Vascular pedicle ligation techniques during laparoscopic colectomy

Best Evidence for Each Surgical Step in Minimally Invasive Right Hemicolectomy: A Systematic Review

Objective

The aim of this study was to systematically review the literature for each surgical step of the minimally invasive right hemicolectomy (MIRH) for non-locally advanced colon cancer, to define the most optimal procedure with the highest level of evidence.

Background

High variability exists in the way MIRH is performed between surgeons and hospitals, which could affect patients' postoperative and oncological outcomes.

Methods

A systematic search using PubMed was performed to first identify systematic reviews and meta-analyses, and if there were none then landmark papers and consensus statements were systematically searched for each key step of MIRH. Systematic reviews were assessed using the AMSTAR-2 tool, and selection was based on highest quality followed by year of publication.

Results

Low (less than 12 mmHg) intra-abdominal pressure (IAP) gives higher mean quality of recovery compared to standard IAP. Complete mesocolic excision (CME) is associated with lowest recurrence and highest 5-year overall survival rates, without worsening short-term outcomes. Routine D3 versus D2 lymphadenectomy showed higher LN yield, but more vascular injuries, and no difference in overall and disease-free survival. Intracorporeal anastomosis is associated with better intra- and postoperative outcomes. The Pfannenstiel incision gives the lowest chance of incisional hernias compared to all other extraction sites.

Conclusion

According to the best available evidence, the most optimal MIRH for colon cancer without clinically involved D3 nodes entails at least low IAP, CME with D2 lymphadenectomy, an intracorporeal anastomosis and specimen extraction through a Pfannenstiel incision.

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. 

Reciprocating Side-Firing Fiber for Laser Sealing of Blood Vessels

Infrared lasers may provide faster and more precise sealing of blood vessels and with lower jaw temperatures than ultrasonic and electrosurgical devices. This study explores an oscillating or reciprocating side-firing optical fiber method for transformation of a circular laser beam into a linear beam, necessary for integration into a standard 5-mm-diameter laparoscopic device, and for uniform irradiation perpendicular to the vessel length. A servo motor connected to a side-firing, 550-μm-core fiber, provided linear translation of a 2.0-mm-diameter circular beam over either 5 mm or 11 mm scan lengths for sealing small or large vessels, respectively. Laser seals were performed, ex vivo, on a total of 20 porcine renal arteries of 1-6 mm diameter (n = 10 samples for each scan length). Each vessel was compressed to a fixed 0.4-mm-thickness, matching the 1470-nm laser optical penetration depth. Vessels were irradiated with fluences ranging from 636 J/cm² to 716 J/cm². A standard burst pressure (BP) setup was used to evaluate vessel seal strength. The reciprocating fiber produced mean BP of 554 ± 142 and 524 ± 132 mmHg, respectively, and consistently sealing blood vessels, with all BP above hypertensive (180 mmHg) blood pressures. The reciprocating fiber provides a relatively uniform linear beam profile and aspect ratio, but will require integration of servo motor into a handpiece.

Computational Simulations for Infrared Laser Sealing and Cutting of Blood Vessels

Blood vessel burst pressures were simulated and predicted for sealing and cutting of vessels in a two-step process, using low (<25 W), medium (~100 W), and high (200 W) power lasers at a wavelength of 1470 nm. Monte Carlo optical transport, heat transfer, Arrhenius integral tissue damage simulations, and vessel pressure equations were utilized. The purpose of these studies was to first validate the numerical model by comparison with experimental results (for low and medium power) and then to use the model to simulate parameters that could not be experimentally tested (for high power). The goal was to reduce the large range of parameters (power, irradiation time, and linear beam dimensions) to be tested in future experiments, for achieving short vessel sealing/cutting times, minimal bifurcated seal zones (BSZ), and high vessel burst pressures. Blood vessels were compressed to 400 μm thickness. A wide range of linear beam profiles (1-5 mm widths and 8-9.5 mm lengths), incident powers (20-200 W) and clinically relevant irradiation times (0.5-5.0 s) were simulated and peak seal and cut temperatures as well as thermal seal zones, ablation zones, and BSZ computed. A simplistic mathematical expression was used to estimate vessel burst pressures based on seal width. Optimal low-power parameters were: 24W/5s/8×2mm (sealing) and 24W/5s/8×1mm (cutting), yielding a BSZ of 0.4 mm, corresponding to experimental burst pressures of ~450 mmHg. Optimal medium-power parameters were: 90W/1s/9.5×3mm (sealing) and 90W/1s/9.5×1mm (cutting), yielding a BSZ of 0.9 mm for burst pressures of ~1300 mmHg. Simulated only optimal high-power parameters were: 200W/0.5s/9×3 mm (sealing) and 200W/0.5s/9×1mm (cutting), yielding a BSZ of 0.9 mm and extrapolated to predict a seal strength of ~1300 mmHg. All lasers produced seal zones between 0.4-1.5 mm, corresponding to high vessel burst pressures of 300-1300 mmHg (well above normal systolic blood pressure of 120 mmHg). Higher laser powers enable shorter sealing/cutting times and higher vessel strengths.

Novel Optical Linear Beam Shaping Designs for use in Laparoscopic Laser Sealing of Vascular Tissues. Annu Int Conf IEEE Eng Med Biol Soc 2020;2020:5049-5052. [PMID: 33019121 PMCID: PMC8311731 DOI: 10.1109/embc44109.2020.9176571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Suture ligation of vascular tissues is slow and skill intensive. Ultrasonic (US) and radiofrequency (RF) devices enable more rapid vascular tissue ligation to maintain hemostasis, than sutures and mechanical clips, which leave foreign objects in the body and require exchange of instruments. However, US and RF devices are limited by excessive collateral thermal damage to adjacent tissues, and high jaw temperatures that require a long time to cool. A novel alternative method using infrared (IR) laser energy is being developed for more rapid and precise sealing of vessels. This study describes design, modeling, and initial testing of several optical beam shaping geometries for integration into the standard jaws of a laparoscopic device. The objective was to transform the circular laser beam into a linear beam, for uniform, cross-irradiation and sealing of blood vessels. Cylindrical mirrors organized in a staircase geometry provided the best spatial beam profile.Clinical Relevance-This study explored several optical designs for potential integration into the standard jaws of a laparoscopic vessel sealing device, transforming a circular laser beam into a linear beam for sealing of vascular structures.

Complete mesocolic excision and central vascular ligation for right colon cancer: an introduction for abdominal radiologists

OBJECTIVE

To provide an overview of complete mesocolic excision, along with a review of the relevant vascular anatomy and locoregional staging concepts, for abdominal radiologists.

RESULTS

Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer has emerged as a technique that has growing interest in surgical oncology. Specific anatomic considerations and patterns of nodal spread have thus gained clinical significance, and should be familiar to abdominal radiologists. This review article provides an overview of CME with CVL, and discusses some of the important anatomic considerations in patients with colon cancer that are relevant to radiologists.

CONCLUSION

Knowledge of CME with CVL and the relevant anatomic and staging considerations is important for abdominal radiologists, as this surgical technique becomes increasingly utilized.

Gastrocolic trunk of Henle and its variants: review of the literature and clinical relevance in colectomy for right-sided colon cancer

PURPOSE

Venous vascular anatomy of the right colon presents a high degree of variability. Henle's Gastrocolic Trunk is considered an important anatomical landmark by colorectal surgeons. The classical description concerns a bipod vascular structure or tripod, but several variants are associated to it. The aim of this study is to merge the most updated literature on the anatomy knowledge of the Gastrocolic Trunk by evaluating all possible variants, as well as to underline its surgical importance due to its topographical relationships.

METHODS

Twelve studies describing the anatomy of the gastrocolic trunk were selected, each of them dealing with a more or less extensive series of cases. A distinction was drawn between the gastropancreatic trunk, devoid of the colonic component, and the gastrocolic trunk; and then the frequency of the different resulting variants was reported. The data obtained from cadavers and radiological studies were analyzed separately.

RESULTS

The Gastrocolic Trunk is found in 74% of cadaver studies, and in 86% of radiological studies. Its most frequent configuration is represented by the union of right gastroepiploic vein + anterior superior pancreaticoduodenal vein + superior right colic vein, respectively, 32.5% and 42.5%, followed by the right colic vein which replaces (26.9%, 12.3%) or is added (10%, 20.1%) to the superior right colic vein.

CONCLUSIONS

The superior right colic vein joins the right gastroepiploic vein and the anterior superior pancreaticoduodenal vein thus forming, in most cases, the gastrocolic trunk. The anatomical knowledge of vascular structures forms the basis for both the interpretation of preoperative radiological images and the surgical procedure itself, despite the considerable anatomical variability of tributaries.

Surgical Anatomy of the Superior Mesenteric Vessels Related to Colon and Pancreatic Surgery: A Systematic Review and Meta-Analysis

The surgeon dissecting the base of the mesenterium, around the superior mesenteric vein (SMV) and artery, is facing a complex tridimensional vascular anatomy and should be aware of the anatomical variants in this area. The aim of this systematic review is to propose a standardized terminology of the superior mesenteric vessels, with impact in colon and pancreatic resections. We conducted a systematic search in PubMed/MEDLINE and Google Scholar databases up to March 2017. Forty-five studies, involving a total of 6090 specimens were included in the present meta-analysis. The pooled prevalence of the ileocolic, right colic and middle colic arteries was 99.8%, 60.1%, and 94.6%, respectively. The superior right colic vein and Henle trunk were present in 73.9%, and 89.7% of specimens, respectively. In conclusion, the infra-pancreatic anatomy of the superior mesenteric vessels is widely variable. We propose the term Henle trunk to be used for any venous confluence between gastric, pancreatic and colic veins, which drains between the inferior border of the pancreas and up to 20 mm downward on the right-anterior aspect of the SMV. The term gastrocolic trunk should not be synonymous, but a subgroup of the Henle trunk, together with to gastropancreatocolic, gastropancreatic, or colopancreatic trunk.

Rapid sealing of porcine renal blood vessels, ex vivo, using a high power, 1470-nm laser, and laparoscopic prototype

Energy-based, radiofrequency (RF) and ultrasonic (US) devices currently provide rapid sealing of blood vessels during laparoscopic procedures. We are exploring infrared lasers as an alternate energy modality for vessel sealing, capable of generating less collateral thermal damage. Previous studies demonstrated feasibility of sealing vessels in an in vivo porcine model using a 1470-nm laser. However, the initial prototype was designed for testing in open surgery and featured tissue clasping and light delivery mechanisms incompatible with laparoscopic surgery. In this study, a laparoscopic prototype similar to devices currently in surgical use was developed, and performance tests were conducted on porcine renal blood vessels, ex vivo. The 5-mm outer-diameter laparoscopic prototype featured a traditional Maryland jaw configuration that enables tissue manipulation and blunt dissection. Laser energy was delivered through a 550 - ? m -core-diameter optical fiber with side-delivery from the lower jaw and beam dimensions of 18 - mm ? length × 1.2 - mm ? width . The 1470-nm diode laser delivered 68 W with 3-s activation time, consistent with vessel seal times associated with RF and US-based devices. A total of 69 fresh porcine renal vessels with mean diameter of 3.3 ± 1.7 ?? mm were tested, ex vivo. Vessels smaller than 5-mm diameter were consistently sealed (48/51) with burst pressures greater than malignant hypertension blood pressure (180 mmHg), averaging 1038 ± 474 ?? mmHg . Vessels larger than 5 mm were not consistently sealed (6/18), yielding burst pressures of only 174 ± 221 ?? mmHg . Seal width, thermal damage zone, and thermal spread averaged 1.7 ± 0.8 , 3.4 ± 0.7 , and 1.0 ±

Prospective analysis of the sealing ability of the ENSEAL® G2 Articulating Tissue Sealer and transector on human mesenteric vessels in colorectal surgery

BACKGROUND

The sealing and transection of mesenteric vessels is a crucial step in minimally invasive colorectal surgery. We examined the sealing quality of the ENSEAL^® G2 Articulating Tissue Sealer in three different articulations in mesenteric vessels.

METHODS

This was a prospective experimental study within a tertiary healthcare center, and 30 patients were recruited. Burst pressures for each specimen were measured as the primary outcome. Ten specimens at each of the three articulations were also histologically assessed for the quality of seal.

RESULTS

We evaluated 54 sets of specimens from 30 patients for bursting pressure, all of which were harvested and sealed in the operating room. No statistical difference was seen in burst pressures from seals recorded at no angulation, half-maximal angulation, or maximal angulation (1604, 1507, 1478 mmHg; p = 0.07). Histological analysis showed no statistical differences in the average vessel diameter (p = 0.57), lateral extent of thermal injury (p = 0.48), degree of vascular sclerosis, or the integrity of seal at the three articulations. No cases of intraoperative or postoperative bleeding were observed in any of the patients. Five (16.7%) of the ENSEAL^® devices developed breaks in the black, heat-shrink, polyethylene covering as a result of repeated articulation and disarticulation. Electrical arcing did not appear to have occurred as a result of the break, although this was not formally examined.

CONCLUSIONS

The maximum sustainable pressure in mesenteric vessels sealed with a bipolar electrothermal device is supraphysiological, and consequently, the device can be safely used at various articulations to seal vessels during colorectal surgery.

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.

Vascular Structures of the Right Colon: Incidence and Variations with Their Clinical Implications

BACKGROUND AND AIMS

There is a demand for a better understanding of the vascular structures around the right colonic area. Although right hemicolectomy with the recent concept of meticulous lymph node dissection is a standardized procedure for malignant diseases among most surgeons, variations in the actual anatomical vascular are not well understood. The aim of the present review was to present a detailed overview of the vascular variation pertinent to the surgery for right colon cancer.

MATERIALS AND METHODS

Medical literature was searched for the articles highlighting the vascular variation relevant to the right colon cancer surgery.

RESULTS

Recently, there have been many detailed studies on applied surgical vascular anatomy based on cadaveric dissections, as well as radiological and intraoperative examinations to overcome misconceptions concerning the arterial supply and venous drainage to the right colon. Ileocolic artery and middle colic artery are consistently present in all patients arising from the superior mesenteric artery. Even though the ileocolic artery passes posterior to the superior mesenteric vein in most of the cases, in some cases courses anterior to the superior mesenteric artery. The right colic artery is inconsistently present ranging from 63% to 10% across different studies. Ileocolic vein and middle colic vein is always present, while the right colic vein is absent in 50% of patients. The gastrocolic trunk of Henle is present in 46%-100% patients across many studies with variation in the tributaries ranging from bipodal to tetrapodal. Commonly, it is found that the right colonic veins, including the right colic vein, middle colic vein, and superior right colic vein, share the confluence forming the gastrocolic trunk of Henle in a highly variable frequency and different forms.

CONCLUSION

Understanding the incidence and variations of the vascular anatomy of right side colon is of crucial importance. Failure to recognize the variation during surgery can result in troublesome bleeding especially during minimal invasive 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.

Electrothermal bipolar vessel ligation improves operative time during laparoscopic total proctocolectomy: a large single-center experience

BACKGROUND

Laparoscopic total proctocolectomy (TPC) with or without ileoanal pouch is a major operation for which the traditional benefits of laparoscopy were not immediately apparent, in part due to the longer operating times. The use of energy devices has been shown to improve operative outcomes for patients who undergo laparoscopic segmental colectomies, but there are limited data for laparoscopic TPC (LTPC).

METHODS

All patients who underwent LTPC between January 2002 and July 2011 were identified from a prospectively maintained institutional-review-board-approved database. Univariate and multiple linear regression analyses were performed to assess the impact of electrothermal bipolar vessel sealers (EBVS) for vessel ligation on operative time. Secondary outcomes included vessel ligation failures, estimated blood loss, and other intra- and postoperative outcomes.

RESULTS

One hundred and forty-five patients underwent LTPC, including 126 restorative ileoanal pouch and diverting ileostomy operations and 19 TPC and end ileostomy procedures. Fifteen percent of LTPCs were totally laparoscopic, 45 % were laparoscopic-assisted, 32 % were hand-assisted, and 8 % were laparoscopic-converted cases. Laparoscopic vessel ligation was performed using EBVS (76 %), endoscopic staplers (12 %), or hybrid techniques (12 %). Vessel ligation groups were similar in demographics, body mass index, surgical indication, immunosuppression, and prior surgery. EBVS were associated with shorter median operative times (247 vs. 290 vs. 300 min, p = 0.018) and fewer vessel ligation failures (1 vs. 11 vs. 12 %, p = 0.027) compared with endoscopic staplers and hybrid techniques, respectively. There were no differences in estimated blood loss and intra-operative complications among the three groups. Length of stay, 30-day morbidity, and 30-day re-operation rates were also similar. On multiple linear regression analysis, EBVS were a significant predictor of operative time (p = 0.019).

CONCLUSIONS

Routine use of electrothermal bipolar vessel ligation for LTPC is associated with shorter operative time and fewer vessel ligation failures without higher risk of complications than other vessel control methods.

A prospective study of in vivo and ex vivo sealing of the human inferior mesenteric artery using an electrothermal bipolar vessel-sealing device

BACKGROUND

Mesenteric vascular ligation is a critical step in minimally invasive colorectal surgery. This study assessed the quality of in vivo and ex vivo sealing of the human inferior mesenteric artery (IMA), as well as the relation of IMA stump and bursting pressure.

PATIENTS AND METHODS

This was a prospective experimental study in a tertiary-care teaching hospital. In total, 25 patients were included in the study. For the main outcome measures, bursting pressures were measured for each specimen. Ten freshly sealed specimens were histologically assessed for seal quality and lateral thermal damage.

RESULTS

We evaluated 54 specimens from 25 patients for bursting pressure, of which 25 were primary sealed vessels (sealed in vivo at surgery) and 29 were secondary sealed vessels (sealed in the laboratory). The mean bursting pressure was 862 mm Hg. The mean diameter was 4 mm (range, 3-5 mm) with a standard deviation of 1 mm. Pearson correlation showed no correlation between diameter and bursting pressure (P=.187) or the length and bursting pressure (P=.247). There was no statistically significant difference in bursting pressures in the four groups of vessels based on length. One calcified vessel had a significantly lower bursting pressure of 89 mm Hg. There was no intraoperative or postoperative bleeding. Ten sealed specimens were sent for histological evaluation, which showed mean lateral thermal damage of 0.57 mm (range, 0-1.75 mm).

CONCLUSIONS

The bursting pressure in IMAs sealed with a bipolar device is significantly higher than physiological pressures; thus, the device can be safely used in sealing the vessel during colorectal surgery. Additionally, the length of the vessel stump does not correlate with the bursting pressures. Care needs to be taken when the vessel is calcified, which can be a potential cause of a weak seal.

Novel surgery for refractory mixed constipation: Jinling procedure - technical notes and early outcome

INTRODUCTION

The treatment of slow-transit constipation combined with outlet obstruction is controversial. This study introduced a new surgical strategy, subtotal colectomy combined with a modified Duhamel procedure (Jinling procedure), of which the safety and satisfactory rate were examined.

MATERIAL AND METHODS

Ninety patients with refractory slow-transit constipation associated with outlet obstruction were consecutively included between Jan 2010 and Dec 2010. All underwent the laparoscopic-assisted Jinling procedure, which added a new side-to-side anastomosis to the colorectal posterior anastomosis after subtotal colectomy. The pre- and post-operative data were collected.

RESULTS

There was no surgery-related death. A total of 39 complications and adverse events were reported in 22 patients (morbidity rate of 24.4%). Most complications were managed conservatively without significant events. The satisfactory rate was 93.1% at 6-month follow-up.

CONCLUSIONS

The Jinling procedure is safe for refractory slow-transit constipation associated with outlet obstruction, with minimal major complications and a high satisfaction rate. However, this procedure requires rigorous preoperative examination, exquisite surgical and laparoscopic techniques and excellent perioperative management. The pelvic floor, especially the presacral space, is damaged, and therefore it may be unsalvageable if severe complications, such as anastomosis leakage or ischemia, occur.

Rapid sealing and cutting of porcine blood vessels, ex vivo, using a high-power, 1470-nm diode laser

Suture ligation with subsequent cutting of blood vessels to maintain hemostasis during surgery is time consuming and skill intensive. Energy-based electrosurgical and ultrasonic devices are often used to replace sutures and mechanical clips to provide rapid hemostasis and decrease surgery time. Some of these devices may create undesirably large collateral zones of thermal damage and tissue necrosis, or require separate mechanical blades for cutting. Infrared lasers are currently being explored as alternative energy sources for vessel sealing applications. In a previous study, a 1470-nm laser was used to seal vessels 1 to 6 mm in diameter in 5 s, yielding burst pressures of ∼500  mmHg. The purpose of this study was to provide vessel sealing times comparable with current energy-based devices, incorporate transection of sealed vessels, and demonstrate high vessel burst pressures to provide a safety margin for future clinical use. A 110-W, 1470-nm laser beam was transmitted through a fiber and beam shaping optics, producing a 90-W linear beam 3.0 by 9.5 mm for sealing (400  W/cm2), and 1.1 by 9.6 mm for cutting (1080  W/cm2). A two-step process sealed and then transected ex vivo porcine renal vessels (1.5 to 8.5 mm diameter) in a bench top setup. Seal and cut times were 1.0 s each. A burst pressure system measured seal strength, and histologic measurements of lateral thermal spread were also recorded. All blood vessels tested (n=55 seal samples) were sealed and cut, with total irradiation times of 2.0 s and mean burst pressures of 1305±783  mmHg. Additional unburst vessels were processed for histological analysis, showing a lateral thermal spread of 0.94±0.48  mm (n=14 seal samples). This study demonstrated that an optical-based system is capable of precisely sealing and cutting a wide range of porcine renal vessel sizes and, with further development, may provide an alternative to radiofrequency- and ultrasonic-based vessel sealing devices.

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.

Role of CT angiography with three-dimensional reconstruction of mesenteric vessels in laparoscopic colorectal resections: a randomized controlled trial

BACKGROUND

Laparoscopic surgery, despite its well-known advantages and continuous technological innovations, still has limitations such as the lack of tactile sensation and reduced view of the operative field. These limitations are particularly evident when performing laparoscopic colorectal resection due to the variability of the number and course of mesenteric vessels. Today, the patient's vascular anatomy can be mapped using computed tomography (CT) angiography and processing of the images with rendering software to reconstruct a three-dimensional model of the mesenteric vessels. To assess how prior knowledge of the patient's mesenteric vascular anatomy represents an advantage when performing laparoscopic colorectal resections, we conducted a randomized, parallel, single-blinded controlled trial.

METHODS

From January 2010 to January 2012, all patients with surgical indication to undergo standardized right or left hemicolectomy and anterior rectal resections were randomly assigned to two groups and subjected to CT angiography with three-dimensional reconstruction of mesenteric vessels. In the first group the surgeon was able to view the 3D reconstruction before and during surgery, while in the second group the surgeon was only able to view the 3D reconstruction after surgery.

RESULTS

Evaluation of data from 112 patients shows statistically significantly lower operative time, episodes of difficult identification of right anatomy, and incidence of intraoperative and postoperative complication related to difficult or erroneous identification of mesenteric vessels in the group in which the surgeon was able to view the 3D reconstruction before and during surgery compared with the control group.

CONCLUSION

This study shows that prior knowledge of the patient's mesenteric vascular anatomy represents an advantage when performing laparoscopic colorectal resection.

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.

Randomized clinical trial comparing the cost and effectiveness of bipolar vessel sealers versus clips and vascular staplers for laparoscopic colorectal resection

BACKGROUND

The widespread use of laparoscopy has resulted in a variety of instruments being used routinely for vascular control. This randomized controlled trial evaluated the cost-effectiveness of bipolar vessel sealer (BVS) compared with clips and vascular stapler (CVS) in straight laparoscopic colorectal resection.

METHODS

Patients scheduled for elective colorectal resection, including benign and malignant diseases, were randomized to either BVS or CVS for vascular control. Patients whose operation was converted to an open approach before pedicle ligation were excluded. The primary endpoints were duration of operation, including time taken to control vascular pedicles, and cost of disposable instruments for vascular control.

RESULTS

Of 114 patients randomized to BVS (60 patients) or CVS (54), 14 did not receive the allocated vascular control device, leaving 55 and 45 respectively for analysis. The BVS reduced the time spent for vascular control by a mean of 6·9 min (P = 0·031) and reduced the cost of disposable instruments for vascular control by US $ 80·7 per patient (P = 0·043). For total colectomy, the BVS reduced the operating time by 103·6 min (P = 0·023) and the time taken for vascular control by 16·8 min (P = 0·022). For left colectomy, it decreased the time to vascular control by 9·3 min (P = 0·021). In multivariable analysis, the cost of disposable instruments for vascular control was independently reduced by randomization to BVS, type of procedure, female sex and estimated blood loss. The mean cost reduction was $ 88·2 for left colectomy (P = 0·037), $ 377·7 (P = 0·005) for total colectomy and $ 366·9 (P = 0·012) for proctectomy. Conversely, use of the BVS increased the cost of instruments used for vascular control in right colectomy by $ 92·6 (P = 0·012).

CONCLUSION

BVS devices are expedient and cost-efficient in proctectomy, left and total colectomy procedures.

Three-Dimensional Vascular Anatomy Relevant to Oncologic Resection of Right Colon Cancer

We analyzed data on the three-dimensional vascular anatomy of the right colon from the operative documents of 215 patients undergoing oncologic resection for right colon cancer. The right colic artery (RCA) was absent in 146 patients (67.9%), with the ileocolic artery (ICA) crossing the superior mesenteric vein (SMV) ventrally in 78 patients (36.3%). When the RCA was present, both the ICA and the RCA crossed the SMV ventrally in 44 patients (20.5%), dorsally in 10 patients (4.7%), the RCA crossed the SMV ventrally and the ICA dorsally in 10 patients (4.7%), and the RCA crossed the SMV dorsally and the ICA ventrally in 5 patients (2.2%). The arterial branches toward the hepatic flexure crossed the SMV ventrally in 151 eligible cases: the branch originated from the common trunk of the middle colic artery in 97 patients (64.2%) and 1 and 2 arteries directly originated from the SMA in 49 patients (32.5%) and in 5 patients (3.3%), respectively. These data would be useful to safely perform lymph node dissection around the SMV.

Energy source instruments for laparoscopic colectomy

BACKGROUND

Colectomy is a common procedures for both benign and malignant conditions. Increasingly more colectomy has been performed laparoscopically and there are several available instruments being used for this procedure. Of which three common dissecting instruments are: monopolar electrocautery scissors (MES), ultrasonic coagulating shears (UCS) and electrothermal bipolar vessel sealers (EBVS). 

OBJECTIVES

The aim is to assess the safety and effectiveness of these instruments.

SEARCH STRATEGY

Studies were identified from PubMed, EMBASE, Cochrane Controlled Trials Register, Cochrane Colorectal Cancer Group Trials Register.  Major journals were specifically hand searched.  All randomised controlled trials were included.

SELECTION CRITERIA

All patients underwent elective laparoscopic or laparoscopic-assisted right, left or total colectomy or anterior resection for either benign or malignant conditions were included in the study.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies from the literature searches, assessed the methodological quality of the trials and extracted data. The three primary outcomes were: overall blood loss, complications and operating time.

MAIN RESULTS

Six randomised controlled trials including 446 participants. Two trials compared three types of instruments (MES vs UCS vs EBVS). One trial compared MES and UCS. One trial compared UCS and EBVS. One trial compared 5 mm versus 10 mm EBVS. One trial compared the technique of laparoscopic staplers and clips versus EBVS in pedicle ligation during laparoscopic colectomy. The limitation of this review is the heterogeneity of the trials included. The measured outcomes were covered by one to three studies with small number of participants. With this in mind, there was significant less blood loss in UCS compared to MES. The operating time was significantly shorter with the use of EBVS than MES. No difference between UCS and EBVS apart from EBVS appeared to be handling better than UCS in one study. Haemostatic control was better in UCS and EBVS over MES. No definite conclusion on the cost difference between these three instrument but this would lie in the balance between the instrument cost and the operating time. The handling of 5 mm EBVS was better than 10 mm and its main advantage was trocar flexibility. Laparoscopic staplers/clips used for pedicle ligation in colectomy associated with more failure in vessel ligation and cost more when compared to EBVS.

AUTHORS' CONCLUSIONS

The limitations of this review is the small number of trials and heterogeneity of the studies included. With the current evidence it is not possible to demonstrate which is the best instrument in laparoscopic colectomy. Hopefully more data would follow and subsequent updates of this review could become more informative.

A single-institution review of the absorbable clips used in laparoscopic colorectal and gallbladder surgery: feasibility, safety, and effectiveness

This retrospective study was conducted to examine the safety and effectiveness of polymeric absorbable clips in laparoscopic gallbladder and colorectal surgery. The prospectively maintained database review included all patients undergoing elective laparoscopic cholecystectomy and colorectal resection at the institution between November 2004 and December 2009. In each patient, absorbable clips were used as the only system of vascular and cystic duct ligation. Of the 911 patients who satisfied the inclusion criteria, 664 underwent laparoscopic cholecystectomy and 247 underwent laparoscopic colonic resection. No intra-operative or post-operative bleeding related to absorbable clip use occurred in either procedure. No bile duct injuries or cystic duct leakages were observed. There were no peri-operative deaths with either procedure. In this experience, absorbable clips demonstrated easy handling and high reliability. They provided safe hemostasis and permitted complete and adequate oncologic resection.

Preliminary results of anatomic lung resection using energy-based tissue and vessel coagulative fusion technology

OBJECTIVES

Mechanical stapling devices have been established as the mainstay of therapy in the selective isolation and division of bronchial and vascular structures during anatomic lung resection. Few data are available regarding the application of energy-based tissue fusion technology during anatomic lung resection. In the present study, we evaluated the use of energy-based instruments for the division of the pulmonary arterial and venous branches during anatomic lung resection.

METHODS

Anatomic lung resection (segmentectomy or lobectomy) was performed using energy-based coagulative fusion technology. A low-profile jaw can be used to facilitate dissection in both open and video-assisted thoracic surgery cases, applying a seal 6 mm wide by 22 mm in length. Two energy applications were applied to the arterial and venous branches before vessel division.

RESULTS

The bipolar tissue fusion system was used in 211 patients between 2008 and 2010 (104 lobectomies and 107 anatomic segmentectomies). Initially, we used a device with a smaller, curved jaw (n = 12), producing a 3.3- to 4.7-cm seal. No arterial dehiscences and 2 partial venous dehiscences that were recognized and controlled intraoperatively occurred. For the remaining cases, we used a new device with a larger jaw that applied a seal 6 mm wide by 22 mm in length. No arterial or venous dehiscences (vessel size range, 0.4-1.2 cm) occurred.

CONCLUSIONS

The bipolar tissue fusion system provided safe and reliable control of pulmonary arterial and venous branches during anatomic lung resection. The use of energy-based tissue fusion technology represents a reasonable alternative to mechanical stapling devices during anatomic lung resection.

Combined blunt-clamp dissection and LigaSure ligation for hepatic parenchyma dissection: postcoagulation technique

BACKGROUND

Blunt-clamp dissection allows for visualization of intrahepatic vessels and individual ligation of major blood or bile vessels. Recently, many instruments have been developed for "precoagulation" of liver parenchyma before sharp transection, but suffer from the possibility of injuring major blood and biliary vessels that are not well-visualized, along with high cost. In this article, we describe a "postcoagulation" technique combining clamp dissection and sealing of vessels under direct vision using a tissue-sealing device.

STUDY DESIGN

Clinical evaluation of 400 patients from 2 centers subjected to liver resection using this technique.

RESULTS

There were no cases complicated by hemorrhage. There was an incidence of 1.8% for bile leaks. This low incidence of biloma formation was seen even with the high incidence (49%) of abnormal parenchyma encountered in this cohort.

CONCLUSIONS

Combining the clamp-crushing method with use of the LigaSure device (Valleylab) allows identification of intraparenchymal vessels followed by sealing. This method of parenchymal transaction optimizes ease of use with confidence in vessel ligation.

Can the gastrocolic trunk of Henle serve as an anatomical landmark in laparoscopic right colectomy? A postmortem anatomical study

BACKGROUND

The use of the gastrocolic trunk of Henle (GTH) as a landmark has been advocated in laparoscopic right colectomy. The aim of this study was to evaluate the GTH as a possible landmark in laparoscopic right colectomy in the context of the adjacent arteries.

METHODS

Corrosion casting (30 specimens) and anatomic dissection were performed on formol-fixed cadavers (12 specimens).

RESULTS

The GTH was found in 34 specimens (81.0%). Among its closely related neighboring arterial vessels, the right colic artery was the most frequent (19 cases [55.9%]). It passed by the GTH at a mean distance of 3.6 mm. The course of the arteries in relation to the GTH was caudal and parallel in most cases (29 [85.3%]), but there was also a significant portion of crossing schemes (11.7%).

CONCLUSIONS

Although the GTH is a constant and conspicuous anatomic entity, it is not easily accessible, because of its tight relations to the right colon arteries. Instead, the authors advocate the use the superior right colic vein as an anatomic landmark leading to the GTH during laparoscopic right colectomy.

Principles and initial experience of a new device for dissection and hemostasis

Electrosurgery is a commonly used technology in laparoscopy. Electrosurgical devices are being used in many medical subdisciplines in order to coagulate, cut, and ablate tissue and to produce hemostasis. The latest advance in electrosurgery is the introduction of novel simultaneous hemostatic sealing and cutting bipolar devices that minimize force by delivering energy as high current and low voltage output. One of these systems is the Gyrus Plasma Trissector (GPT), (Gyrus Group PLC, Gyrus International, Ltd.UK), a novel radiofrequency (RF) system based on bipolar technology, which consists of a proprietary PlasmaKinetic (PK) generator and specific instruments, designed as a system. The instrument consists of a 17 mm long gold-coated curved jaw with a ceramic insulated cutting element. The PK system uses high-powered pulsed bipolar energy to produce a plasmakinetic field around the working elements and is designed to operate at temperatures that allow effective tissue dissection but result in minimal collateral damage and adherence to tissue. The GPT was used with the Gyrus G400 WorkStation generator in laparoscopic radical prostatectomies (LRP). Our initial experience with this novel bipolar device demonstrates it to be safe and effective in dissection and hemostasis. The GPT permits us to act quickly when bloody fields are present, improves coagulation, reduces or eliminates sticking, seals large vessels such as dorsal vein complex (DVC) and allows secure grasping and dissecting of tissue. The urologist is familiar with electrosurgery, as we have become comfortable using GPT to dissect, cut, and coagulate tissue. We feel that the GPT can be used in a variety of laparoscopic procedures in urology.

Safety and efficacy of the electrothermal bipolar vessel sealer in trauma

The electrothermal bipolar vessel sealer (EBVS) was developed as an alternative to sutures, clips, and the ultrasonic scalpel for haemostasis during open and laparoscopic surgery. The purpose of this prospective clinical study was to objectively evaluate the performance of the EBVS during trauma surgery. Data from trauma cases, in which the EBVS was used, was collected prospectively for 19 consecutive months. Data collected included: total number of EBVS applications, need for additional haemostatic devices after application, calculated time savings or loss, and hemorrhagic complications. The EBVS was used in 23 trauma cases consisting of 13 small bowel resections, 4 ileocolectomies, 2 left hemicolectomies, 1 transverse colectomy, 1 right hemicolectomy with roux-en-Y gastrojejunostomy and duodenostomy, 1 Hartmann's procedure, and 1 splenorrhaphy with omental injury repair. A total of 631 applications of the device were used, averaging 27.4 applications per case. An additional suture ligature or clip placed for an inadequate EBVS seal (failure) was needed in only 1.5% of the total EBVS applications. All of these (10) occurred in one patient undergoing Hartmann's procedure for massive colonic injury. An additional 45 sutures or clips for non-EBVS failure were used in 5 cases due to proximity of bleeding to critical vascular, biliary, or bowel structures. In 17 trauma cases (74%) with intestinal resection no other means of hemostasis (sutures or clips) was required except the EBVS. The mean calculated time savings using the EBVS was 26.8 min (range 9.8-48) per case. There were no haemorrhagic complications. The EBVS is safe and effective for intestinal resections and haemostasis in trauma surgery. This novel energy source reliably seals major mesenteric vessels with little need for sutures or clips. Using the EBVS can substantially shorten operative time.

Electrothermal bipolar vessel sealing system vs. harmonic scalpel in colorectal laparoscopic surgery: a prospective, randomized study

PURPOSE

This study was designed to compare the efficacy and safety of laparoscopic colorectal surgery performed with the aid of LigaSure vessel-sealing system or Ultracision.

METHODS

Patients eligible for elective laparoscopic right or left hemicolectomy or anterior resection of rectum were randomly assigned to either the use of Ligasure or Ultracision. The primary end point was intraoperative reduction of blood loss. Secondary end points were intraoperative and postoperative morbidity and operative time.

RESULTS

Between April 2005 and December 2006, 140 consecutive patients were included in the study (70 Ligasure and 70 Ultracision. We performed 31 right hemicolectomies, 69 left hemicolectomies, and 40 anterior resections of rectum. Blood loss was 109.6 ml (Ultracision 107.9 ml vs. Ligasure 111.2 ml, P value = 0.72). Intraoperative complication rate was 2.8 percent (Ultracision 1.4 percent vs. Ligasure 4.2 percent, P value < 0.01). Postoperative mortality was 0.7 percent. The overall conversion rate was 7.8 percent, 6 in the Ligasure group and 5 in the Ultracision group (P value = 0.09). Operative time, considered from pneumoperitoneum to minilaparotomy, was 115.7 minutes (Ultracision 114.8 minutes vs. Ligasure 116.3 minutes, P value = 0.89).

CONCLUSIONS

Results showed that Ligasure and Ultracision are both useful instruments for laparoscopic colorectal surgery with no significant difference in terms of intraoperative/postoperative morbidity and operative time. Choice of which technique to perform should be according to the surgeon's preference.

Prospective randomized study of monopolar scissors, bipolar vessel sealer and ultrasonic shears in laparoscopic colorectal surgery

Background

Many instruments are used for laparoscopic dissection, including monopolar electrosurgery scissors (MES), electrothermal bipolar vessel sealers (BVS) and ultrasonically coagulating shears (UCS). These three devices were compared with regard to dissection time, blood loss, safety and costs.

Methods

Sixty-one consecutive patients undergoing laparoscopic left-sided colectomy were randomized to MES, BVS or UCS. The primary endpoint was dissection time.

Results

Patient and operation characteristics did not differ between the groups. Median dissection time was significantly shorter with BVS (105 min) and UCS (90 min) than with MES (137 min) (P &lt; 0·001). With BVS and UCS, significantly fewer additional clips were required (MES 9 versus BVS 0 versus UCS 3; P &lt; 0·001) and there was a trend towards lower blood loss (125 versus 50 versus 50 ml respectively; P = 0·223) and a reduced volume of suction fluid (425 versus 80 versus 110 ml; P = 0·058). Overall satisfaction was similar for the three instruments. Dissection with BVS and UCS was significantly cheaper than with MES, assuming a centre volume of 200 cases per year (P = 0·009).

Conclusion

BVS and UCS shorten dissection time in laparoscopic left-sided colectomy and are cost-effective compared with MES. Registration number: NCT00517608 (http://www.clinicaltrials.com).

Division of the small bowel with the LigaSure Atlas device during the right laparoscopic colectomy

BACKGROUND

Bowel division and anastomosis were facilitated greatly with the advent of stapling techniques. Since then, there have not been any new evolving technologies to facilitate these maneuvers. For this reason, we recently applied the LigaSure Atlas device (Valleylab, Boulder, CO) to the division of the small bowel during this procedure to obtain a reliable and low-cost division of the ileum.

METHODS

After vessel ligation and ileocolic mobilization, the terminal ileum is sealed and divided with the LigaSure Atlas. This device is applied sequentially along the small bowel twice to ensure an adequate seal before the cut. A terminolateral ileotransversostomy is performed extracorporeally with a mechanical circular stapling device, installing the anvil of the circular stapler into the ileal stump.

RESULTS

We have not encountered any problems with this technique since its introduction in our institution, and no leakage or bursting of the ileal stumps.

CONCLUSIONS

This technique enables an easy, reliable, and inexpensive technical option to optimize the right laparoscopic colectomy procedure.

Comparison of four energy-based vascular sealing and cutting instruments: A porcine model

AIM

To compare the safety and efficacy of four energy-based vascular sealing and cutting instruments.

METHODS

Blood vessels of various types and diameters were harvested from four pigs using four instruments: Harmonic ACE (Ethicon Endo-Surgery, Cincinnati, OH), LigaSure V and LigaSure Atlas (Valleylab, Inc., Boulder, CO; a division of Tyco Healthcare), and EnSeal vessel fusion system (SurgRx, Inc. Redwood City, CA). The diameters of the vessels, speed and adequacy of the cutting and sealing process, and bursting pressures were compared. An additional set of specimens was sealed and left in situ for up to 4 h after which the vessels were harvested and histopathologically analyzed for the degree of thermal injury.

RESULTS

The bursting pressures were significantly higher with EnSeal compared to all other instruments (p < 0.0001). The sealing process was significantly shorter with Harmonic ACE and significantly longer with LigaSure Atlas (p <0.0001). The mean seal width was larger with the LigaSure Atlas compared to the other instruments, and it was smaller with EnSeal and Harmonic ACE. Less radial adventitial collagen denaturation was present with EnSeal and LigaSure V than with the other two instruments; there were no significant differences in collagen denaturation although proximal thermal injury to the smooth muscle in the media of the vessel wall was less common with LigaSure Atlas than with the other instruments; however, the numbers were too small for statistical analysis.

CONCLUSIONS

The bursting pressures with EnSeal were significantly higher than with all the other instruments. Harmonic ACE was the fastest sealing instrument and LigaSure Atlas was slowest. EnSeal created less radial thermal damage to the adventitial collagen of the vessels and LigaSure Atlas created less thermal damage to the media of the vessels. The clinical significance of these findings is unknown.

Vascular relationships in right colectomy for cancer: clinical implications

AIMS

The study aim was to provide data on pattern and length of crossing of the ileocolic artery (ICA) and right colic artery (RCA) with the superior mesenteric vein (SMV).

METHODS

Specimens from 30 fresh human cadavers underwent corrosion casting. Methylacrylate was injected into the SMV and superior mesenteric artery (SMA). Length of crossing was measured with a scaleable ruler and copper wire. Values are mean (SD; range).

RESULTS

ICA was present in all specimens and crossed posterior to the SMV in 19 (63.33%) of 30 specimens. Length of crossing was 17.01 (7.84; 7.09-42.89) mm. RCA was present in 19 (63.33%) of 30 specimens. RCA crossed anterior to SMV in 16 (84.21%) of 19 specimens. Length of crossing was 20.63 (8.09; 6.3-35.7) mm.

CONCLUSIONS

ICA was always present, crossed posterior to SMV in 60% of specimens with a crossing length of 17 mm. RCA was present in 63% of specimens, crossed anterior to the SMV in 84% of specimens with a crossing length of 20 mm. Clinical implications include arterial length left behind with main nodes, arterial bleeding and safety of laparoscopic access.

Electrothermal bipolar vessel sealing device vs. ultrasonic coagulating shears in laparoscopic colectomies: a comparative study

BACKGROUND

Many devices are available for vascular control during laparoscopic colorectal procedures. Ultrasonic coagulating shears (UCS), vascular staplers, titanium or plastic clips, and electrothermal bipolar vessel sealing (EBVS) are currently used according to the surgeon's preference. This study aimed to compare EBVS Ligasure with UCS.

METHODS

We report the outcome of 200 consecutive unselected patients who underwent laparoscopic colorectal resections of which 100 were performed with EBVS Ligasure (from September 2004 to December 2005, group 1) and 100 with UCS harmonic scalpel (from December 2002 to June 2004, group 2). Only the following three types of operation were performed: right colectomy (RC), left colectomy (LC), and low anterior resections (LAR). Emergency procedures have been excluded. The same attending surgical teams performed or supervised all procedures. Operating time, blood loss, complications, and postoperative hospital stay were investigated.

RESULTS

Age, gender, previous surgical abdominal procedures, and ASA risk were similar between the two groups, as well as was the percentage of malignant cases (74% vs. 71%, respectively). There were 32 vs. 37 RC, 50 vs. 47 LC, and 18 vs. 16 LAR in groups 1 and 2, respectively. There was no mortality in either group. A conversion to open surgery and two major complications occurred in group 2. There were no statistically significant differences in mean operating time (111 vs. 133, 140 vs. 176, and 153 vs. 201 min) and in the mean postoperative hospital stay (5.2 vs. 6.1, 6.5 vs. 7.1, and 6.8 vs 7.3 days) for RC, LC, and LAR between group 1 and 2, respectively. We do report interesting data about statistically significant differences in the blood loss: 115 vs. 370, 150 vs. 455, and 185 vs. 495 ml for RC (p < 0.001), LC (p < 0.001), and LAR (p = 0.002) between group 1 and group 2, respectively.

CONCLUSIONS

In our laparoscopic colorectal experience, EBVS Ligasure has proven safe and effective in vessel sealing. Patients in whom this device was used had less blood loss and slight advantages in operating time and postoperative hospital stay.

Laparoscopic approach to colonic cancer: critical appraisal of the literature

BACKGROUND/AIMS

As laparoscopic colectomy finds its place in the surgical armamentarium, the literature concerning the safety, efficacy, and oncological rational for treatment of colonic cancer is also enriched. A review and critical appraisal of the literature on this subject was the aim of this paper.

METHODS

A systematic research and a hand search were conducted to gain access to all controlled studies involving laparoscopic colectomy using the Medline, Embase, HealthSTAR, Cumulative Index for Nursing and Allied Health Literature, CancerLit data bases and the Cochrane Central Register of Controlled Trials for the years 1991-2006.

RESULTS

Over 40 controlled randomized trials and ten systematic reviews and/or meta-analyses were found. Several of the completed controlled randomized trials have published either short- or long-term results; only partial and short-term results are available in rectal cancer. The principal conclusions are that the laparoscopic approach affords better short-term outcomes including surgical site morbidity, but with increased operative times and direct costs. Among the proven long-term outcomes, cancer recurrence and survival do not seem to be worse. Whether conversion, a source of increased operative time and costs, is responsible for poorer outcomes or whether specific settings associated with poorer outcomes are among the causes of conversion remains to be shown. However, there are still concerns as regards specific laparoscopic-related complications.

CONCLUSION

There seems to no real safety problems in performing laparoscopic colectomy for cancer; improvement in operative times, conversion rates, and complications should make laparoscopy the best cost-effective approach to colectomy.

Laparoscopic colon surgery: past, present and future

Since its first described case in 1991, laparoscopic colon surgery has lagged behind minimally invasive surgical methods for solid intra-abdominal organs in terms of acceptability, dissemination, and ease of learning. In colon cancer, initial concerns over port site metastases and adequacy of oncologic resection have considerably dampened early enthusiasm for this procedure. Only recently, with the publication of several large, randomized controlled trials, has the incidence of port site metastases been shown to be equivalent to that of open resection. Laparoscopic surgery for colon cancer has also been demonstrated to be at least equivalent to traditional laparotomy in terms of adequacy of oncologic resection, disease recurrence, and long-term survival. In addition, numerous reports have validated short-term benefits following laparoscopic resection for cancer, including shorter hospital stay, shorter time to recovery of bowel function, and decreased analgesic requirements, as well as other postoperative variables. In benign colonic disease, much less high-quality literature exists supporting the use of laparoscopic methods. Two recent randomized controlled trials have demonstrated some short-term benefits to laparoscopic ileocolic resection for CD, in addition to evident cosmetic advantages. On the other hand, the current evidence on laparoscopic surgery for UC does not support its routine use among nonexpert surgeons outside of specialized centers. Laparoscopic colonic resection for diverticular disease appears to provide several short-term benefits, although these advantages may not translate to cases of complicated diverticulitis. Despite the increasing acceptability of minimally invasive methods for the management of benign and malignant colonic pathologies, laparoscopic colon resection remains a prohibitively difficult technique to master. Numerous technological innovations have been introduced onto the market in an effort to decrease the steep learning curve associated with laparoscopic colon surgery. Good evidence exists supporting the use of second-generation, sleeveless, hand-assist devices in this context. Similarly, new hemostatic devices such as the ultrasonic scalpel and the electrothermal bipolar vessel sealer may be particularly helpful for extensive colonic mobilizations, in which several vascular pedicles must be taken. The precise role of these hemostatic technologies has yet to be established, particularly in comparison with stapling devices and significantly cheaper laparoscopic clips. Finally, recent advances in camera systems are promising to improve the ease with which difficult colonic dissections can be performed.