intervention. After autopsy macroscopic changes were evaluated and tissue samples were subjected to myeloperoxidase (MPO) assay and histological examination.

Results

No significant differences in the extent of thermal spread, MPO activity and histological signs of inflammation were observed between groups. Regardless of the power settings, the heat spread exceeded 2 cm laterally along the mesoappendix when application time exceeded 3 s. The spread of heat through tubular structures in both groups caused a significant temperature rise in the nearby intestinal loop, resulting in perforation (n = 3) and necrosis (n = 1).

Conclusions

Application time is critical in thermal spread during appendectomy aided by ME. Tubular anatomic structures can enhance thermal injury on distant tissues. The observed effects of ME bear clinical relevance that need further investigation.

Novel Energy Devices in Head and Neck Robotic Surgery - A Narrative Review

The advent of trans-oral robotic surgery (TORS) has facilitated removal of tumors previously deemed unresectable, by providing access to the deep structures of the head and neck. Despite this, the wider dissemination of TORS has been restricted due to issues with line of access, as the da Vinci robot was never designed with head and neck surgery in mind. Flexible instruments and novel energy delivery devices offer great potential in overcoming some of the existing challenges surrounding TORS. This review aimed to summarize the existing literature surrounding energy delivery in TORS and highlight areas of future innovation. MEDLINE was searched for studies relating to energy delivery in TORS in November 2019. The existing literature surrounding monopolar and bipolar electrocautery, LASER (CO₂, Tm:YAG and blue LASER), Ligasure and Harmonic was reviewed. Additionally, the latest iteration of the da Vinci; the SP, and the FLEX robot were evaluated as novel methods of energy delivery in TORS. Overall, these novel energy devices and robotic systems are predicted to further improve energy delivery to the head and neck. The use of flexible LASER in particular is well substantiated in the literature. This has the potential to achieve treatment de-escalation, based on the excellent outcomes demonstrated for disease-free margins and post-operative morbidity.

Determination of Tissue Thermal Conductivity as a Function of Thermal Dose and Its Application in Finite Element Modeling of Electrosurgical Vessel Sealing

OBJECTIVE

Electrosurgical vessel sealing is a process commonly used to control bleeding during surgical procedures. Finite element (FE) modeling is often performed to obtain a better understanding of thermal spread during this process. The accuracy of the FE model depends on the implemented material properties. Thermal conductivity is one of the most important properties that affect temperature distribution. The goal of this study is to determine the tissue thermal conductivity as a function of thermal dose. Methods: We developed an iterative approach to correlating tissue thermal conductivity to more accurately calculated thermal dose, which cannot be experimentally measured. The resulting regression model was then implemented into an electrosurgical vessel sealing FE model to examine the accuracy of this FE model. Results: The results show that with the regression model, more reasonable temperature and thermal dose prediction can be achieved at the center of the sealed vessel tissue. The resulting electrical current and impedance from the FE model match with the experimental results. Conclusion: The developed approach can be used to determine the correlation between thermal dose and thermal conductivity. Describing the thermal conductivity as a function of thermal dose allows modeling of irreversible changes in tissue properties. Significance: By having a more accurate temperature estimation at the center of the sealed vessel, more insight is provided into how the tissue reacts during the vessel sealing process.

A SYSTEMATIC REVIEW ON CURRENT RESEARCH TRENDS IN ELECTROSURGICAL SYSTEMS

The use of electrosurgery (also referred to as radiosurgery) is a type of surgery that uses electrical currents in order to perform the surgery. This type of surgery dates back to more than 100 years. For over five decades, different reviews have been conducted in the field of electrosurgery. This has led to a dramatic increase in interest in electrosurgery, resulting to an incredible intervention in microvascular surgery that has provoked the most noteworthy use of radio frequency instruments. The controlled and exact use of these radio frequency electrical current on delicate tissue sites to be cut is accomplished by methods for deliberately composed anodes. This is a persistently advancing field with dynamic research going on in various new applications. There are different sorts of surgery, which can be delivered with high recurrence instruments such as Diathermy, Bipolar, and Monopolar. This paper performs a systematic review by extracting information from a wide variety of research papers in electrosurgery topics. The purpose of a systematic review is to classify and categorize the field of electrosurgery in an unbiased way, listing the current existing trends in electrosurgery, can lead to the classification and understanding of electrosurgery as a whole, and to predict the future direction of the field by analyzing the research interest over the last couple of years.

Seizures Following Cranioplasty: Risk Factors and Prevention Exploration

BACKGROUND

The aim of this study was to identify risk factors and explore the possible prevention measures for seizures following cranioplasty.

METHODS

The authors performed a retrospective review of 142 consecutive patients who underwent cranioplasty following craniectomy for trauma or cerebral hemorrhage in Dezhou People's Hospital between January 2010 and January 2017. Patients who were diagnosed with aneurysms, arteriovenous malformations, cerebral infarction, and tumors (14), had seizures prior to cranioplasty (9) and those lost to follow-up (7) were excluded. Patients did not use antiepilepsy drugs from treatment of postcranioplasty seizures. The median follow-up time was 51.11 ± 31.59 months (range: 17-98 months). Analyses were performed on a database tracking age, sex, reason for craniectomy, operative time, time between operations, presence of dural substitute, diabetic status, hypertensive status, tobacco use, alcohol use, location of cranioplasty, classification, time and times of seizures following cranioplasty development.

RESULTS

One hundred twelve patients met study criteria. The overall rate of seizures following cranioplasty was 35.7% (40 out of 112 patients). There were no statistically significant associations between postcranioplasty seizures and sex, age, location of cranioplasty, cranioplasty materials, or dural substitute used in craniectomy. Postcranioplasty seizure frequency differed significantly according to reasons for depressive craniectomy. The incidence of postcranioplasty seizures was significantly higher in the first year than in later years. Incidence decreased progressively in subsequent years.

CONCLUSION

Incidence of seizures following cranioplasty was associated with the reason for depressive craniectomy.

A Model to Study Thermal Energy Delivery to the Choroid: A Comparison of Surgical Devices

Purpose

We measure and compare surgical devices using an ex vivo, temperature-controlled, choroidal incision model during thermal energy transfer with a high-resolution infrared camera.

Methods

Ex vivo porcine choroidal tissue specimens (n = 516) were isolated and placed on a temperature-regulated (37°C) perfusion platform. We tested the pulsed electron avalanche knife (PEAK), micropulse laser (MpL), continuous laser (CL), and bipolar cautery (BpC) at three energy settings (11 [low], 45 [medium], and 134 [high] mJ/mm). Each device was clamped to a stationary mechanical arm. Movement of tissue specimens beneath the surgical device was achieved using a stepping motor-driven x-y table. An infrared video camera measured orthogonal temperature variation in the surrounding tissue.

Results

Increased power resulted in greater lateral thermal spread using all modalities (P < 0.001). Mean (standard deviation) lateral thermal spread at low energy was smallest for the MpL at 0.0 (0.01) mm (P < 0.001), whereas BpC had the least collateral tissue damage at medium and high energies (0.02 [0.08] and 0.34 [0.22] mm, respectively; P < 0.001). Fluidics of the ex vivo system may limit thermal spread. The PEAK had the greatest thermal spread across all energy groups (P < 0.001), with clinically relevant variation between disposable blades.

Conclusions

Our ex vivo model enabled direct comparison of threshold thermal tissue injury across four devices. MpL and BpC showed the least thermal damage. PEAK had a higher variation in energy delivery, but also has the advantage of more effective tissue cutting.

Translational Relevance

Our ex vivo surgical device analysis provides thermal tissue injury predictions for choroidal surgery.

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.

Robotic-assisted total mesorectal excision (TME) for rectal cancer results in a significantly higher quality of TME specimen compared to the laparoscopic approach-report of a single-center experience

AIM

Robotic surgery allows for a better visualization and more precise dissection especially in the narrow male pelvis and mid and lower third of the rectum. However, superiority to laparoscopic TME has yet to be proven. We therefore analyzed short-term outcomes of laparoscopic and robotic low anterior rectal resection for rectal cancer.

PATIENTS AND METHODS

From 2011 to 2016, 44 robotic (RTME) and 41 laparoscopic (LTME) low anterior rectal resection with total mesorectal excision were performed at a single institution. Specimen quality was assessed and reported by an independent pathologist following international guidelines.

RESULTS

The groups did not differ significantly regarding gender, age, ASA stage, BMI, and distance of the lower tumor margin from the anal verge. More patients in the RTME group underwent preoperative chemoradiation (43.2 vs. 19.5%, p = 0.019). The quality of the TME specimen was significantly better in the RTME group (complete/nearly complete/incomplete for RTME 97/0/3% and for LTME 78/17/5%, p = 0.03). The conversion rate tended to be lower in the RTME group (7 vs. 17%, p = 0.143). There was no difference in CRM positivity between the groups.

CONCLUSION

Robotic surgery is safe and can improve the quality of TME for rectal cancer compared to laparoscopy. Any effect on long-term survival remains to be established.

Robotic Approach to Ureteral Endometriosis: Surgical Features and Perioperative Outcomes

Introduction: Surgical treatment of ureteral endometriosis is necessary to relieve urinary symptoms of obstruction and to preserve renal function. Which surgical approach to ureteral endometriosis should be considered the most appropriate is debated, due to the lack of scientific evidence. The aim of the present study is to assess the feasibility and to describe the perioperative outcomes of minimally invasive treatment of deep ureteral endometriosis using robotic assistance, highlighting the technical benefits and the limits of this approach.

Method: A case-series including 31 consecutive patients affected by high-stage endometriosis including ureteral endometriosis using robotic assistance in our Department between November 2011 and September 2017.

Results: All procedures were successfully completed by robotic technique, resulting in full excision of the parametrial nodules involving the ureter. Mean operating time was 184.8 ± 81 min. Mean hospital stay was 4.02 ± 3 days. Perioperative complications occurred in five patients and 4 out of 5 involved the urinary tract.

Conclusions: Robotic surgery for deep infiltrating endometriosis of the ureter was feasible and allowed complete resection of ureteral nodules in all cases. No intraoperative complications arose, but a non-negligible rate of urinary tract complications was detected. This calls for a careful assessment of the benefits and specific risks associated with the use of robotic surgery for the treatment of deep infiltrating endometriosis of the ureter.

Transpapillary endopancreatic surgery: decompression of duct system and comparison of greenlight laser with monopolar electrosurgical device in ex vivo and in vivo animal models

BACKGROUND

Endopancreatic surgery (EPS) is an experimental minimally invasive technique for resection of pancreatic tissue from inside the pancreatic duct, accessed via the duodenum and papilla. It is proposed as an alternative to duodenum-preserving pancreatic head resection in benign diseases such as chronic pancreatitis (CP). This study evaluated the use of EPS for resection of pancreatic duct stenoses. Moreover, greenlight laser (GLL) and monopolar electrosurgical device (MES) were compared as resection tools for EPS.

METHODS

The suitability of EPS for resection of stenoses was evaluated in ex vivo bovine pancreas (n = 8). Artificially created stenoses in the pancreatic head were accessed via the duodenal papilla and resected from inside the organ with MES through a rigid endoscope. Furthermore, standardized pancreatic resections were performed in an in vivo porcine model using either GLL (n = 18) or MES (n = 18) to compare blood loss, operating time, and complications. Thermal damage to the surrounding tissue was assessed using a standardized histological classification.

RESULTS

Stenosis resection by EPS was feasible in 8/8 bovine pancreases, with a procedure time of 17 (12-24) min. No perforation of the organ occurred. Resection by GLL was associated with reduced blood loss [median 1.7 (interquartile range 0.6-2.6) ml vs. 5.1 (3.8-13.2) ml; p < 0.01] and shorter operating time [109 (81-127) s vs. 390 (337-555) s; p < 0.01] compared with MES. The zone of thermal tissue damage was more extensive when using GLL than with MES [4.12 (3.48-4.89) mm vs. 1.33 (1.09-1.48) mm; p < 0.01].

CONCLUSION

Transduodenal-transpapillary EPS can be used to resect stenoses and decompress the pancreatic duct system. Both GLL and MES are feasible resection methods for EPS. However, GLL showed better hemostatic characteristics than MES in an in vivo porcine model. Safety measures such as temperature control and image-guided navigation should be employed to monitor the resection and tissue heating.

Ultrasonic versus monopolar energy-based surgical devices in terms of surgical smoke and lateral thermal damage (ULMOST): a randomized controlled trial

BACKGROUND

The purpose of this study was to compare the degree of surgical smoke or vapor and lateral thermal damage caused by two different energy-based surgical devices (ESDs) used in colpotomy during total laparoscopic hysterectomy.

METHODS

Patients undergoing laparoscopic hysterectomy were randomly assigned to an ultrasonic ESD group (n = 20) or monopolar ESD group (n = 20). Colpotomy was performed using the assigned ESD. The degree of surgical smoke or vapor obstructing the laparoscopic view was assessed by two independent reviewers using a 5-point Likert scale, in which a higher score indicates worse visibility. The degree of the lateral thermal damage was measured as the width from the point of instrument application to the margins of the unchanged nearby tissue using a light microscope.

RESULTS

The baseline characteristics did not statistically differ between the two groups. The degree of surgical smoke or vapor obstructing vision was 1.2 ± 0.8 points in the ultrasonic group and 3.9 ± 0.7 points in the monopolar groups (p < 0.001). The lateral thermal damage was significantly increased in the monopolar group compared to in the ultrasound group (1500 µm [1200-2500 µm] vs. 950 µm [650-1725 µm], p = 0.037).

CONCLUSION

Ultrasonic ESD had better laparoscopic visibility and caused less lateral thermal damage during colpotomy compared to monopolar device.

Seizure After Cranioplasty: Incidence and Risk Factors

BACKGROUND

To investigate clinical characteristics of postcranioplasty seizures (PCS) first observed after cranioplasty after decompressive craniectomy (DC) to treat traumatic brain injury and to define factors that increase PCS risk.

METHODS

This retrospective study, covering the period between January 2008 and July 2015, compared PCS in postcranioplasty patients. Postcranioplasty seizures risk factors included diabetes mellitus, hypertension, time between DC and cranioplasty, duraplasty material, cranioplasty contusion location, electrocautery method, PCS type, and infection. Multivariate logistic regression analysis was performed and confidence intervals (CIs) were calculated (95% CI).

RESULTS

Of 270 patients, 32 exhibited initial PCS onset postcranioplasty with 11.9% incidence (32/270). Patients fell into immediate (within 24 hours), early (from 1 to 7 days), and late (after 7 days) PCS groups with frequencies of 12, 5, and 15 patients, respectively. Generalized, partial, and mixed seizure types were observed in 13, 13, and 6 patients, respectively. Multivariate logistic regression analysis showed increased risk with increasing age (>50 years). Cranioplasty contusion location, precranioplasty deficits, duraplasty material, and monopolar electrocautery were predictive of PCS onset (P < 0.05). Increased DC to cranioplasty interval increased risk but was not statistically significant (P = 0.062).

CONCLUSIONS

Understanding risk factors for PCS will benefit the management of cranioplasty patients.

Simple Technique for Reducing the Buccal Fat Pad During Mandibular Orthognathic Surgery

Sagittal split ramus osteotomy and intraoral vertical ramus osteotomy are commonly performed for the correction of jaw deformities. However, during mandibular orthognathic surgeries such as sagittal split ramus osteotomy and intraoral vertical ramus osteotomy , the authors sometimes encounter exposure of the buccal fat pad (BFP), which decreases the surgical field. The exposed BFP makes it difficult to perform these operations, may result in unexpected complications, and may increase the operation time. Therefore, the authors herein describe a simple, safe, and convenient technique for reducing the volume of the exposed BFP during mandibular orthognathic surgery using an electric knife in the coagulation mode.

Electrothermal bipolar vessel sealing device (LigaSure™) versus conventional diathermy in laparoscopic myomectomy: A propensity-matched analysis

The purpose of this study was to compare the safety and efficacy of an electrothermal bipolar vessel sealing device (LigaSure™) and traditional electrical cauterization in laparoscopic myomectomy (LM). A total of 756 patients with symptomatic uterine myomas who underwent LM were reviewed retrospectively. A total of 225 cases of LM using LigaSure™ (LML group) were compared with a control group treated with traditional electrical cauterization (LME group) under propensity-matched analysis. Outcome measures for both groups were compared, such as operative time, blood loss (BL), complications, need for blood transfusion, hospital expenses, and hospital stay. Six subgroups were divided according to main myoma size and energy source. No cases required switching to abdominal myomectomy. The number of myomas removed, BL, need for blood transfusion, and complications were not significantly different, whereas hospital stay was longer in the LME group than in the LML group and total hospital expenses were higher in the LML group (p < 0.001). The overall operation duration was significantly longer in the LML group but was not significantly different for main myoma >10 cm (LML vs LME, 121.58 ± 41.77 vs 121.69 ± 44.95, p = 0.99); this likely reflects the operative efficiency on using LigaSure™ to manage large tumors. Significant linear correlations between myoma weight and operative time and BL were seen in both groups. Conventional diathermy is more effective for small-to-medium myomas. Use of the LigaSure™ was efficient for myomas >10 cm.

Lymphangiomatous Tumors of the Neck: Tips to Avoid Iatrogenic Nerve Injuries in the Brachial Plexus Region

Lymphangiomas are rare malformations of the lymphatic system and can often be found in the neck region, where its proximity to the brachial plexus may cause compressive neuropathy and possible iatrogenic injuries during dissection. We report 4 cases of lymphangiomas with compression of the brachial plexus that were successfully removed without permanent nerve injuries and present a literature review of the preoperative approach and surgical techniques. A preoperative multidisciplinary approach can help surgeons predict what they may encounter during the surgery. A careful and stepwise dissection of the vital structures surrounding the tumor, especially the brachial plexus anatomy, is critical to avoiding severe complications. Incomplete resection or leakage of the lymph could result in higher rate of recurrence.

In silico evaluation of geometry variations with respect to the thermal spread during coagulation of egg white using bipolar vessel sealing instruments

BACKGROUND

Bipolar vessel sealing is an efficient electrosurgical procedure for the occlusion of blood vessels particularly during minimally invasive surgery. Reliable knowledge of the thermal spread is crucial for a safe application of bipolar vessel sealing instruments when operating close to thermo-sensitive structures, such as nerves. The evolution of the thermal spread over time and space depends on a variety of parameters, such as the biological tissue, the energy applied to the tissue, and the geometry of the vessel sealing instrument. Mathematical modeling has proven useful for the prediction of the thermal spread. It is, thus, a promising tool for the systematic analysis of the influence of geometrical changes on the thermal spread.

RESULTS

We present an experimentally validated in silico study to evaluate the impact of geometry variations on the progression of chicken egg white coagulation and the final shape of coagulated egg white as an approximation of the temporal and spatial evolution of the thermal spread during bipolar vessel sealing. Egg white has similar thermal and electrical properties to human tissue, with the advantage being that the spatial and temporal evolution of the thermal spread can be visually gauged. The simulations were performed using a mathematical model based on the finite element analysis of chicken egg white. The progression of egg white coagulation was predicted for two different peak voltages and various electrode geometries. Starting with two planar electrodes, one electrode was gradually changed to adopt a wedge shape. These changes to the geometry showed a distinct influence on the progression of egg white coagulation in the simulations. The predictions were successfully validated using an experimental setup with two different electrodes representing the extreme geometries.

DISCUSSION

The predicted spatial temperature distributions were experimentally validated for two geometries. Our simulation study shows that the geometry has a pronounced influence on the thermal spread and, thus, is a suitable parameter to reduce thermal damage. The in silico optimization of instrument designs is a suitable tool to accelerate the development of new vessel sealing instruments, with only a few promising designs having to be tested as prototypes.

Impact of monopolar radiofrequency coagulation on intraoperative blood loss during liver resection: a prospective randomised controlled trial

PURPOSE

To evaluate the impact of using monopolar thermal coagulation based on radiofrequency (RF) currents on intraoperative blood loss during liver resection.

MATERIALS AND METHODS

A prospective randomised controlled trial was planned. Patients undergoing hepatectomy were randomised into two groups. In the control group (n = 10), hemostasis was obtained with a combination of stitches, vessel-sealing bipolar RF systems, sutures or clips. In the monopolar radiofrequency coagulation (MRFC) group (n = 18), hemostasis was mainly obtained using an internally cooled monopolar RF electrode.

RESULTS

No differences in demographic or clinical characteristics were found between groups. Mean blood loss during liver resection in the control group was more than twice that of the MRFC group (556 ± 471 ml vs. 225 ± 313 ml, p = .02). The adjusted mean bleeding/transection area was also significantly higher in the control group (7.0 ± 3.3 ml/cm² vs. 2.8 ± 4.0 ml/cm², p = .006). No significant differences were observed in the rate of complications between the groups.

CONCLUSIONS

The findings suggest that the monopolar electrocoagulation created with an internally cooled RF electrode considerably reduces intraoperative blood loss during liver resection.

Ultrasonically Activated Shears Reduce Blood Loss without Increasing Inflammatory Reactions in Open Distal Gastrectomy for Cancer: A Randomized Controlled Study

BACKGROUND

Previous studies regarding ultrasonically activated shears (UAS) were performed without controlled surgical procedures or consideration of potential thermal injury due to high temperature of active blade of UAS. The purpose of this study was to evaluate the efficacy and safety of UAS through a comparison with conventional monopolar electrocautery (CME) in open distal gastrectomy for gastric cancer.

METHODS

From October 2011 to November 2012, 56 gastric cancer patients eligible for open distal gastrectomy were randomized into UAS or CME groups. Primary endpoints were estimated blood loss (EBL) during surgery and amount of drainage through the fifth postoperative day. Secondary endpoints were operation time, length of hospital stay, postoperative morbidity, changes in cytokine levels in serum, peritoneal irrigation saline, and peritoneal drainage, and inflammatory markers of serum. (Registration-number of ClinicalTrials.gov: NCT01971775).

RESULTS

EBL was lower in the UAS group than that in the CME group (339.8 ± 201.2 vs. 428.6 ± 165.8 mL, p = 0.021). However, the amount of postoperative drainage was not significantly different between the two groups. Although the complication rate was not different between the two groups, there were three cases of intra-abdominal bleeding requiring transfusion only in the CME group. Inflammatory markers from the cytokine assays and serum laboratory tests showed no significant differences between the two groups.

CONCLUSIONS

UAS reduced EBL without increasing inflammatory reactions.