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

Evaluation of thermal effects of surgical energy devices: ex vivo study

This study evaluated the direct and indirect thermal effects of various surgical energy devices using an ex-vivo model. Two types of three devices were evaluated: ENSEAL™ X1 Curved Jaw Tissue Sealer (X1) and ENSEAL™ G2 Curved Tissue Sealer (G2) as vessel sealing systems (VSSs), and HARMONIC® HD1000i Shears (HA) as an ultrasonic activating device (USAD). Each device was activated once under DRY or WET conditions. The tissue's maximum temperature (MT), steam MT surrounding the activation site, and steam spread area (SSA) were measured. Under WET conditions, the median MT of a porcine common carotid artery at 1 mm from the activation site by X1, G2, and HA were 84.4, 83.3, and 50.5 °C, respectively. The direct thermal effect of HA was the lowest among the three devices. VSSs showed higher tissue MT under WET conditions compared with DRY conditions. Conversely, USAD showed the opposite trend. G2 demonstrated a significantly higher MT than X1 and HA (P < 0.05). A significant decrease in SSA was observed with decreasing grasping range. In conclusion, VSSs generated higher temperatures than USAD, especially under WET conditions. Surgeons should consider minimizing thermal effects by creating DRY conditions or performing gradual incisions when using VSS devices.

Harmonic Scalpel Versus Monopolar Electrotome in Endoscopic-Assisted Transaxillary Dual-Plane Augmentation Mammaplasty: A Retrospective Study in 122 Patients

BACKGROUND

The transaxillary approach of breast augmentation is the most popular method in Asia, but longer period of recovery was observed in spite of the assistance of endoscope.

OBJECTIVES

Introducing the ultrasonic dissection devices might be a solution to minimizing tisue damage thus relieving pain and shortening the period of recovery.

METHOD

Between March 2020 and September 2022, we retrospectively reviewed the cases of 122 patients underwent endoscopic augmentation mammoplasty via the transaxillary approach using either the monopolar electrotome (ME) alone or assisted with Harmonic Scalpel (HS) in defining the retropectoral pocket and severing the pectoralis major muscle.

RESULT

The total drainage volume was significantly lower in the HS group than ME group (74.33 ± 48.81 vs. 180.30 ± 125.10 mL; p < 0.0001). VAS score of the first 24 hour after surgery of the ME group was significantly higher than that of the HS group (6.10 ± 1.27 vs. 2.88 ± 1.29, p < 0.0001). Operation time in HS group was reduced compared to ME group (113.1 ± 14.46 mins vs. 131.3 ± 35.51 mins, p < 0.001). The duration of drainage placement (1.08 ± 0.27 vs. 2.72 ± 1.18 days) and hospital stay after surgery (3.08 ± 0.42 vs. 5.64 ± 2.78 days; p < 0.0001) were largely reduced in HS group.

CONCLUSION

The assistance of Harmonic Scalpel significantly reduced total postoperative drainage, relieved pain and shortened operation time, length of drainage placement and hospital stay compared to using monopolar electrotome alone in endoscopic-assisted transaxillary dual-plane augmentation mammaplasty.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Use and Abuse of Electrocautery in Adenoidectomy Hemostasis

Background and objectives: Bipolar electrocautery is commonly used to control bleeding after cold-instrument pediatric adenoidectomy, but the surgeon should be aware of the possible side effects. OBJECTIVE: The aim of our study is to investigate the effects of bipolar electrocautery when used for bleeding control at the end of an adenoidectomy procedure. Materials and Methods: We evaluated the effect of electrocautery on postoperative pain, velopharyngeal insufficiency symptoms, postoperative nasal obstruction, and rhinorrhea in a group of 90 children undergoing adenoidectomy in our ENT department over a period of 3 months. Results: After statistically analyzing the data, we found that the duration of postoperative pain, the duration of rhinorrhea and nasal obstruction, and the duration of painkiller administration, as well as the velopharyngeal insufficiency symptoms, were significantly longer in patients in whom electrocautery was used for hemostasis. A significantly higher incidence of posterior neck pain and halitosis (oral malodor) was noted in the patients in whom electrocautery was used for adenoidectomy hemostasis. Conclusions: Bipolar electrocautery use should be limited during pediatric adenoidectomy hemostasis because of the possible side effects: longer postoperative pain, prolonged nasal obstruction, rhinorrhea and velopharyngeal insufficiency, and halitosis. We noted some side effects that were specific to electrocautery use during adenoidectomy: posterior neck pain and oral malodor. Acknowledging the risk for these symptoms can help to alleviate the anxiety of both the parents and the patients regarding the expected postoperative outcomes.

Complication Differences Between the Tumescent and Non-Tumescent Dissection Techniques for Mastectomy: A Meta-Analysis

Purpose

We conducted a systematic literature search and pooled data from studies to compare the incidence of complications between the tumescent and non-tumescent techniques for mastectomy.

Methods

We searched PubMed, Embase, BioMed Central, Ovid, and CENTRAL databases for studies comparing the two mastectomy techniques up to November 1^st, 2020. We used a random-effects model to calculate odds ratios (OR) with 95% confidence intervals (CI).

Results

Nine studies were included with one randomized controlled trial (RCT). Meta-analysis indicated no statistically significant difference in the incidence of total skin necrosis (OR 1.18 95% CI 0.71, 1.98 I² = 82% p=0.52), major skin necrosis (OR 1.58 95% CI 0.69, 3.62 I² = 71% p=0.28), minor skin necrosis (OR 1.11 95% CI 0.43, 2.85 I² = 72% p=0.83), hematoma (OR 1.19 95% CI 0.80, 1.79 I² = 4% p=0.39), and infections (OR 0.87 95% CI 0.54, 1.40 I² = 54% p=0.56) between tumescent and non-tumescent groups. Analysis of studies using immediate alloplastic reconstruction revealed no statistically significant difference in the incidence of explantation between the two groups (OR 0.78 95% CI 0.46, 1.34 I² = 62% p=0.37). Multivariable-adjusted ORs on total skin necrosis were available from three studies. Pooled analysis indicated no statistically significant difference between tumescent and non-tumescent groups (OR 1.72 95% CI 0.72, 4.13 I² = 87% p=0.23).

Conclusion

Low-quality evidence derived mostly from non-randomized studies is indicative of no difference in the incidence of skin necrosis, hematoma, seroma, infection, and explantation between the tumescent and non-tumescent techniques of mastectomy. There is a need for high-quality RCTs to further strengthen the evidence.

An Analysis of Tumor Margin Shrinkage in the Surgical Resection of Squamous Cell Carcinoma of the Oral Cavity

Background

Surgical resection of the oral cavity squamous cell carcinoma with clear surgical margins is the key to preventing local recurrence and avoiding the need for adjuvant treatment or margin re-resection. There is often a discrepancy observed between the clinically determined margins of the tumor when it is being resected and the histopathological result after the specimen has been processed.

Methods

A total of six patients who underwent primary surgical resection of oral squamous cell carcinoma between June and October 2020 were included. Surgical margins of the tumor were measured and recorded at three stages of tumor resection: pre-incision, post-resection, and post-formalin fixation. The 1 cm pre-incision anterior margin was compared to both the anterior post-resection and post-formalin fixation margins to document any shrinkage between the different stages of tumor resection.

Results

The overall mean surgical margin shrinkage was 26% (95% confidence interval {CI} 9.34-42.66, p=0.012). The greatest amount of margin shrinkage occurred between pre-incision and post-resection measurements, which is statistically significant at 19.7% (95% CI 7.49-31.83, p=0.009). To a lesser extent, tumor surgical margins also decreased by 12.7% (95% CI -2.66 to 28.09, p=0.083) between post-resection and post-formalin fixation.

Conclusion

Dimensions of tumor surgical margins in oral cavity squamous cell carcinoma specimens decrease from surgical resection to histopathological processing. Most of this shrinkage occurs between the clinically determined pre-incision and immediately after tumor resection in the post-resection measurement. These findings suggest that it might be prudent to consider surgical margin shrinkage when outlining initial margins to ensure adequate and complete resection of the tumor.

Application of multi-component fluid model in studies of the origin of skin burns during electrosurgical procedures

This paper reports on safety challenges regarding spark created when the applied electric field exceeds the dielectric breakdown strength as a source of complication during electrosurgery. Despite the unquestionable benefits of electrosurgery, such as minimal chances of infection and fast recovery time, the interaction of the electrosurgical tool with the tissue may result in tissue damage and force feedback to the tool. Some risks of complications often depend on a surgeon's knowledge of instruments and safety aspects of technical equipment that can be eliminated by clarifying the causation and conditions of their development. Current trends in electrosurgery include computational algorithms and methods to control the effect of delivered energy to the patient. For this study, calculations were performed by using the COMSOL simulation package based on a multi-component plasma fluid model. The emphasis is put on conditions that lead to the breakdown of the dielectric medium. It was found that breakdown occurs most easily when both electrodes are cylindrical. For configurations with one or two spherical electrodes, breakdown voltages are higher up to 25% and 48%, respectively. With decreasing the cathode radius, the breakdown voltage may decrease even to 41%. On the other hand, the temperature increase lowers the breakdown voltage. Also, electrical asymmetries appear to be a response to the non-symmetry of the electric field between the electrodes causing differences in the breakdown voltage between 36% and 70%. The results presented here could be very useful for the design of surgical devices to prevent potential complications of electrosurgical procedures.

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.

Existence of Cervical Discopathy in Non-Cyclic Mastodynia

Background

Mastodynia is a subjective symptom that impairs the quality of life. It may be directly related with breast disorders. Moreover, a substantial rate is caused of reflective pain.

Objectives

Non-cyclic mastodynia is multifactorial, and treatment should be planned according to the underlying cause. In this study, we aim to evaluate the existence of cervical discopathy via cervical magnetic resonance imaging (MRI) in the etiology of non-cyclic mastodynia.

Methods

The study included 60 patients with normal physical examination results and imaging findings. Management was determined individually in patients. Patients with pathological MRI findings were evaluated by physical therapy, rehabilitation, and neurosurgery specialists, and appropriate treatment was planned. Patients were evaluated with the visual analogue scale (VAS) scoring system at initial presentation and after 1 and 3 months of treatment.

Results

The majority of patients had positive findings on MRI (53 [88.4%] vs. 7 [11.6%]). The mean VAS scores at the time of presentation, after 1, and after 3 months of treatment were 7.41, 6.39, and 3.35, respectively. The decrease in the scores was statistically significant (p ≤ 0,01).

Conclusions

We suggest that cervical discopathy should be kept in mind in cases of idiopathic non-cyclic mastodynia. Furthermore, cervical discopathy-related mastodynia seems to have a good response to appropriate treatment.