Use of a new sealing device to simplify jejunal resection during pancreaticoduodenectomy

The Feasibility of LigaSure to Create Intestinal Anastomosis

Objective. To evaluate the feasibility and the effectiveness of LigaSure Forced Triad to create intestinal anastomosis in an ex vivo porcino model. Methods. Colon samples (n = 100) were prospectively randomized into 2 groups: LigaSure group (n = 90) and Stapler group (n = 10). The LigaSure group was divided into 9 subgroups, each of 10 samples, according to the different power levels of the LigaSure system (Bar 1, Bars 2, and Bars 3) and radiofrequency application (1 application, 2 applications, and 3 applications) used. All anastomoses were tested for early burst pressure. The LigaSure subgroup having the highest burst pressure was compared with the Stapler group. Finally, the specimen was reviewed by the same pathologist. Results. The burst pressures of the 9 subgroups of LigaSure segments were the following: 29.7 ± 4.5 (Subgroup a); 27.4 ± 3.1 (Subgroup b); 25.3 ± 4 (Subgroup c); 32.9 ± 2.3 (Subgroup d); 30.7 ± 3.8 (Subgroup e); 25.7 ± 4.8 (Subgroup f); 42 ± 4.7 (Subgroup g); 31.8 ± 3.8 (Subgroup h); and 28.5 ± 3 (Subgroup j). Subgroup g (3 bars-power levels/1 frequency application) had the highest burst pressure ( P < .001; ANOVA test). No significant difference was found between burst pressure of Subgroup g and Stapler group (42 ± 4.7 vs 42 ± 4.3, respectively, P = .9). On histological view, the LigaSure anastomosis was formed by collagen sealed without cavitation defects. Conclusions. Our study seems to confirm the feasibility of creating intestinal anastomosis using LigaSure. However, further researches in in vivo models are mandatory before recommending its clinical usage in such settings.

Safety and efficacy of LigaSure usage in pancreaticoduodenectomy

BACKGROUND

Over recent years, use of the LigaSure™ vessel sealing device has increased in major abdominal surgery to include pancreaticoduodenectomy (PD). LigaSure™ use during PD has expanded to include all steps of the procedure, including the division of the uncinate margin. This introduces the potential for thermal major vascular injury or margin positivity. The aim of the present study was to evaluate the safety and efficacy of LigaSure™ usage in PD in comparison to established dissection techniques.

METHODS

One hundred and forty-eight patients who underwent PD from 2007 to 2012 at Robert Wood Johnson University Hospital were identified from a retrospective database. Two groups were recognized: those in which the LigaSure™ device was used (N = 114), and in those it was not (N = 34). Peri-operative outcomes were compared.

RESULTS

Vascular intra-operative complications directly caused by thermal injury from LigaSure™ use occurred in 1.8% of patients. Overall vascular intra-operative complications, uncinate margin positivity, blood loss, length of stay, and complication severity were not significantly different between groups. The mean operative time was 77 min less (P < 0.010) in the LigaSure™ group. Savings per case where the LigaSure™ was used amounted to $1776.73.

CONCLUSION

LigaSure™ usage during PD is safe and effective. It is associated with decreased operative times, which may decrease operative costs in PD.

Harmonic scalpel versus conventional dissection technique in pylorus-preserving partial duodenopancreatectomy

BACKGROUND/AIMS

Pancreatic head resection is performed with low mortality, but morbidity remains high. Extensive preparation, long operating times, intraoperative blood loss and the need for blood transfusions are risk factors for postoperative morbidity. The aim of our study was to evaluate the feasibility and safety of the ultrasonic dissection device in pylorus-preserving duodenopancreatectomy (PPPD).

METHODS

Fifty consecutive patients who underwent PPPD with an ultrasonic dissection device (group 1) were compared with a match-controlled group of 50 consecutive patients who underwent PPPD with conventional dissection techniques (group 2). Duration of surgery, intraoperative blood loss, blood units, complications, mortality and duration of hospital stay were analyzed.

RESULTS

There was no difference in age, gender or BMI between groups. In group 1, mean blood loss (446 ± 281.8 ml, p = 0.008) and number of blood units (0.32 ± 0.86, p = 0.001) were significantly lower than in group 2 (819 ± 915.4 ml; 1.36 ± 2.83 units). Duration of surgery was shorter in group 1 (345.6 vs. 373 min, p = 0.28). The rate of postoperative complications, mortality and hospital stay were not significantly different.

CONCLUSIONS

Use of an ultrasonic dissection device in PPPD might significantly reduce intraoperative blood loss and the need for blood transfusions. These results should be verified in a prospective randomized controlled trial.

LigaSure versus conventional dissection technique in pancreatoduodenectomy: a pilot study

BACKGROUND

Pancreatic surgery requires extensive preparation and tissue dissection. Therefore, LigaSure (Valleylab, Boulder, CO) provides an alternative to conventional dissection techniques. The aim of the present study was to describe the feasibility, safety, and cost efficiency of LigaSure in pancreatoduodenectomy.

METHODS

Seven patients underwent surgery with the Ligasure and 7 patients underwent surgery with conventional dissection techniques. The patients were investigated for surgical time, intraoperative blood loss, complications, mortality, duration of hospital stay, and surgery-related costs.

RESULTS

Surgical time was 207 minutes in the LigaSure group and 255 minutes in the conventional group (P = .020). Intraoperative blood loss was 271 and 771 mL, respectively (P = .010). Other perioperative outcomes were comparable. The respective surgery-related costs averaged €4,125 and €4,931 (P = .023).

CONCLUSIONS

The use of LigaSure in pancreatoduodenectomy seems to be feasible and safe. In addition, it might lead to a reduction in the surgery-related costs.

Minimizing intraoperative bleeding using a vessel-sealing system and splenic hilum hanging maneuver in laparoscopic splenectomy

BACKGROUND/PURPOSE

The most common cause of conversion to laparotomy (open splenectomy) during laparoscopic splenectomy (LS) is bleeding from the splenic hilar vessels. Recently, the efficacy of Ligasure (a vessel-sealing system) as a safety device for sealing vessels and reducing intraoperative blood loss has been reported with various laparoscopic procedures. The objective of this report was to describe our techniques for minimizing bleeding during LS, characterized by the application of Ligasure (which reduces the number of clips and staples, and reduces unnecessary bleeding) and a splenic hilum hanging maneuver with a Diamond-Flex flexible retractor to obtain optimal exposure of the splenic hilum.

METHODS

We have performed 87 LSs since February 1993, and have employed the Ligasure instead of metal clips and staplers since September 2003. We have also introduced the splenic hilum hanging maneuver paired with Ligasure use. We have performed this new LS in 30 consecutive adult patients presenting with idiopathic thrombocytopenic purpura (n = 14), benign splenic tumor (n = 5), lymphoma (n = 4), hereditary spherocytosis (n = 2), liver cirrhosis (n = 2), and other pathologies (n = 3). The splenic ligaments and vessels, including the splenic artery and vein, were divided using a 5-mm Ligasure instead of a clip or stapler. The splenic hilum was encircled and elevated, using a Diamond-Flex, to ensure better exposure in all patients.

RESULTS

LS was successfully completed in 29 patients (97%), with only one conversion to open splenectomy. Mean blood loss for all patients with completed LS was only 21.6 ml (range 0-250 ml). Moreover, blood loss was not determinable (considered as 0 ml in this study) in 15 patients (52%). Mean spleen weight and operating time were 319.4 g (range 80-1605 g) and 143.4 min (range 90-180 min), respectively. No postoperative mortalities were encountered. Two patients experienced complications, including grade B pancreatic fistula and atelectasis, for an overall morbidity rate of 6.7%. Mean postoperative stay was 6.5 days (range 3-14 days).

CONCLUSIONS

LS using a Ligasure in combination with the splenic hilum hanging maneuver may reduce intraoperative blood loss.

Exploring new technologies to facilitate laparoscopic surgery: creating intestinal anastomoses without sutures or staples, using a radio-frequency-energy-driven bipolar fusion device

INTRODUCTION

Intestinal anastomotic healing requires apposition of the collagen containing submucosal layers of the opposing intestinal walls, which is traditionally achieved by staples or sutures. Recently, a feedback-controlled bipolar sealing system (LigaSure) has been successfully introduced to seal and transect vessels. Since this technology depends on fusion of collagen fibres which are abundantly present in the intestinal wall, the possibility to create intestinal anastomoses using this technology was investigated in the present study.

MATERIALS AND METHODS

For this purpose a new-generation radiofrequency (RF) generator and a prototype of the Ligasure Anastomotic Device (LAD) have been developed. The generator incorporates a closed loop control system which monitors tissue fusion, compares it with a mathematical model of ideal fusion based on the density and compliance of intestinal tissue and adjusts energy output accordingly. In total 8 anastomoses were created in a porcine model (4 pigs, 2 anastomoses each) and healing was assessed by macroscopic and histological examination.

RESULTS

All seals were macroscopic intact both immediate after creation and at sacrifice at the 7th postoperative day. Between operations, pigs appeared healthy and had normal intestinal passage. Histological examination of the anastomoses revealed undisturbed healing with granulation tissue, newly synthesised collagen in the submucosa and re-epithelialization at the borders of the seals.

CONCLUSION

These results confirm the feasibility to create experimental intestinal anastomoses using LigaSure technology. This may be an important step towards the development of new laparoscopic equipment combining dissecting and reconstructive properties within one single instrument.