Influence of multiple reuse and resterilization cycles on the performance of a bipolar vessel sealing device (LigaSure) intended for single use

Incidence of residual biologic debris and contamination of reused bipolar vessel sealing devices after ethylene oxide sterilization following splenectomy

OBJECTIVE

The aim of the present study was to quantify the amount of biologic debris present within disposable bipolar vessel sealing devices after each use for canine splenectomies and determine the aerobic bacterial load of the debris following instrument resterilization with ethylene oxide.

STUDY DESIGN

Prospective observational clinical study.

STUDY POPULATION

Client-owned dogs (n = 40) presenting to a single specialty hospital for open, routine, or emergency splenectomies.

METHODS

A total of 16 bipolar vessel sealing devices were randomly assigned to undergo one, two, three, or four splenectomies, manual hand cleanings, and ethylene oxide sterilizations before being dismantled. After final use and sterilization, each handset was agitated in phosphate-buffered saline before disassembly, which was submitted for aerobic culture. Following aseptic disassembly, all biological residue was photo-documented, collected, quantified using a subjective scoring system, and submitted for culture.

RESULTS

Biologic debris was present within the inner mechanics of all devices, specifically under the blade used for vessel transection. A linear increase in debris was not appreciated amongst devices used once versus devices used multiple times. None of the devices nor any of the biologic debris cultured positive following sterilization with ethylene oxide.

CONCLUSION

The presence of biologic debris was documented after the initial use of disposable bipolar vessel sealing devices, but no devices or debris yielded positive culture results following ethylene oxide sterilization after splenectomies.

CLINICAL SIGNIFICANCE

Increased risk of iatrogenic surgical site contamination from reused vessel sealing devices is unlikely when they have been cleaned and sterilized with ethylene oxide after up to four splenectomy surgeries.

Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review

OBJECTIVE

To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures.

DATA SOURCES

We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022.

METHODS OF STUDY SELECTION

Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated.

TABULATION, INTEGRATION, AND RESULTS

The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity.

CONCLUSION

Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022327490.

Reuse of Single-Use Devices in Endourology: A Review

Introduction: Single-use medical devices (SUDs) are labeled for single use only, but rising health care costs along with the absence of visible deterioration in the quality of SUDs after one use have led to their reprocessing and reuse. In the past, SUDs mainly consisted of equipment such as guidewires and catheters. However, SUDs have now expanded to flexible endoscopes and energy devices that are much more expensive. Reuse of such devices raises concerns of infection transmission, safety, and lack of effectiveness. We reviewed the disinfection process, cost benefits, potential harms, and legal status of the reuse of SUDs in endourology. Materials and Methods: PUBMED, Embase, and the Cochrane Library databases were searched for articles published between 1970 and March 2023 that reported the reuse of SUDs using the search terms "reuse"; "single-use device"; "disposable medical devices"; "reprocessing of single-use device"; "endourology"; and keywords related to cost, safety, sterilization, and legal status. Online resources were found using Google search engines. Articles on cost savings, device malfunction, disinfection, or legal status in different countries were reviewed. Results and Conclusions: Reusing SUDs has financial, environmental, and practical advantages. The potential savings on medical expenses is the most compelling argument for reprocessing disposable devices. Reusing medical equipment also contributes to the reduction of toxic biodegradable waste. However, there is a scarcity of data on the safety and efficacy of reused SUDs. For patient safety and to avoid complications, the practice must be regulated with established reprocessing standards.

Comparison of mortality of brachycephalic dogs undergoing partial staphylectomy using conventional incisional, carbon dioxide laser, or bipolar vessel sealing device

OBJECTIVE

To compare mortality of dogs undergoing partial staphylectomy using conventional incisional, carbon dioxide (CO2 ) laser, and bipolar vessel sealing device (BVSD) techniques for the treatment of brachycephalic obstructive airway syndrome (BOAS).

STUDY DESIGN

Retrospective multicenter cohort study.

ANIMALS

A total of 606 client-owned English bulldogs, French bulldogs, and pugs.

METHODS

Medical records from 2011 to 2021 were reviewed for signalment, history, surgical technique, length of hospitalization, and complications. Multivariate statistical analysis was performed to compare odds of mortality between the three techniques of staphylectomy.

RESULTS

The overall mortality rate was 24/606 (4.0%). Of those 24 dogs, staphylectomy was performed with BVSD technique in 13 cases, with CO2 laser in nine, and using conventional incisional technique in two. Nine dogs were graded II or III laryngeal collapse, 14 were graded I, and one was unknown. BVSD technique was associated with mortality prior to discharge compared to the other two techniques (OR = 6.0, 95% CI: 1.3-28.4, p = .023). No differences were detected between conventional incisional and CO2 laser techniques. Concurrent higher grade (stage II or III) laryngeal collapse was independently associated with mortality prior to discharge (OR = 4.6, 95% CI: 1.8-11.8, p = .002).

CONCLUSION

The use of BVSD and grade of laryngeal collapse were associated with a higher risk of perioperative mortality.

CLINICAL SIGNIFICANCE

Clinical studies using a randomized trial design should be conducted to further determine the putative influence of surgical instrumentation in the perioperative mortality rate following multilevel surgery in dogs with BOAS.

Comparison of two advanced bipolar tissue sealer/dividers for laparoscopic ovariectomy in dogs: articulating enseal G2 versus Ligasure Maryland device

BACKGROUND

Advanced bipolar tissue sealer/dividers provide the most reliable and efficient means of tissue dissection and blood vessel sealing in laparoscopic surgery and the techniques are continuously improved. In veterinary practice, cost-effectiveness is of major impact, leading to re-use of instruments designed and sold for single use. Two high-end devices were evaluated and compared in a highly standardized laparoscopic ovariectomy procedure in dogs: The new generation Ligasure Maryland Sealer/Divider (LMSD) with improved atraumatic curved jaw shape for delicate tissue handling and dissection and non-stick nanocoating, and the new-generation Articulating Enseal G2 (AENG2) with several proclaimed features improving surgical performance, including articulation of the forceps tip; improved tissue compression during sealing; unique offset electrode configuration; and specific nanoparticle coating minimizing thermal spread and tissue sticking. Twenty-one client-owned dogs admitted for elective laparoscopic ovariectomy were randomly assigned to one of two groups: ovariectomy using AENG2 on the left ovary and LMSD in the right ovary or vice-versa. Procedural video recordings were used to assess ovarian ligament fat score, smoke formation, occurrence of bleeding, and excision duration. Excised tissues were examined histopathologically and collateral thermal damage was scored in three anatomic zones: suspensory ligament, vascular pedicle, and uterine junction. Tissue sealers were used repeatedly following standardized cleaning protocol with instrument washing machine and ethylene oxide gas sterilization and the number of uses until device failure was recorded.

RESULTS

Excision times were significantly increased for AENG2 (median 01:35 min) compared to LMSD (median 01:00 min). Minor hemorrhage from incomplete sealing occurred in 3 sites in 2 patients (2x AENG2, 1x LMSD) and was not significantly different between groups. Smoke production as scored on videos and thermal tissue damage scores on histopathology also did not differ between AENG2 and LMSD. Both vessel sealers could be re-used repeatedly.

CONCLUSION

AENG2 provides a good alternative to LMSD in laparoscopic ovariectomy, with only minor differences in measured variables. Subjectively, the articulating feature of AENG2 did not improve surgical performance in laparoscopic ovariectomy and the use of LMSD appeared more straight-forward for this specific procedure. However, differences in operating these devices may be subject to personal preference.

Comparison between intracorporeal and extracorporeal ligations in a laparoscopic ovariectomy model in dogs

OBJECTIVE

To compare the influence of extracorporeal and intracorporeal ligations on the duration of and complications associated with laparoscopic ovariectomy in dogs.

STUDY DESIGN

Prospective randomized experimental study.

ANIMALS

Healthy intact female dogs (n = 18).

METHODS

The left and right ovarian pedicles of dogs undergoing laparoscopic ovariectomy were randomly assigned to intracorporeal (n = 18) or extracorporeal (n = 18) ligation groups. Surgeries were performed by two American College of Veterinary Surgeons (ACVS) diplomates and two ACVS residents. The time required to place extracorporeal and intracorporeal ligations, duration of surgery, and intraoperative complications were compared between ligation techniques. Postoperative complications were recorded.

RESULTS

The time required for intracorporeal ligation (17.3 ± 8.7 minutes) did not differ from that required for extracorporeal ligation (15.1 ± 6.1 minutes; P = .38). The total duration of surgery was 102.7 ± 28.7 minutes including portal placement and veterinary student closure of incisions. Ligation of the ovarian pedicle was successful in 16 of 17 dogs. Intraoperative hemorrhage occurred in three dogs, and postoperative complications were noted in three dogs, without apparent difference between ligation techniques.

CONCLUSION

No difference was identified between extracorporeal and intracorporeal ligations of ovarian pedicles.

CLINICAL SIGNIFICANCE

This study does not provide evidence to support one ligation technique rather than the other.

LigaSure for the Creation of Bloodless Breast Pockets in Patients Undergoing Transaxillary Breast Augmentation

Background:

The energy-based LigaSure device is widely utilized to facilitate dissection and hemostasis during various open and endoscopic procedures. Previous studies have demonstrated that this device can reduce intraoperative blood loss in various surgical settings. The present study aimed to report our experience with LigaSure and the advantages of using this device during transaxillary submuscular pocket dissection over those of a monopolar electrocautery dissector in patients undergoing breast augmentation.

Methods:

A total of 156 patients who underwent transaxillary breast augmentation between November 2019 and May 2020 were retrospectively reviewed. Submuscular pocket dissection using LigaSure was performed in 92 patients and a conventional technique using a monopolar electrocautery dissector was performed in the remaining 64 patients. A bloodless breast pocket was defined as a clear operating field with little or no blood staining at any stage of the procedure. All endoscopic procedures were recorded to determine whether bloodless pockets had been established. The amount of postoperative drainage at 1 day after surgery was also assessed to compare between the LigaSure and conventional groups.

Results:

Bloodless breast pockets were successfully established in 83 patients (90.2%) in the LigaSure group and in 38 patients (59.4%) in the conventional group (P < 0.001). Postoperative drainage amount at 1 day following surgery was significantly lower in the LigaSure group than in the conventional group (P < 0.001).

Conclusion:

Our findings indicate that the LigaSure system is a safe and effective alternative in breast augmentation requiring transaxillary submuscular dissection.

Assessing organic material on single-use vessel sealing devices: a comparative study of reprocessed and new LigaSure™ devices

Background

Reprocessed devices must be thoroughly cleaned prior to sterilization to ensure efficacy of sterilization agents. Many single-use devices are not designed to be thoroughly cleaned. Interlocking design features inherent to LigaSure™ vessel sealing devices may prevent thorough cleaning and promote accumulation of human tissue that cannot be removed. Thus, the aim of this study was to compare industry reprocessed and new LigaSure™ vessel sealing devices for organic material.

Methods

A total of 168, 84 new and 84 reprocessed, vessel sealing devices were disassembled and inspected for the presence of residual organic matter using visual, microscopic, and chemical analysis. Devices were randomized and test conductors blinded to group membership. Devices were aseptically disassembled and sent through visual inspection. Next, devices were either examined using light microscopy, scanning electron microscopy (SEM) or exposed to a solution that luminesces in the presence of hemoglobin. Additionally, 165 reprocessed devices were sent to a 3rd party lab for sterility testing via direct immersion culture for 14 days.

Results

Significant amounts of remnant organic material (C, N, O, S, Na, P) were observed with 81/84 reprocessed and 0/84 new devices failing inspection protocols. When tested for the presence of hemoglobin, only 1/12 reprocessed devices passed inspection. SEM of reprocessed devices revealed residues with liquid patterns and diffuse soiling with foreign material. Sterility testing of reprocessed devices revealed a sterility level < 6^–3.

Conclusions

The abundance of material resembling human tissue observed on reprocessed VSDs suggests inadequate cleaning prior to sterilization. Atomic and morphological analyses of the remnant materials suggest that bacterial biofilms could also be present. Additionally, surface degradation and release of reinforcing glass fibers from the device were observed. Devices designed for single use can harbor significant amounts of remnant material that likely interfere with the sterilization process.

Ex vivo comparison of sliding knot ligatures vs. haemostatic clips for equine small intestinal mesenteric vessel occlusion

BACKGROUND

In equine abdominal surgery, resection and anastomosis of strangulated intestine is a commonly performed procedure. To date, ligatures, vessel sealing devices and the ligate-divide stapler have been described for this use in horses. The objective of this study was to compare the application of haemostatic clips and ligatures to occlude equine mesenteric vessels. Portions of jejunum with ten associated mesenteric vessels were collected from 12 horses at a local abattoir and divided into two groups. Portions of intestine were divided into two sections comprising five vessels each and assigned to Group A or Group B. Each vessel was occluded with a triple ligature. In Group A, vessels were ligated with three circumferential ligatures tied with a sliding knot with two overthrows. In Group B, vessels were occluded with application of three haemoclips. The procedures were performed by the same experienced surgeon. Intestinal length, construction time and vessel leaking pressure were measured and compared between groups.

RESULTS

The intestinal length (mean ± SD) was 3.78 ± 0.43 m in Group A and 3.04 ± 0.83 m in Group B. The difference was not significant (p = 0.297). The construction time (mean ± SD) was 7.03 ± 0.34 min in Group A and 2.40 ± 0.43 min in Group B. The difference was significant (p < 0.0001). The leaking pressure was 1000 (750-1050) mmHg (median, IQ range) in Group A and 1050 (800-1050) mmHg (median, IQ range) in Group B. The difference was not significant (p = 0.225).

CONCLUSIONS

Haemoclip application is comparable in terms of leaking pressure but quicker than sliding knots to apply.

Partial cystectomy with a bipolar sealing device in seven dogs with naturally occurring bladder tumors

OBJECTIVE

To describe the use of a bipolar sealing device (BSD) for partial cystectomy in dogs undergoing excision of bladder tumors.

STUDY DESIGN

Multicenter, prospective, clinical pilot study.

SAMPLE POPULATION

Seven client-owned dogs with nontrigonal urinary bladder lesions.

METHODS

Dogs underwent a sealed partial cystectomy with a BSD, with or without cystoscopic guidance of the resection. The sealed cystectomy site was oversewn with a single-layer simple continuous pattern with monofilament absorbable suture.

RESULTS

Sealed partial cystectomy was successfully performed in all dogs, with a median surgical duration of 69 minutes (range, 50-120). Lesions were located at the apex in six dogs and on the ventral midbody of the bladder in one dog. No urine leakage from the BSD luminal seal was visible prior to suture closure in three dogs, while varying amounts of urine leaked from the sealed site in four dogs. Suture was placed over the seal in grossly normal bladder tissue in six dogs and in the BSD peripheral thermal effect zone in one dog; in this latter dog, revision cystorrhaphy was required 3 days later because of uroabdomen. The other six dogs had no clinical evidence of urinary bladder healing complications.

CONCLUSION

The integrity of the seal generated by the BSD tested here on partial cystectomies varied between dogs and was unpredictable.

CLINICAL SIGNIFICANCE

Sealed partial cystectomy with a BSD may reduce exposure of urinary bladder luminal contents to the surgical site. However, the placement of sutures over the seal and through grossly normal bladder tissue is recommended to prevent postoperative uroabdomen.

Technological Advances in Surgical Equipment in Exotic Pet Medicine

Surgery can be challenging in exotic pets owing to their small size and blood volume, and their increased anesthetic risk compared with small animals. Various devices are available to facilitate suturing, cutting, and hemostasis in the human and veterinary fields. These surgical equipment improve the simplicity, rapidity, and effectiveness of surgery. Vessel-sealing devices, radiosurgery, lasers, and ultrasound devices are commonly used because of their ease of use and increase in surgical efficiency. Other surgical devices are available (eg, stapling devices) but are not discussed in this article.

Effect of multiple use and sterilization on sealing performance of bipolar vessel sealing devices

Background

Advanced bipolar vessel sealing devices are widely used in human and veterinary medicine to reduce the operation time and intraoperative blood loss. Because most devices are made for a single use, their application is cost intensive. The aim of this study was to investigate the influence of multiple uses and sterilization on the performance of bipolar vessel sealing devices.

Methods

The burst pressure of sealed porcine renal arteries was compared between the disposable devices „LigaSure”(Valleylab) and „Caiman“(Braun Vetcare) and the reuseable device „MarSeal”(KLS Martin). Additionally, the influence of the sterilization process was investigated, and the sealing time, number of cutting activations and tissue sticking were noted.

Results

The disposable devices showed reliable performances over multiple activations and sterilization cycles, except for one Caiman device. Seals created with all devices achieved supra-physiologic burst pressures, with the highest pressure measured in a cycle using a MarSeal device.

Discussion

During 25 activations with and without intermittent sterilization, no correlation was found between increasing seal numbers and decreasing burst pressure. However, the number of cycles in our study was limited to five.

Conclusion

For limited numbers of cycles and sterilization procedures, seals created with the disposable vessel sealing devices LigaSure and Caiman achieved burst pressures comparaable to those produced with the reuseable MarSeal.

Performance and microbiological safety testing after multiple use cycles and hydrogen peroxide sterilization of a 5-mm vessel-sealing device

OBJECTIVE

To evaluate the functional and microbiological safety of a single-use laparoscopic vessel-sealing device in a multiuse setting.

STUDY DESIGN

Ex vivo study.

SAMPLE POPULATION

Twelve 5-mm LigaSure Maryland jaw devices.

METHODS

Handsets underwent repeated test cycles until failure. The handset packaging was opened, and handsets were agitated in phosphate-buffered saline (PBS). The PBS was removed, centrifuged, and submitted for culture. Canine ovariectomy was simulated on cadaveric tissue, after which vascular seal quality was evaluated by pressure testing of sealed porcine carotid arteries. The handsets were cleaned and sterilized with hydrogen peroxide gas and repackaged.

RESULTS

Mean ± SD cycles to failure was 7.7 ± 2.8, with a minimum of 4 and a maximum of 12 use cycles achieved. Eleven of the 12 handsets failed by failure of handset activation after depression of the activation trigger. Only 1 handset failed to hold an adequate vascular seal under 300 mm Hg of pressure. No handset exhibited positive bacterial culture at any cycle.

CONCLUSION

The sterilization method used in this study resulted in an excellent microbiological safety profile. Most of the handsets failed by activation button failure.

CLINICAL SIGNIFICANCE

Under the conditions of this study, hydrogen peroxide sterilization achieved microbiological safety. Handsets can successfully be reused until activation button failure without negative effects on the vascular seal or increased risk of infection to the patient.