Energy sources for laparoscopic colectomy: a prospective randomized comparison of conventional electrosurgery, bipolar computer-controlled electrosurgery and ultrasonic dissection. Operative outcome and costs analysis

Ultrasonic Shears Decrease Postoperative Hematomas in Head and Neck Microvascular Reconstruction

OBJECTIVE

To evaluate postoperative hematoma and takeback rates in a large series of microvascular reconstructions. We sought to determine whether the use of ultrasonic shears reduced these rates.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary referral hospital.

METHODS

A total of 2288 patients undergoing free flap reconstruction for head and neck defects between 1995 and 2022 were reviewed. Patients undergoing dissection with and without ultrasonic shears were compared to determine postoperative hematoma and takeback rates.

RESULTS

The overall hematoma rate was 1.3% (29/2288) for the entire cohort. The postoperative hematoma rates with and without ultrasonic shears were 0.63% (9/1418) and 2.3% (20/870), relative risk = 0.28, P = .0015. Of 870 patients undergoing surgery without ultrasonic shears, 14 (1.61%) were taken back to the operating room for control of bleeding compared to 8 of 1418 (0.56%) in the ultrasonic shears cohort.

CONCLUSION

Our large series of patients undergoing microvascular reconstruction shows a decrease in postoperative hematoma rate and takeback for bleeding with the adoption of ultrasonic shears. Ultrasonic shears are an effective tool that can help decrease perioperative morbidity secondary to hematoma after head and neck tumor resection and microvascular reconstruction.

High-energy devices in different surgical settings: lessons learnt from a full health technology assessment report developed by SICE (Società Italiana di Chirurgia Endoscopica)

BACKGROUND

The present paper aims at evaluating the potential benefits of high-energy devices (HEDs) in the Italian surgical practice, defining the comparative efficacy and safety profiles, as well as the potential economic and organizational advantages for hospitals and patients, with respect to standard monopolar or bipolar devices.

METHODS

A Health Technology Assessment was conducted in 2021 assuming the hospital perspective, comparing HEDs and standard monopolar/bipolar devices, within eleven surgical settings: appendectomy, hepatic resections, colorectal resections, cholecystectomy, splenectomy, hemorrhoidectomy, thyroidectomy, esophago-gastrectomy, breast surgery, adrenalectomy, and pancreatectomy. The nine EUnetHTA Core Model dimensions were deployed considering a multi-methods approach. Both qualitative and quantitative methods were used: (1) a systematic literature review for the definition of the comparative efficacy and safety data; (2) administration of qualitative questionnaires, completed by 23 healthcare professionals (according to 7-item Likert scale, ranging from - 3 to + 3); and (3) health-economics tools, useful for the economic evaluation of the clinical pathway and budget impact analysis, and for the definition of the organizational and accessibility advantages, in terms of time or procedures' savings.

RESULTS

The literature declared a decrease in operating time and length of stay in using HEDs in most surgical settings. While HEDs would lead to a marginal investment for the conduction of 178,619 surgeries on annual basis, their routinely implementation would generate significant organizational savings. A decrease equal to - 5.25/-9.02% of operating room time and to - 5.03/-30.73% of length of stay emerged. An advantage in accessibility to surgery could be hypothesized in a 9% of increase, due to the gaining in operatory slots. Professionals' perceptions crystallized and confirmed literature evidence, declaring a better safety and effectiveness profile. An improvement in both patients and caregivers' quality-of-life emerged.

CONCLUSIONS

The results have demonstrated the strategic relevance related to HEDs introduction, their economic sustainability, and feasibility, as well as the potentialities in process improvement.

An advanced bipolar device helps reduce the rate of postoperative pancreatic fistula in laparoscopic gastrectomy for gastric cancer patients: a propensity score-matched analysis

BACKGROUND

Advanced bipolar devices (ABD; e.g., LigaSure™) have a lower blade temperature than ultrasonically activated devices (USAD; e.g., Harmonic® and Sonicision™) during activation, potentially enabling accurate lymph node dissection with less risk of postoperative pancreatic fistula (POPF) due to pancreatic thermal injury in laparoscopic gastrectomy. Therefore, we compared the efficacy and safety of ABD and USAD in laparoscopic gastrectomy for gastric cancer patients.

METHODS

A retrospective cohort study was conducted on patients who underwent laparoscopic distal gastrectomy (LDG) between August 2008 and September 2020. A total of 371 patients were enrolled, and short-term surgical outcomes, including the incidence of ISGPF grades B and C POPF, were compared between ABD and USAD. The risk factors for POPF in LDG were investigated by univariate and multivariate analyses.

RESULTS

A propensity score-matching algorithm was used to select 120 patients for each group. The POPF rate was significantly lower (0.8 vs. 9.2%, p < 0.001), the morbidity rate was lower (13.3 vs. 28.3%, p < 0.001), the length of postoperative hospitalization was shorter (14 vs. 19 days, p < 0.001), and the lymph node retrieval rate was higher (34 vs. 26, p < 0.001) with an ABD than with a USAD. There were no mortalities in either group. A multivariate analysis showed that a USAD was the only independent risk factor with a considerably high odds ratio for the occurrence of POPF (USAD/ABD, odds ratio 8.38, p = 0.0466).

CONCLUSION

An ABD may improve the safety of laparoscopic gastrectomy for gastric cancer patients.

A pilot randomized controlled trial comparing THUNDERBEAT to the Maryland LigaSure energy device in laparoscopic left colon surgery

BACKGROUND

The THUNDERBEAT is a multi-functional energy device which delivers both ultrasonic and bipolar energy, but there are no randomized trials which can provide more rigorous evaluation of the clinical performance of THUNDERBEAT compared to other energy-based devices in colorectal surgery. The aim of this study was to compare the clinical performance of THUNDERBEAT energy device to Maryland LigaSure in patients undergoing left laparoscopic colectomy.

METHODS

Prospective randomized trial with two groups: Group 1 THUNDERBEAT and Group 2 LigaSure in a single university hospital. 60 Subjects, male and female, of age 18 years and above undergoing left colectomy for cancer or diverticulitis were included. The primary outcome was dissection time to specimen removal (DTSR) measured in minutes from the start of colon mobilization to specimen removal from the abdominal cavity. Versatility (composite of five variables) was measured by a score system from 1 to 5 (1 being worst and 5 the best), and adjusted/weighted by coefficient of importance with distribution of the importance as follow: hemostasis 0.275, sealing 0.275, cutting 0.2, dissection 0.15, and tissue manipulation 0.1. Other variables were: dryness of surgical field, intraoperative and postoperative complications, and mortality. Follow-up time was 30 days.

RESULTS

60 Patients completed surgery, 31 in Group 1 and 29 in Group 2. There was no difference in the DTSR between the groups, 91 min vs. 77 min (p = 0.214). THUNDERBEAT showed significantly higher score in dissecting and tissue manipulation in segment 3 (omental dissection), and in overall versatility score (p = 0.007) as well as versatility score in Segment 2 (retroperitoneal dissection p = 0.040) and Segment 3 (p = 0.040). No other differences were noted between the groups.

CONCLUSIONS

Both energy devices can be employed effectively and safely in dividing soft tissue and sealing mesenteric blood vessels during laparoscopic left colon surgery, with THUNDERBEAT demonstrating some advantages over LigaSure during omental dissection and tissue manipulation.

CLINICALTRIAL

gov # NCT02628093.

Comparison of Conventional Bipolar Electrocautery and Ultrasonic Harmonic Scalpel in Colorectal Cancer Surgeries

Background and objective

Colorectal cancer (CRC) is the third most common malignancy and the second most deadly cancer worldwide. Powered equipment has transformed modern surgery, revolutionizing the delicacy, precision, and accuracy of many surgeries. The safety and efficacy of tissue dissection and artery sealing in colorectal surgery remain highly debatable. With the increased use of minimally invasive procedures in colon and rectal surgery, energy devices for tissue dissection and vascular sealing have become widely used. In light of this, we aimed at comparing the use of bipolar electrocautery and harmonic scalpel in CRC surgeries.

Methods

Our study was a hospital-based comparative study conducted at our tertiary care hospital. Fifty patients were divided equally into two groups by block randomization, and bipolar electrocautery was used in one group, and harmonic scalpel was used in the second group during surgery. The mean operative time, blood loss, and hospital stay were calculated in both groups. The comparison between bipolar electrocautery and harmonic scalpel was evaluated using independent t-tests.

Results

The mean operative time, blood loss, and hospital stay were significantly lower in the harmonic scalpel group than in the electrocautery group. The results were statistically significant (p < 0.001).

Conclusion

Based on our findings, the harmonic scalpel is a better energy source when compared to bipolar electrocautery in CRC surgeries. 

Comparing the safety, efficacy, and oncological outcomes of laparoscopic and open colectomy in transverse colon cancer: a meta-analysis

INTRODUCTION

In order to compare the safety, efficacy, and oncological outcomes of laparoscopic (LC) and open colectomy (OC) for transverse colon cancer (TCC) patients, the present systematic review of the literature and meta-analysis was designed.

METHODS

This study was conducted following the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. A systematic screening of the electronic databases was performed (Medline, Web of Science and Scopus). The validity of the pooled results was verified through the performance of trial sequential analysis (TSA). The level of evidence was estimated using the GRADE approach.

RESULTS

Overall, 21 studies and 2498 patients were included in our study. Pooled comparisons and TSA analyses reported a superiority of LC over OC in terms of postoperative complications (OR 0.64, p = 0.0003), blood loss (WMD - 86.84, p < 0.00001), time to first flatus (WMD - 0.94, p < 0.00001) and oral diet (WMD - 1.25, p < 0.00001), and LOS (WMD - 2.39, p < 0.00001). Moreover, OC displayed a lower operation duration (p < 0.00001). A higher rate of complete mesocolic excision (p = 0.001) was related to OC. Although inconclusive in TSA, the recurrence rate in LC group was lower. LC and OC were equivalent in terms of postoperative survival outcomes.

CONCLUSIONS

Considering several limitations of the eligible studies and the subsequent low level of evidence, further RCTs of a higher quality and methodological level are required to verify the findings of our meta-analysis.

Abdominoplasty after bariatric surgery: comparison of three different techniques

BACKGROUND

Abdominoplasty after massive weight loss is not a cosmetic procedure. The aim of this study was to compare three different techniques for postbariatric abdominoplasty.

METHODS

All postbariatric patients that have undergone abdominoplasty from January 2013 to December 2016 were included in the study. Patients were divided into 3 groups: subjects who underwent standard procedure were allocated ingroup A; those cases performed using a synthetic glue were assigned to group B; cases performed with an energy device were inserted in group C. Operative time, length of stay and complications were recorded.

RESULTS

Seventy-one abdominoplasties were performed in the selected period. Mean operative time was shorter (P<0.01) in group C (94.3±2.7 minutes) than in group A (112.1±16.8 minutes) and in group B (121±13.2 minutes). Mean length of stay was significantly reduced (P<0.01) in group C (2.4±0.7) when compared to group A (3.5±0.6 days) and group B (3.1±0.5 days). Bleeding occurred in 21 (29.5%) patients (15 in group A, 4 in groupB, 3 in group C; P<0.01). Seroma was detected in 22(30.9%) subjects (14 in group A, 2in group B, 6 in group C; P<0.01). Wound dehiscence and umbilical necrosis were recorded in 7 (9.9%) and 9 (12.6%) patients respectively, without statistical differences.

CONCLUSIONS

Both synthetic glue and energy device improve outcomes of postbariatric abdominoplasties. The glue reduces rates of bleeding and seroma. The energy deviceimproves intraoperative hemostasis and shortens operative time.

Energy-Based Tissue Fusion for Sutureless Closure: Applications, Mechanisms, and Potential for Functional Recovery

As minimally invasive surgical techniques progress, the demand for efficient, reliable methods for vascular ligation and tissue closure becomes pronounced. The surgical advantages of energy-based vessel sealing exceed those of traditional, compression-based ligatures in procedures sensitive to duration, foreign bodies, and recovery time alike. Although the use of energy-based devices to seal or transect vasculature and connective tissue bundles is widespread, the breadth of heating strategies and energy dosimetry used across devices underscores an uncertainty as to the molecular nature of the sealing mechanism and induced tissue effect. Furthermore, energy-based techniques exhibit promise for the closure and functional repair of soft and connective tissues in the nervous, enteral, and dermal tissue domains. A constitutive theory of molecular bonding forces that arise in response to supraphysiological temperatures is required in order to optimize and progress the use of energy-based tissue fusion. While rapid tissue bonding has been suggested to arise from dehydration, dipole interactions, molecular cross-links, or the coagulation of cellular proteins, long-term functional tissue repair across fusion boundaries requires that the reaction to thermal damage be tailored to catalyze the onset of biological healing and remodeling. In this review, we compile and contrast findings from published thermal fusion research in an effort to encourage a molecular approach to characterization of the prevalent and promising energy-based tissue bond.

Surgical outcomes according to the type of monopolar electrocautery device used in laparoscopic surgery for right colon cancer: a comparison of endo-hook versus endo-shears

BACKGROUND

Although monopolar electrocautery is preferred by many laparoscopic surgeons and is more cost-effective than bipolar or ultrasonic scissors, few studies have compared these outcomes between different monopolar electrocautery devices used in laparoscopic surgery. Therefore, this study compared the surgical outcomes between monopolar endo-hook versus endo-shears during laparoscopic right hemicolectomy for right colon cancer.

METHODS

Using a prospective database of patients treated at our institute, we analyzed the surgical outcomes of 358 consecutive patients with right colon cancer who underwent curative laparoscopic surgery with a monopolar endo-hook (n = 164) or endo-shears (n = 194) between March 2009 and March 2017.

RESULTS

There were no differences in age, sex, body mass index, American Society of Anesthesiologists' grade, previous operative history, or clinical stage between the endo-hook and endo-shears groups. The estimated blood loss was similar between the endo-hook and endo-shears groups (90.9 ± 60.3 vs. 92.0 ± 89.3 mL; P = 0.893). The number of harvested lymph nodes was greater in the endo-hook group (53.5 ± 20.3 vs. 48.1 ± 18.5; P = 0.008). Hospital stay was shorter in the endo-hook group (6.8 ± 2.2 vs. 7.8 ± 4.8 days; P = 0.013). Although chylous ascites was more frequent in the endo-hook group (21.3% vs. 7.7%, P < 0.001), the postoperative morbidity rate was lower in this group (9.8% vs. 18.0%; P = 0.025). All instances of chylous ascites healed spontaneously without intervention.

CONCLUSIONS

This study showed that the use of a monopolar endo-hook during laparoscopic right hemicolectomy might permit more meticulous lymph-node dissection and reduce morbidity compared with the use of monopolar endo-shears. Therefore, we suggest that the outcomes of laparoscopic surgery might be associated with the type of electrocautery device used.

Short-Term Outcomes of Robotic versus Laparoscopic Total Mesorectal Excision for Rectal Cancer: A Cohort Study

The aim of this study was to evaluate and compare the intestinal function recovery time and other short-term outcomes between robotic-assisted total mesorectal excision (R-TME) and laparoscopic total mesorectal excision (L-TME) for rectal cancer. This is a retrospective study using a prospectively collected database. Patients’ records were obtained from Gansu Provincial Hospital between July 2015 and October 2017. Eighty patients underwent R-TME, and 116 with the same histopathological stage of the tumor underwent an L-TME. Both operations were performed by the same surgeon, comparing intra- and postoperative outcomes intergroups. The time to the first passage of flatus ( P < 0.001), the time to the first postoperative oral fluid intake ( P < 0.001), and the length of hospital stay ( P < 0.01) of the R-TME group were about three days faster than those in the L-TME group. The rate of conversion to open laparotomy ( P = 0.038) and postoperative urinary retention ( P = 0.016) were significantly lower in the R-TME group than in the L-TME group. Intraoperative blood loss of the R-TME group was more than that of the L-TME group ( P < 0.01).The operation time, number of lymph nodes harvested, and rate of positive circumferential resection margin were similar intergroup. The total cost of the R-TME group was higher than that of the L-TME group, but with a lack of statistical significance (85,623.91 ± 13,310.50 vs 67,356.79 ± 17,107.68 CNY, P = 0.084). The R-TME is safe and effective and has better postoperative short-term outcomes and faster intestinal function recovery time, contrasting with the L-TME. The large, multicenter, prospective studies were needed to validate the advantages of robotic surgery system used in rectal cancer.

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.

Feasibility Study of a Newly Developed Hybrid Energy Device Used During Laparoscopic Liver Resection in a Porcine Model

BACKGROUND

Although various devices have been clinically used for laparoscopic liver resection (LLR), the best device for liver parenchymal transection remains unknown. Olympus Corp (Tokyo, Japan) developed a laparoscopic hybrid pencil (LHP) device, which is the first electric knife to combine ultrasound and electric energy with a monopolar output. We aimed to evaluate the feasibility of using the LHP device and to compare it with the laparoscopic monopolar pencil (LMP) and laparoscopic ultrasonic shears (LUS) devices for LLR in a porcine model.

METHODS

Nine male piglets underwent laparoscopic liver lobe transections using each device. The operative parameters were evaluated in the 3 groups (n = 24 lobes) during the acute study period. The imaging findings from contrast-enhanced computed tomography and histopathological findings of autopsy on postoperative day 7 were compared among groups (n = 6 piglets) during the long-term study.

RESULTS

The transection time was shorter ( P = .001); there was less blood loss ( P = .018); and tip cleaning ( P < .001) and instrument changes were less often required ( P < .001) in the LHP group than in the LMP group. The LHP group had fewer instances of bleeding ( P < .001) and coagulator usage ( P < .001) than did the LUS group. In the long-term study, no postoperative adverse events occurred in the 3 groups. The thermal spread and depth of the LHP device were equivalent to those of the LMP and LUS devices (vs LMP: P = .226 and .159; vs LUS: P = 1.000 and .574).

CONCLUSIONS

The LHP device may be an efficient device for LLR if it can be applied to human surgery.

Procedure costs associated with the use of Harmonic devices compared to conventional techniques in various surgeries: a systematic review and meta-analysis

Background

As compared to conventional techniques, recent meta-analyses have reported cost savings with Harmonic devices; however, only in thyroidectomy. Thus, the aim of this study was to evaluate the costs associated with Harmonic devices versus conventional techniques across a range of surgical procedures.

Methods

A systematic search of MEDLINE, EMBASE, and Cochrane Library was conducted from inception to October 01, 2016 without language restrictions to identify randomized controlled trials comparing Harmonic devices to conventional techniques and reporting procedure costs (operating time plus operating equipment/consumables/device costs). Costs were pooled using the ratio of geometric means, and a random effects model was applied. Sensitivity analyses varying statistical methods, number of included studies, and cost outcomes were completed to test the robustness of the results.

Results

Thirteen studies met the inclusion criteria. A total of 561 and 540 participants had procedures performed with Harmonic devices and conventional methods, respectively, with procedures including gastrectomy, thyroidectomy, colectomy, cholecystectomy, Nissen fundoplication, and pancreaticoduodenectomy. As compared to conventional methods, Harmonic devices reduced total procedure costs by 8.7% (p=0.029), resulting in an absolute reduction of US$227.77 from mean conventional technique costs, derived primarily from a reduction in operating time costs. When operating time costs, excluding operating equipment/consumables/device costs, were analyzed, costs were reduced by $544 per procedure with the use of Harmonic devices. The results from all sensitivity analyses demonstrated cost reductions with Harmonic devices.

Conclusion

This systematic review and meta-analysis showed that despite a higher device cost, Harmonic devices provide a statistically significant reduction in procedure costs, derived primarily from a reduction in operating time costs, across surgical procedures. In addition to functionality benefits, Harmonic devices may represent a potentially cost saving method to reduce overall hospital resource use. Future research should focus on potential costs and benefits from use of Harmonic devices in procedures not covered here.

LAPAROSCOPIC OVARIECTOMY IN THE ASIATIC BLACK BEAR (URSUS THIBETANUS) WITH THE USE OF THE SONICISION™ DEVICE

Laparoscopic ovariectomy was performed in two Asiatic black bears ( Ursus thibetanus ). Bears were placed in a 20° Trendelenburg position on a surgical table. A three-portal technique was used. A camera port was established 10 cm caudal to the umbilicus with a 5-mm cannula. Two instrument ports were made 1 cm caudal to the umbilicus with a 5-mm cannula and 8 cm caudal to the camera port with a 12-mm cannula, respectively. The suspensory ligament, ovarian vasculature, and uterine horn tip were progressively dissected following coagulation with the Sonicision™ cordless ultrasonic dissection device. The resected ovary was exteriorized through the 12-mm instrument portal site but enlarged to a 2-cm incision length. The abdominal musculature, subcutaneous tissue, and skin of the portal sites were closed separately. Total surgical time was 113 min (Bear A) and 49 min (Bear B), and no postoperative complications were encountered. This is the first report of laparoscopic ovariectomy in the Asiatic black bear.

Lateral thermal damage of mesoappendix and appendiceal base during laparoscopic appendectomy in children: comparison of the harmonic scalpel (Ultracision), bipolar coagulation (LigaSure), and thermal fusion technology (MiSeal)

BACKGROUND

The aim of this study was to compare lateral thermal damage of mesoappendix and appendiceal base using three different instruments for sealing and cutting of mesoappendix.

MATERIALS AND METHODS

A total number of 99 patients (54 males and 45 females) who underwent laparoscopic appendectomy because of suspected appendicitis between December 2013 and May 2015 were enrolled in the study. The patients were divided in three groups based on instrument used for sealing of mesoappendix: group 1 (Ultracision; n = 36), group 2 (LigaSure; n = 32), and group 3 (MiSeal; n = 31). Lateral thermal damage, intraoperative and postoperative complications, duration of surgery, hospital stay, and economic value were compared within groups.

RESULTS

The median age of patients was 14 y (range 3-17). A histopathologic analysis revealed a positive diagnosis of appendicitis in 84 patients (85%). The median lateral thermal damage on appendiceal base using Ultracision, LigaSure, and MiSeal was 0.10 mm, 0.16 mm, and 0.10 mm respectively, and on mesoappendix, 0.08 mm, 0.13 mm, and 0.08 mm, respectively. Significantly higher thermal damage was found on mesoappendix (P = 0.015) and appendiceal base (P = 0.012) in patients treated with LigaSure than in patients from other groups. There were no statistical differences among the groups regarding intraoperative and postoperative complications (P = 0.098). No significant difference in thermal damage between appendicitis and nonappendicitis group was found (P = 0.266).

CONCLUSIONS

Using of Ultracision, LigaSure, and MiSeal for sealing of mesoappendix in laparoscopic appendectomy in children is safe and useful. LigaSure produces significantly greater lateral thermal damage compared with other instruments.

Efficacy and Safety of Combined Ultrasonic and Bipolar Energy Source in Laparoscopic Surgery

AIM

Energy devices represent an alternative to clips and staplers for vessel sealing. Outcome data of patients undergoing laparoscopic surgery with use of a novel combined ultrasonic and bipolar energy device (TB, Thunderbeat™) was gathered.

METHODS

Consecutive patients undergoing laparoscopic surgery using TB were prospectively included between November 2011 and January 2016. Large vessels were dissected using the energy device without additional clips or staplers. The type of procedure, operative time, length of stay, complications, blood transfusions, number and type of vessels being dissected, and need for additional clips were noted.

RESULTS

Six hundred eighty-three patients underwent 758 procedures with dissection of 1310 large vessels. No additional hemoclips or vascular staplers were used. There were 0.7 % (5/758) intraoperative and 2.6 % (20/758) postoperative bleeding complications. Eleven bleeding occurred at the stapler line of anastomosis, leaving 1.8 % (14/758) bleeding that were potentially related to inadequate hemostasis. Failure of large vessel dissection occurred in two cases (0.15 %, 2/1310) and device-related complications in 1.1 % (8/758). Two of 42 conversions (5.5 %) were bleeding-related.

CONCLUSION

TB provides a reliable and effective hemostasis. However, ligation failure may occur. As with any kind of electrosurgery, the hot tip of the instruments bears the risk of potentially fatal thermal injuries.

The Thunderbeat and Other Energy Devices in Laparoscopic Colorectal Resections: Analysis of Outcomes and Costs

BACKGROUND

The THUNDERBEAT™ (TB) is a recently developed energy-based device. To date, there are no clinical studies comparing TB and other energy sources, such as standard electrosurgery (ES), ultrasonic coagulating shears (US) and electrothermal bipolar vessel sealers (EBVS) in patients undergoing laparoscopic colorectal resection (LCR). The aim of this study was to compare outcomes and costs in patients undergoing LCR with TB, US, EBVS, or ES for both benign and malignant colorectal diseases.

METHODS

This study is a retrospective analysis of a prospective database of patients undergoing LCR. Unselected consecutive patients who had the laparoscopic dissection conducted by using TB were compared with consecutive patients undergoing LCR with US, EBVS, or ES.

RESULTS

Mean operative time did not significantly differ between the groups (P = .947). Estimated blood loss was significantly higher in the ES group (P < .001). Device-related complications occurred in 2.5% of ES patients, in 2.5% of US patients, and in 5% of EBVS patients, while no complications occurred in TB patients (P = .768). No significant differences were observed in postoperative complication rates between the groups. Mean postoperative hospital stay was similar in the groups. Cost analysis showed no significant differences between US (1519.1 ± 303 €), EBVS (1474.4 ± 372.8 €), and TB (1474.3 ± 176.3 €) (P = .737).

CONCLUSION

This is the first clinical study comparing TB and other energy-based devices in LCR. They all appear to be equally safe and effective. Costs of surgery are very similar. Further large randomized controlled trials are needed to confirm these data.

Free Flap Elevation Times in Head and Neck Reconstruction Using the Harmonic Scalpel Shears

Free tissue transfer has become the mainstay of head and neck cancer (HNC) reconstructive surgery. The objective of the study is to examine the efficacy of the Harmonic Scalpel (HS) Shears on free flap elevation time and complication rates after HNC reconstruction compared with traditional electrocautery. A retrospective review of 215 HNC patients undergoing surgical ablation and free flap reconstruction from January 2010 to April 2013 at the University of Alberta Hospital was undertaken. All patients requiring free flap reconstruction with radial forearm free flap or fibula free flap were included. Overall, there was no significant difference demonstrated between the HS and electrocautery groups for free flap elevation time for RFFFs (P = 0.563) or FFFs (P = 0.087). No differences were observed in donor-site complications. The HS is a reliable, safe, and alternative method of free flap elevation in HNC reconstructive surgery.

Large-Vessel Sealing in Laparoscopic Colectomy with an Ultrasonic Device

BACKGROUND AND OBJECTIVE

The Harmonic ACE+7 Shears with Advanced Hemostasis Mode (Ethicon, Somerville, NJ, USA) is an ultrasonic device designed to transect and seal vessels up to 7 mm in diameter. The device applies an algorithm that optimizes ultrasonic energy delivery combined with a longer sealing cycle. The purpose of this study was to assess the initial clinical experience with the Harmonic device by evaluating large-vessel sealing during laparoscopic colectomy in consecutive cases.

METHODS

This prospective, multicenter, observational series involved 40 adult patients who were to undergo elective laparoscopic colectomy where dissection and transection of the inferior mesenteric artery was indicated. The primary study endpoint was first-pass hemostasis, defined as a single activation of the Advanced Hemostasis Mode to transect and seal the inferior mesenteric artery. The use of any additional energy device or hemostatic product to establish or maintain hemostasis was noted. Patients were observed after surgery for ∼4 weeks for adverse events that were considered to be related to the study procedure or study device. Descriptive statistical analyses were performed for study endpoints.

RESULTS

Forty patients underwent the laparoscopic colectomy procedure. First-pass hemostasis of the inferior mesenteric artery was achieved and maintained in all 40 patients, with no required additional hemostatic measures. Exposure of the vessel was reported as skeletonized in 22 of 40 (55%) patients. Mean transection time was 21.9 ± 7.4 s. One adverse event (postoperative anemia) was considered possibly related to the study device.

CONCLUSION

In this initial clinical consecutive series, the device demonstrated successful transection and sealing of the large mesenteric vessels during laparoscopic colorectal surgery.

Energy vessel sealing systems versus mechanical ligature of the inferior mesenteric artery in laparoscopic sigmoidectomy

PURPOSE

With the development of new devices, our ligation technique of the inferior mesenteric artery changed from mechanical ligature (ML) to energized vessel sealing systems (EVSS) ligature. The aim of this study was to determine if EVSS could be considered as safe and effective as the more convention ML of the inferior mesenteric vessels division during elective laparoscopic left colectomy.

METHODS

Between 2001 and 2014, 200 consecutive patients (111 males) of mean age 54.1 years were operated laparoscopically for a symptomatic sigmoid diverticulitis. Vascular interruptions were performed using mechanical ligatures including double clipping, staples or surgical thread (100 patients) or, starting from 2006, with EVSS thereafter (100 patients). Section of the inferior mesenteric artery is performed systematically at its origin in our institution for teaching purposes. Technical results were prospectively collected perioperatively and postoperatively.

RESULTS

There was no mortality. Mean operating time was 253.7 and 200.7 min in the ML and EVSS groups, respectively (p < 0.001). Mean hospital stay was 10.4 and 8.1 days (p < 0.001). Thirty-day complications occurred in 31 versus 25 % of patients (p = 0.26). Leakage with peritonitis occurred in 3 patients in the ML group. Hemorrhagic events occurred in both groups (2 in ML group versus 1 in EVSS group). Limitations of the study are its retrospective design and the bias due to the comparison of two historical cohorts.

CONCLUSIONS

EVSS for the inferior mesenteric artery are as safe and effective as ML in elective sigmoidectomy for diverticular disease with lower operative time and hospital stay.

A comparison of electrothermal bipolar vessel sealing system and electrocautery in selective neck dissection

The use of LigaSure™ vessel sealing system in head and neck surgery was reported to be reliable and safe, providing sufficient hemostasis and reducing operating time. The aim of this study was to evaluate efficacy of this technique in patients undergoing selective neck dissections. This study was carried out as a prospective controlled study at an otolaryngology department of a tertiary medical center between July 2013 and July 2015. Twenty-five patients older than 18 years who underwent unilateral selective neck dissection for head and neck cancer were included in the study. In the control group (group 2, 10 patients) only monopolar and bipolar diathermy was used; in the Ligasure group (group 1, 15 patients) Ligasure was used for hemostasis and dissection in addition to the conventional techniques. Cervical lymphadenectomy time, operation time, preoperative hemoglobin levels, preoperative hematocrit levels, postoperative hemoglobin levels, postoperative hematocrit levels, total neck drainage and drain removal time were analyzed and compared between the groups. Median operation time in group 1 and 2 were 95 min (IQR = 35) and 142.5 min (IQR = 63), respectively. Median cervical lymphadenectomy time in group 1 and 2 were 55 min (IQR = 23) and 102.5 min (IQR = 49), respectively. Median operation time and cervical operation time were significantly lower in group 1 (p < 0.05). In conclusion, LigaSure™ vessel sealing system is a safe, efficacious technique and significantly lowers cervical lymphadenectomy and operation time in selective neck dissections compared to controls. Given the superb hemostatic properties, this technique should be in the surgeon's armamentarium when possible.

Single-Use Energy Sources and Operating Room Time for Laparoscopic Hysterectomy: A Randomized Controlled Trial

STUDY OBJECTIVES

To compare the intraoperative direct costs of a single-use energy device with reusable energy devices during laparoscopic hysterectomy.

DESIGN

A randomized controlled trial (Canadian Task Force Classification I).

SETTING

An academic hospital.

PATIENTS

Forty-six women who underwent laparoscopic hysterectomy from March 2013 to September 2013.

INTERVENTIONS

Each patient served as her own control. One side of the uterine attachments was desiccated and transected with the single-use device (Ligasure 5-mm Blunt Tip LF1537 with the Force Triad generator). The other side was desiccated and transected with reusable bipolar forceps (RoBi 5 mm), and transected with monopolar scissors using the same Covidien Force Triad generator. The instrument approach used was randomized to the attending physician who was always on the patient's left side. Resident physicians always operated on the patient's right side and used the converse instruments of the attending physician.

MEASUREMENTS AND MAIN RESULTS

Start time was recorded at the utero-ovarian pedicle and end time was recorded after transection of the uterine artery on the same side. Costs included the single-use device; amortized costs of the generator, reusable instruments, and cords; cleaning and packaging of reusable instruments; and disposal of the single-use device. Operating room time was $94.14/min. We estimated that our single use-device cost $630.14 and had a total time savings of 6.7 min per case, or 3.35 min per side, which could justify the expense of the device. The single-use energy device had significant median time savings (-4.7 min per side, p < .001) and total intraoperative direct cost savings ($254.16 per case).

CONCLUSIONS

A single-use energy device that both desiccates and cuts significantly reduced operating room time to justify its own cost, and it also reduced total intraoperative direct costs during laparoscopic hysterectomy in our institution. Operating room cost per minute varies between institutions and must be considered before generalizing our results.

Efficacy of a half-grip technique using a fine tip LigaSure™, Dolphin Tip Sealer/Divider, on liver dissection in swine model

BACKGROUND

Recently, a lot of energy devices in the surgical field, especially in the liver surgery, have been developed, and a fine tip LigaSure™, Dolphin Tip Sealer/Divider (DT-SD) also has been used frequently to dissect liver parenchyma as well as ultrasonically activated device (USAD). However, the utility of this instrument for liver dissection (LD) is still unknown. Moreover, to reduce bleeding during LD, a half-grip technique (HGT) was contrived. We herein report an experimental study in swine model to evaluate the feasibility and effectiveness of HGT using DT-SD for LD.

METHODS

The swine model experiment was carried out under general anesthesia by veterinarians. LD was performed repeatedly by DT-SD with the HGT (Group A, n = 6), or the conventional clamp-crush technique (CCT) (Group B, n = 6), and by variable mode USAD (Group C, n = 6). The dissection length and depth (cm) as well as bleeding volume (g) were measured carefully, and the dissection area (cm(2)) and speed (cm(2)/min) were calculated precisely. Histological examinations of the dissection surfaces were also executed. Mann-Whitney's U test was used for Statistical analyses with variance at a significance level of 0.05.

RESULTS

Among the three groups, the three averages of dissection lengths were unexpectedly equalized to 8.3 cm. The dissection area (cm(2)) was 9.9 ± 5.1 in Group A, 9.8 ± 4.7 in Group B, and 9.9 ± 4.5 in Group C. The mean blood loss during LD was 10.6 ± 14.8 g in Group A, 41.4 ± 39.2 g in Group B, and 34.3 ± 39.2 g in Group C. For Group A, the bleeding rate was the least, 0.9 ± 1.0 g/cm(2), and the average depth of coagulation was the thickest, 1.47 ± 0.29 mm, among the three groups (p < 0.05). The dissection speed in Group A (1.3 ± 0.3 cm(2)/min) was slower, than that in Group C (p < 0.05).

CONCLUSIONS

This report indicates firstly that the HGT using DT-SD bring the least blood loss when compared with CCT or USAD. Although the HGT is feasible and useful for LD, to popularize the HGT, further clinical studies will be needed.

Ultrasonic dissection versus conventional electrocautery during gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials

OBJECTIVE

Use of ultrasonic surgical instrument is gaining popularity for dissection and coagulation in open surgery. However, there is still no consensus on the efficacy and safety of its use compared with conventional surgical technique in open gastrectomy for gastric cancer. The aim of this meta-analysis was to evaluate the role and surgical outcomes of ultrasonic dissection (UD) compared with conventional electrocautery (EC).

METHODS

A systematic literature search was performed to identify all studies comparing UD and EC in gastric cancer surgery. Intraoperative and postoperative outcomes were compared using weighted mean differences (WMDs) and odds ratios (ORs).

RESULTS

Five studies were included in this meta-analysis, comprising 489 patients. Meta-analysis results showed that compared with EC, UD was associated with significantly shorter operation time (P = 0.03), less intraoperative blood loss (P = 0.002), lower morbidity (P = 0.02), and reduced postoperative hospital stay (P = 0.03). However, there was no significant difference between the two surgical techniques with regards to postoperative abdominal drainage (P = 0.17), and total cost in hospital (P = 0.59).

CONCLUSIONS

Compared to EC, the use of UD during open gastrectomy can provide several improved outcomes for operation time, intraoperative blood loss, overall morbidity, and postoperative hospital stay. It appears that UD can be used instead of conventional EC in open gastric cancer surgery, although more larger trials with long follow-up should be performed.

The Covidien LigaSure Maryland Jaw Device

Since its invention nearly 20 years ago, the Covidien LigaSure device along with its ForceTriad generator has dominated the Electrothermal Bipolar Vessel Sealing market. The LigaSure was used for surgical procedures, both open and laparoscopic. The purpose of this review is to provide evidence of the safety and utility of the LigaSure device compared to more traditional means of hemostasis and its ultrasonic competitor, particularly in laparoscopic applications. We will provide evidence related to electrothermal bipolar vessel sealing in general and look specifically at Covidien's newest product, the LigaSure Maryland Jaw Device.

Single-session baseline virtual reality simulator scores predict technical performance for laparoscopic colectomy: a study in the swine model

OBJECTIVE

Virtual reality (VR) simulation helps reducing the learning curve of laparoscopic colectomy. Moreover, it may be used to ascertain surgeons' pretraining skills. It was aimed to establish predictive validity of specific parameters gathered during VR simulation training on sigmoid colectomy and whether simulator parameters correlate with technical performance during the same operation in a swine model.

DESIGN

Surgeons novice to laparoscopic colectomy underwent a single VR simulation session on sigmoid colectomy. Next, all participants performed a laparoscopic sigmoidectomy in the swine. Operations were recorded. Performance evaluation was conducted by 2 board-certified colorectal surgeons blinded to surgeons' simulator scores using an instrument specific to laparoscopic colectomy. For each participant, a mean score of specific skills was calculated. Linear regression analysis was used to identify simulator parameters that were best related to the score. The stepwise method was used to select parameters. The magnitude of the regression model was measured by the coefficient of determination (R(2)) value.

SETTING

The University of Sao Paulo Medical Center is a high-volume, public practice, university-affiliated hospital.

PARTICIPANTS

A total of 14 first-year residents in digestive tract surgery were included.

RESULTS

Analysis of variance demonstrated that the regression model was significant (p = 0.0001), and an association between simulation scores and specific skills was confirmed. The R(2) value was 99%. The VR simulator parameters that strongly correlated with specific skills during laparoscopic colectomy in the swine were safe use of electrosurgery/energy device and safety of medial-to-lateral dissection.

CONCLUSIONS

A single VR simulation session for novice surgeons in the sigmoid colectomy module generates baseline scores that highly correlated with performance of specific skills during a laparoscopic colectomy in the swine. This information may be useful in an attempt to tailor VR simulator practice according to a surgeon's needs.

Advanced sealing and dissecting devices in laparoscopic adrenal surgery

OBJECTIVES

This study sought to analyze the impact of advanced sealing/dissecting devices on operative and postoperative outcomes in laparoscopic adrenalectomy.

METHOD

Patients were divided into three groups according to the devices used during their procedures [electrothermal bipolar vessel system (EBVS), ultrasound shears (US), and monopolar electrocautery (ME)]. A comparison of the perioperative outcomes was performed.

RESULTS

Conversion rates and intraoperative and postoperative complication rates did not differ among the three groups. Major blood loss that required transfusion was registered in only two cases, all of which were performed with ME. Procedures with EBVS were shorter than those with US or ME. For left adrenalectomies only, operative times were similar for US and EBVS. The use of EBVS was found to be an independent predictor of decreased operative time.

CONCLUSION

The use of advanced sealing devices was associated with reduced operative time, with particular benefits in left adrenalectomy. EBVS and US may provide better hemostasis than ME.

Blood loss and operative duration using monopolar electrosurgery versus ultrasound scissors for surgical preparation during thoracoscopic ventral spondylodesis: results of a randomized, blinded, controlled trial

PURPOSE

Monopolar electrosurgery is the gold standard for surgical preparation in thoracoscopic spine procedures. However, use of ultrasound scissors could decrease blood loss, accelerate the preparation time and improve patient safety, while minimizing operative costs. This trial compares both preparation techniques for ventral thoracoscopic spondylodesis.

METHODS

The study design is an open, prospective, randomized, and double-blinded two-armed clinical trial performed in two centres. Forty-one patients with vertebral body fractures from T10 to L2 were included. Primary endpoint: preparation time. Secondary endpoints: blood loss, organ injuries, duration of hospitalization.

RESULTS

Primary and secondary endpoints did not differ significantly between groups (p level 0.05). Increased blood loss (150 ml or more) was eliminated with ultrasound scissors (p = 0.0014).

CONCLUSIONS

Primary and secondary endpoints did not differ significantly between the two preparation techniques. The use of either ultrasound scissors or electric scalpel offers safe and effective preparation for thoracoscopic spine surgery.

Economics and energy sources

Energy-based instrumentation has not only facilitated the rapid adoption of laparoscopic surgery, but could be considered essential for the completion of abdominal and pelvic procedures under endoscopic guidance. For decades, relatively simple and generic reusable monopolar and bipolar systems were the only options available. More recently, the available options for energy-based surgical instrumentation have become more crowded with the introduction of ultrasound-based cutting and sealing instruments and proprietary, impedance monitoring radiofrequency coagulation devices. Such instrumentation is presented as being easier to use as well as providing greater safety and efficacy. However, these new instruments typically require the expenditure of capital for proprietary energy generators and are usually designed to be for single use, a circumstance that increases per case costs, a circumstance that begs the question of value. Do the additional costs expended for the more expensive devices translate into reduced complications, faster operating time, or even wider access to minimally invasive procedures because they enable more surgeons to offer the service? Herein is explored the complex economic issues associated with the use of energy-based surgical devices as they apply to minimal access surgery in general and to laparoscopic procedures specifically.

New harmonic scalpel versus conventional hemostasis in right colon surgery: a prospective randomized controlled clinical trial

BACKGROUND

The Harmonic Scalpel (HS) is a device that uses vibrations to coagulate and cut tissues simultaneously. Its advantages are represented by minimal lateral thermal tissue damage, less smoke formation, no neuromuscular stimulation and no transmission of electricity to the patient.

METHODS

A total of 211 consecutive patients (113 men, 98 women; mean age 64 years) undergoing hemicolectomy for cancer of the right colon were divided into two groups, namely those in whom the operation was performed using a new HS handpiece (NHS; 108 patients) and those assigned to conventional hemostasis (CH; 103 patients). The two surgical groups were compared regarding patients' age and sex, tumor size, location, histotype and local invasiveness assessed by American Joint Cancer Committee stage, operative time, fluid content in the suction balloon (drainage volume) during the first 1-3 days after surgery, hospital stay and complications.

RESULTS

Ultrasonic energy delivered through an HS has been shown to be safe and to produce minimal damage to the surrounding tissues because of its minimal heat production. Electrical devices allow hemostatic control in vessels up to 3 mm in diameter, while HS can coagulate vessels up to 5 mm in diameter; thus, HS allows not only better control of bleeding but also of lymphorrhea. In fact, the amount of fluid collected in the drainage was significantly lower in the NHS group compared to the CH group. Protein depletion influences the patient's regenerative capacity and thus also the occurrence of complications and recovery time.

CONCLUSION

NHS is a useful device in colon surgery; it facilitates surgical maneuvers and reduces operative times and blood and lymphatic losses, allowing satisfactory maintenance of protein storage. This results in a lower incidence of complications and faster recovery by patients.

Impact of intraoperative blood loss on survival after curative resection for gastric cancer

AIM: To elucidate the potential impact of intraoperative blood loss (IBL) on long-term survival of gastric cancer patients after curative surgery.

METHODS: A total of 845 stage I-III gastric cancer patients who underwent curative gastrectomy between January 2003 and December 2007 in our center were enrolled in this study. Patients were divided into 3 groups according to the amount of IBL: group 1 (< 200 mL), group 2 (200-400 mL) and group 3 (> 400 mL). Clinicopathological features were compared among the three groups and potential prognostic factors were analyzed. The Log-rank test was used to assess statistical differences between the groups. Independent prognostic factors were identified by the Cox proportional hazards regression model. Stratified analysis was used to investigate the impact of IBL on survival in each stage. Cancer-specific survival was also compared among the three groups by excluding deaths due to reasons other than gastric cancer. Finally, we explored the possible factors associated with IBL and identified the independent risk factors for IBL ≥ 200 mL.

RESULTS: Overall survival was significantly influenced by the amount of IBL. The 5-year overall survival rates were 51.2%, 39.4% and 23.4% for IBL less than 200 mL, 200 to 400 mL and more than 400 mL, respectively (< 200 mL vs 200-400 mL, P < 0.001; 200-400 mL vs > 400 mL, P = 0.003). Age, tumor size, Borrmann type, extranodal metastasis, tumour-node-metastasis (TNM) stage, chemotherapy, extent of lymphadenectomy, IBL and postoperative complications were found to be independent prognostic factors in multivariable analysis. Following stratified analysis, patients staged TNM I-II and those with IBL less than 200 mL tended to have better survival than those with IBL not less than 200 mL, while patients staged TNM III, whose IBL was less than 400 mL had better survival. Tumor location, tumor size, TNM stage, type of gastrectomy, combined organ resection, extent of lymphadenectomy and year of surgery were found to be factors associated with the amount of IBL, while tumor location, type of gastrectomy, combined organ resection and year of surgery were independently associated with IBL ≥ 200 mL.

CONCLUSION: IBL is an independent prognostic factor for gastric cancer after curative resection. Reducing IBL can improve the long-term outcome of gastric cancer patients following curative gastrectomy.

Common uses and cited complications of energy in surgery

BACKGROUND

Instruments that apply energy to cut, coagulate, and dissect tissue with minimal bleeding facilitate surgery. The improper use of energy devices may increase patient morbidity and mortality. The current article reviews various energy sources in terms of their common uses and safe practices.

METHODS

For the purpose of this review, a general search was conducted through NCBI, SpringerLink, and Google. Articles describing laparoscopic or minimally invasive surgeries using single or multiple energy sources are considered, as are articles comparing various commercial energy devices in laboratory settings. Keywords, such as laparoscopy, energy, laser, electrosurgery, monopolar, bipolar, harmonic, ultrasonic, cryosurgery, argon beam, laser, complications, and death were used in the search.

RESULTS

A review of the literature shows that the performance of the energy devices depends upon the type of procedure. There is no consensus as to which device is optimal for a given procedure. The technical skill level of the surgeon and the knowledge about the devices are both important factors in deciding safe outcomes.

CONCLUSIONS

As new energy devices enter the market increases, surgeons should be aware of their indicated use in laparoscopic, endoscopic, and open surgery.

Pitfalls of laparoscopic colorectal surgery and how to avoid them

SUMMARY Laparoscopic surgery is commonly used for colorectal diseases. Recently, laparoscopy for colorectal carcinoma has increased in use, especially by colorectal surgeons. Laparoscopy is associated with potential pitfalls that pose challenges to the surgeon and team. The identification and management of these pitfalls may not directly parallel those during an open approach. As such, it is essential for the surgeon to have a good working knowledge of how to avoid potential problems and how to best manage them when they do occur. This review highlights common pitfalls of laparoscopic colorectal surgery, as well as offering practical approaches to their management. Technical, patient and surgeon factors are all discussed.

Evaluation of an innovative, cordless ultrasonic dissector

Ultrasonic thermal energy is commonly used for dissection and vessel ligation. This study compared HARMONIC ACE and Sonicision Cordless Ultrasonic Dissector (SCUD). The devices were used in an in vivo porcine model to coagulate 189 arteries up to 5 mm. Seal times were similar: SCUD, 5.2 ± 1.7 s; ACE, 4.9 ± 1.5 s (P = .20). Burst pressures for SCUD and AVE were 578 ± 284 and 605 ± 288 mm Hg, respectively (P = .48). Stratification by vessel diameter yielded similar results. In all, 17 applications resulted in seal failure on either the proximal or distal side, with no difference between SCUD (4.4%) and ACE (6.6%; P = .37). Histological examination of 48 specimens showed similar thermal spreads: 1.06 ± 0.05 versus 1.08 ± 0.05 mm for SCUD and ACE, respectively (P = .82). In 41 timed mesenteric transections, SCUD required 24.8 ± 4.9 s, which was significantly less than the 33.8 ± 5.4 s for ACE (P < .0001), with no bleeding in either group. SCUD and ACE showed similar vessel seal times, burst pressures, thermal spreads, and seal failure rates. SCUD was more efficient than ACE in mesenteric transection.

Ultrasonic scalpel for gastric cancer surgery: a prospective randomized study

BACKGROUND

The aim of the study was to evaluate the potential advantages of the ultrasonic scalpel compared with the conventional technique in gastric cancer surgery.

METHODS

Patients with resectable adenocarcinoma of the stomach were randomly assigned to ultrasonic scalpel or conventional technique. We used the HARMONIC FOCUS (Ethicon Endo-Surgery, Inc.) as ultrasonic scalpel.

RESULTS

Between February 2010 and December 2010, 60 patients with resectable gastric cancer were enrolled into the study. Operative time was significantly shorter with the ultrasonic arm than with the conventional arm (median 238.5 vs. 300.5 min; P = 0.0004). Blood loss was also significantly lower in the ultrasonic arm than in the conventional arm (median 351.0 vs. 569.5 ml; P = 0.016). Clavien-Dindo grades of postoperative complications were similar in the two groups. From a questionnaire survey of operators, the ultrasonic scalpel significantly reduced the stress of lymph node dissection (3.67 vs. 2.87; P = 0.0006). However, in assisting surgeons, the contributions to surgery, study, and technical improvement of the ultrasonic group were lower than in the conventional group.

CONCLUSIONS

This study shows that the ultrasonic scalpel is a reliable and safe tool for open gastric cancer surgery.

The use of harmonic scalpel for free flap dissection in head and neck reconstructive surgery

Surgeons conventionally use electrocautery dissection and surgical clip appliers to harvest free flaps. The ultrasonic Harmonic Scalpel is a new surgical instrument that provides high-quality dissection and hemostasis and minimizes tissue injury. The aim of this study was to evaluate the effectiveness and advantages of the ultrasonic Harmonic Scalpel compared to conventional surgical instruments in free flap surgery. This prospective study included 20 patients who underwent head and neck reconstructive surgery between March 2009 and May 2010. A forearm free flap was used for reconstruction in 12 patients, and a fibular flap was used in 8 patients. In half of the patients, electrocautery and surgical clips were used for free flap harvesting (the EC group), and in the other half of the patients, ultrasonic dissection was performed using the Harmonic Scalpel (the HS group). The following parameters were significantly lower in the HS group compared to the EC group: the operative time of flap dissection (35% lower in the HS group), blood loss, number of surgical clips and cost of surgical materials. This study demonstrated the effectiveness of the Harmonic Scalpel in forearm and fibular free flap dissections that may be extended to other free flaps.

Radiofrequency versus ultrasonic energy in laparoscopic colorectal surgery: a metaanalysis of operative time and blood loss

BACKGROUND

Various energy sources are available for tissue dissection and vessel sealing in laparoscopic colorectal surgery. The electrothermal bipolar vessel sealing system (EBVS) and ultrasonic energy (UE) devices are widely used to provide hemostatic dissection in laparoscopic procedures. Nevertheless, available evidenced-based data comparing their operative results still are scarce. This study conducted a metaanalysis of controlled clinical trials comparing EBVS and UE in terms of operative time and intraoperative blood losses in laparoscopic colorectal surgery.

METHODS

The MEDLINE and Embase databases were searched using medical subject headings and free text words. All randomized controlled trials (RCTs) and controlled clinical trials using EBVS and UE in laparoscopic colorectal surgery were considered for inclusion in the study. Random effects models were used in case of heterogeneity to obtain summary statistics for the overall difference in operating time and blood loss between instruments.

RESULTS

Four studies comparing EBVS with UE for 397 patients (200 EBVS vs. 197 UE patients) were included in the study. The findings showed that EBVS was associated with a significantly shorter operative time and less intraoperative blood loss than UE (p < 0.05).

CONCLUSIONS

The metaanalysis indicated that EBVS is associated with a shorter operative time and less blood loss than UE in laparoscopic colorectal surgery. However, these results should be interpreted with caution due to the high heterogeneity of the included trials and the limited number of studies with a high level of evidence. More adequately designed RCTs with a larger number of patients are required to confirm the results of this metaanalysis.

Effectiveness of electrothermal bipolar vessel-sealing devices versus other electrothermal and ultrasonic devices for abdominal surgical hemostasis: a systematic review

BACKGROUND

Adequate hemostatic techniques are essential for optimal intra- and postoperative results. A number of different hemostatic techniques and devices have been developed over the past few years, but which device should be preferred during laparoscopic and open abdominal procedures?

METHODS

We conducted a systematic search for randomized controlled trials (RCTs) that compared the effectiveness and costs of vessel-sealing devices with those of other electrothermal or ultrasonic devices in abdominal surgical procedures.

RESULTS

Seven RCTs that included 554 patients met the inclusion criteria. Various procedures that used a vessel-sealing device (LigaSure™) (n = 264) were compared to ultrasonic devices (n = 139) and mono- (n = 20) or bipolar devices (n = 130). LigaSure was favored in two studies with respect to less blood loss, shorter operating time, and lower costs. However, no differences were observed in the other studies. Considering the relatively low number of complications, all hemostatic devices used may be considered relatively safe. None of the studies reported on quality of life or cost effectiveness.

CONCLUSIONS

Vessel-sealing devices may be considered safe and their use may reduce costs due to reduced blood loss and shorter operating time in some abdominal surgical procedures compared to mono- or bipolar electrothermal devices. Wider-ranging RCTs of sufficient quality that assess (cost) effectiveness are required to make firm conclusions.

Safety and effectiveness of 5-mm and 10-mm electrothermal bipolar vessel sealers (LigaSure) in laparoscopic resections for sigmoid colon and rectal cancers

BACKGROUND

LigaSure™ (Covidien, Mansfield, MA) has been used in cases undergoing laparoscopic colon and rectal resections. This study aims to analyze the efficacy and safety of the 5-mm and 10-mm devices.

SUBJECTS AND METHODS

Patients who received a laparoscopic or hand-assisted laparoscopic operation for a tumor located in the sigmoid colon or rectum since 2006 were abstracted from a prospectively designed database, and findings were analyzed in two groups based on size of the device used during the procedure. The videotapes of the procedures were watched, and operation reports were read to obtain further information on specific intra- and postoperative complications. Demographics, tumor and operation-related information, and postoperative data were compared.

RESULTS

Among 215 (128 [59.5%] males; median age, 59.5±13.8 years) patients, data obtained from the 5-mm (n=32) and 10-mm (n=183) groups were identical regarding demographics and data related to tumor (localization and stage) and operation (number of harvested lymph nodes, conversion rates, operation time, intraoperative bleeding, transfusion requirement, reoperation rates, complications, 30-day mortality, and length of hospital stay). However, more patients underwent an anterior resection in the 10-mm group than in the 5-mm group (31.7% versus 15.6%, P<.05). Further analyses found device-related bleeding in 8 (3.7%) cases (2 [6.3%] versus 6 [3.3%] in the 5-mm versus 10-mm group, respectively, P>.05), requiring further attempts for hemorrhage control (n=6), conversion to open surgery (n=1), or relaparotomy (n=1).

CONCLUSIONS

The 5-mm and 10-mm LigaSure devices are similarly effective and safe during laparoscopic sigmoid colon and rectal resections. Severe bleeding from larger vessels may be observed, requiring conversion to open surgery or relaparotomy.