Ultrasonic energy vs monopolar electrosurgery in laparoscopic cholecystectomy

Background: The influence of surgical operations on the systemic immune response is proportional to the degree of trauma. Ultrasonic surgery can dissect structures and divide vessels by the effect produced by vibrations in the tissues. It is believed to be less traumatic than the more commonly used monopolar electrosurgery. This randomized study compares the systemic immune response after laparoscopic cholecystectomy performed using either ultrasonic energy or monopolar electrosurgery. Methods: Eighteen patients scheduled for elective laparoscopic cholecystectomy were randomly assigned to treatment using either a harmonic scalpel and clips or monopolar electrosurgery and clips. Postoperative inflammatory response was assessed via changes in the white blood cell count and levels of C-reactive protein. Postoperative immune function was assessed by measuring monocyte HLA-DR expression. Results: Both the harmonic scalpel and the use of monopolar electrosurgery resulted in activation of the systemic immune response. No significant differences between the two groups were observed. Conclusion: The harmonic scalpel and monopolar electrosurgery are equally traumatic in terms of activation of the systemic immune response.     

A newly designed single dissector useful for laparoscopic cholecystectomy

Summary We developed a modified dissector capable of carrying out a one-hand operation involving three fundamental functions: grasping, sharp or blunt dissection, and dividing the tissues. With this single dissector, laparoscopic cholecystectomy can be rapidly and safely performed without changing the forceps or instruments through the trocar.     

Laparoscopic parenchymal division of the liver in a porcine model: comparison of the efficacy and safety of three different techniques

Background Bleeding is a known and CO₂ embolization a suggested risk factor for increased morbidity after laparoscopic liver resection. Devices for laparoscopic liver parenchymal transection must be evaluated for safety in this context. Method Twelve piglets underwent laparoscopic surgery during CO₂ pneumoperitoneum, each animal receiving three 6 cm long transections into the liver parenchyma made with ultrasonic dissector, ultrasonic shears and vessel sealing system, respectively. Endpoints were bleeding, operation time and gas embolization. The transections and embolization events, evaluated with transesophageal echocardiography, were video recorded. Bleeding and embolization were also assessed on video tapes and operating time measured. Arterial blood gases were recorded on line. Results The ultrasonic dissector was least advantageous in terms of bleeding and operation time. Gas embolization was more frequent with the vessel sealing system than with the ultrasonic dissector and ultrasonic shears. During two episodes of gas embolization, pCO₂ increased and pO₂ and pH decreased. Conclusions Use of all three devices is feasible. Bleeding and operation time are greatest with the ultrasonic dissector. Gas embolization occurs during transection, though in most instances it is completely harmless. Laparoscopic liver surgery with these techniques used may pose a risk of gas embolization with clinical implications. Monitoring for such events is probably to be recommended.     

Water jet cholecystectomy and common bile duct lavage under videolaparoscopic guidance

A new method for performing laparoscopic cholecystectomy, using a water jet dissector, is described. This technique was employed in two patients who were considered suitable candidates for laparoscopic surgery. The use of the water jet dissector proved to be very efficient and safe. No intraoperative bile leak or hemorrhage occurred in any patient. In one of the two patients, choledochotomy and common bile duct lavage were performed, using the same water jet apparatus in combination with extraction of a residual large calculus and T-tude drainage. In both patients the postoperative course was uneventful.     

Laser or electrocautery for laparoscopic cholecystectomy?

There are few concerns related to laparoscopic cholecystectomy that evoke as much emotion as the question of which is the superior energy source, laser or electrocautery. Monopolar radio frequency electricity (electrosurgery) and collimated coherent light (laser) injure tissue by the generation of heat, and in this regard are remarkably similar. The greatest differences between these sources of heat are related to predictability of injury, selective absorption of free beam laser energy, ability to coagulate, and cost. Although there are no prospective data yet available to answer the question of superiority, it appears that electrosurgical dissection may be faster and is generally less costly. Laser dissection may be more precise. In difficult cases, hemostasis appears to be superior with electrosurgery.     

Ultrasonic dissection

Following its development for cataract surgery, and gaining widespread use in neurosurgery and liver resection, ultrasonic dissection has been adapted for laparoscopic use. The turbulence, heat, and pressure generated by imploding bubbles disrupts tissues high in water content. This phenomenon is called cavitation and is the principal means by which ultrasonic dissection is accomplished.A randomized, prospective trial demonstrated the utility of the device for laparoscopic cholecystectomy. It was particularly effective in the presence of acute periportal inflammation or fat. Additional experience with a wide range of laparoscopic procedures is being accumulated by several investigators around the world.The laparoscopic use of ultrasonic dissection will be most valuable whenever selective, precise, and, therefore, safe dissection is desired.     

Incision extension is the optimal method of difficult gallbladder extraction at laparoscopic cholecystectomy

Summary An unsolved problem of laparoscopic cholecystectomy is the optimal method of removing the gallbladder with thick walls and a large stone burden. Proposed solutions include fascial dilatation, stone crushing, and ultrasonic, high-speed rotary, or laser lithotripsy. Our observation was that extension of the fascial incision to remove the impacted gallbladder was time efficient and did not increase postoperative pain. We reviewed the narcotic requirements of 107 consecutive patients undergoing laparoscopic cholecystectomy. Fifty-two patients required extension of the umbilical incision, and 55 patients did not have their fascial incision enlarged. Parenteral meperidine use was 39.5±63.6 mg in the patients requiring fascial incision extension and 66.3±79.2 mg in those not requiring fascial incision extension (mean ± standard deviation). Oral narcotic requirements were 1.1±1.5 doses vs 1.3±1.7 doses in patients with and without incision extension, respectively. The wide range of narcotic use in both groups makes these apparent differences not statistically significant. We conclude that protracted attempts at stone crushing or expensive stone fragmentation devices are unnecessary for the extraction of a difficult gallbladder during laparoscopic cholecystectomy.     

Techniques of liver resection. Comparison of suction knife, ultrasonic dissector, and contact neodymium-YAG laser

Liver resections were performed in 18 pigs with an inexpensive disposable plastic suction knife, an ultrasonic dissector, or a contact neodymium (Nd)-YAG laser. Technical aspects and intraoperative and postoperative data were compared. Intraoperative blood loss was less with the suction knife (112 +/- 28 mL) than with the ultrasonic dissector (149 +/- 45 mL) or Nd-YAG laser (174 +/- 25 mL). Operating time was similar in all groups. The number of ligatures used in the Nd-YAG laser group (12 +/- 1) was significantly less than in the ultrasonic dissector (27 +/- 2) or suction knife (32 +/- 2) groups. In the ultrasonic dissector group, there was an increase in postoperative white blood cell count and liver enzyme levels compared with the other two groups. Light microscopy revealed dilated bile ducts in the ultrasonic dissector resection group, which may reflect biliary stasis. There were no significant differences in mortality among the three experimental groups. Results indicated that the ultrasonic dissector and the contact laser method were not substantially better than an inexpensive, easily modified plastic suction catheter in performing a major nonanatomic liver resection in piglets.     

Anatomical footprint for safe laparoscopic cholecystectomy without using any energy source: a modified technique

Background Over the last two decades, laparoscopic cholecystectomy has become the gold standard for treating cholecystolithiasis and an index operation for evaluation and assessment of laparoscopic surgical skills. Its wider application and continuous refinement have not been accompanied by a commensurate decrease in morbidity due to biliary, vascular, or visceral injuries. Use of an energy source, especially monopolar electrosurgery, has been identified as a culprit for many of these injuries. This study assessed the feasibility of performing laparoscopic cholecystectomy safely without using any energy source by taking advantage of the avascular anatomical planes. Method Patients attending the surgery clinic of our center who were candidates for a laparoscopic cholecystectomy were enrolled. Informed consent was obtained from each patient before the procedure. The study was approved by the Ethical Review Board of the hospital and was conducted as per GCP guidelines. Results Between June 2005 and July 2006, 83 patients were enrolled. All patients underwent laparoscopic cholecystectomy without any energy source being used. There was no incidence of biliary, vascular, or visceral injury. All patients remained hemodynamically stable. There was no conversion or mortality. The hospital stay was 8–16 h. Patients were followed up by telephone for the first 48 hours and then by regulat outpatient visits until they were well. Conclusion A safe laparoscopic cholecystectomy without using any energy source can be performed by following the proper anatomical footprint.     

Laparoscopic cholecystectomy: laser versus electrosurgery.

Laparoscopic cholecystectomy has been reported to be a safe and effective way to remove a diseased gallbladder with essentially no morbidity or mortality (1,2). This procedure was first introduced in Europe using electrosurgery, and later introduced in the United States using the laser (1). No clinical trial compares the laser to the standard electrosurgery method. In a review, as well as an ongoing study, morbidity, mortality, intraoperative procedures, indications, and cost effectiveness are considered in these two groups. Three hundred cases were reviewed with 150 patients in each group. There were no deaths or significant complications in either group. In the laser group, bleeding seemed slightly more excessive during removal of the gallbladder from the liver bed and required more time to control. The electrosurgery group required slightly less operative time and was less costly. The postoperative recovery time was the same in each group.     

The surgical treatment of liver metastases from colorectal carcinoma: our experience

Data from twelve patients who had hepatic resections for colorectal liver metastases were retrospectively analyzed to determine: 1) whether the use of the ultrasonic surgical dissector and the Argon laser can significantly simplify major hepatic resections and decrease both perioperative blood loss and postoperative morbidity and mortality, and 2) whether an adequate patients selection for surgery can effectively determine an improvement in recurrence rate. We performed 4 bisegmentectomies (2 of V and VI; 2 of VI and VII); 1 trisegmentectomy (V, VI, VII); 2 left lobectomies; 1 right hepatectomy and 4 wedge resections, using both the ultrasonic surgical dissector to fractionate and aspirate the hepatic parenchyma and to clear major vascular and biliary structures and the Argon laser for the coagulation of minor vascular and biliary vessels. The resected metastases averaged 5.5 cm (range: 1.5-7.5); blood transfusion requirements were significantly reduced from previous reports, averaging only 1.25 units (range: 0.3); the average operative time was 238 minutes (110 to 420 minutes). There were no operative deaths, operative morbidity rate was 16.6. The results indicate that the ultrasonic surgical dissector and the Argon laser have made a significant contribution to our marked decrease in the average blood loss and transfusion requirement. The long-term results seems to be improved by an adequate patients selection.     

A comparison of NOTES transvaginal and laparoscopic cholecystectomy procedures based upon task analysis

Background

A virtual reality-based simulator for natural orifice translumenal endoscopic surgery (NOTES) procedures may be used for training and discovery of new tools and procedures. Our previous study (Sankaranarayanan et al. in Surg Endosc 27:1607–1616, 2013) shows that developing such a simulator for the transvaginal cholecystectomy procedure using a rigid endoscope will have the most impact on the field. However, prior to developing such a simulator, a thorough task analysis is necessary to determine the most important phases, tasks, and subtasks of this procedure.

Methods

19 rigid endoscope transvaginal hybrid NOTES cholecystectomy procedures and 11 traditional laparoscopic procedures have been recorded and de-identified prior to analysis. Hierarchical task analysis was conducted for the rigid endoscope transvaginal NOTES cholecystectomy. A time series analysis was conducted to evaluate the performance of the transvaginal NOTES and laparoscopic cholecystectomy procedures. Finally, a comparison of electrosurgery-based errors was performed by two independent qualified personnel.

Results

The most time-consuming tasks for both laparoscopic and NOTES cholecystectomy are removing areolar and connective tissue surrounding the gallbladder, exposing Calot’s triangle, and dissecting the gallbladder off the liver bed with electrosurgery. There is a positive correlation of performance time between the removal of areolar and connective tissue and electrosurgery dissection tasks in NOTES (r = 0.415) and laparoscopic cholecystectomy (r = 0.684) with p < 0.10. During the electrosurgery task, the NOTES procedures had fewer errors related to lack of progress in gallbladder removal. Contrarily, laparoscopic procedures had fewer errors due to the instrument being out of the camera view.

Conclusion

A thorough task analysis and video-based quantification of NOTES cholecystectomy has identified the most time-consuming tasks. A comparison of the surgical errors during electrosurgery gallbladder dissection establishes that the NOTES procedure, while still new, is not inferior to the established laparoscopic procedure.     

Cost analysis comparing ultrasonic fundus-first and conventional laparoscopic cholecystectomy using electrocautery

Background

Costs associated with laparoscopic fundus-first cholecystectomy using ultrasonic dissection versus a conventional laparoscopic cholecystectomy has not been compared.

Methods

Adult patients subjected to elective laparoscopic cholecystectomy between June 2002 and March 2004 were randomized to either an ultrasonic fundus-first dissection or dissection from the triangle of Calot with electrocautery. Differences in direct and indirect costs related to either technique were studied.

Results

The duration of the operation and hospitalization was longer when dissection was with the conventional technique. With the ultrasonic fundus-first technique, the direct cost was 1,190 SEK lower, and the total cost, taking also the cost for sick leave into account, was 5,370 SEK lower.

Conclusions

Both direct and indirect costs are lower with a laparoscopic fundus-first cholecystectomy using ultrasonic dissection than conventional laparoscopic cholecystectomy using electrocautery.     

Ultrasonic-mediated laparoscopic liver transection

Parenchymal liver transection represents a fundamental phase of liver surgery. Several devices have been described for safe and careful dissection of the liver parenchyma during laparoscopic liver surgery, but the ideal technique has not yet been defined. This report describes the combined use of ultrasonic dissector and the ultrasonic coagulating cutter for laparoscopic liver resection. The ultrasonic dissector is used to fracture the parenchyma along the line of proposed division, and the uncovered bridging structures are sealed using the ultrasonic coagulating cutter. The combined use of ultrasonic dissector and harmonic scalpel allows liver resection to be safely performed, with the advantage of minimal surgical complication and low blood losses.     

Twenty-millimeter laparoscopic cholecystectomy: fewer ports results in less pain, shorter hospitalization, and faster recovery

Improvements in technology offer the ability to refine operations without compromising safety. In this study, we determine whether a modified method of laparoscopic cholecystectomy using three ports and an aggregate incision length of 20 mm offers any advantage or poses increased risk. Using a 5-mm, 30 degree laparoscope, clip applier, and dissector, the gall bladder is removed through an extended umbilical incision. Standard safety principles were followed: achieving the "critical view," lateral retraction of the fundus, double ligation of the proximal structures, and maintaining sterility for specimen removal. Forty-one consecutive standard laparoscopic cholecystectomies were used as a control group to compare complications, length of stay and surgery, pain scores, and return to work. Sixty patients have undergone the modified technique. There were no differences between the modified and standard technique with regard to cost or complications. Length of surgery was significantly shorter, as was length of stay, narcotics use, and return to work for the modified group versus the control. A modified technique for laparoscopic cholecystectomy poses no increased risk to patients but offers potential for shorter surgery and hospital stays, less need for narcotic analgesia, and faster recovery.     

An innovative bipolar instrument for laparoscopic surgery.

OBJECTIVE: Bipolar electrosurgery is an excellent method for obtaining hemostasis at laparoscopy. The present study describes and evaluates a bipolar device that can be more versatile and cost effective in advanced operative procedures than the traditional instrumentation. METHODS: This was a retrospective, case-controlled analysis of bipolar instrumentation with a design classification of II-2. A single surgeon in a private practice setting performed all procedures. Sixteen patients, matched for age and pathology were evaluated by videotape review to determine the comparative efficiency of the BiCOAG bipolar dissector/grasper versus traditional Kleppinger bipolar forceps. Efficiency here is defined as comparative operating times in each group. RESULTS: The number of instrument changes per case was counted because this appeared to be the only variable other than time that differentiated the 2 groups. The BiCOAG bipolar dissector/grasper device group had 4 times fewer instrument changes and significantly decreased operating room times when compared with that of the Kleppinger forceps group. Because cost per unit of operating room time was a constant figure, the decrease in cost that resulted due to the decrease in operating time is considered a cost-effective measure. CONCLUSIONS: The BiCOAG bipolar dissector/grasper is a cost-effective, efficient instrument for use in operative laparoscopic procedures.     

经脐单孔腹腔镜胆囊切除术

目的 探讨经脐单孔腹腔镜胆囊切除术临床应用的安全性及疗效.方法 回顾性分析2008年1月至2010年5月第三军医大学新桥医院完成的16例行经脐单孔腹腔镜胆囊切除术患者的临床资料.取紧邻脐孔右侧缘行约1.5 cm的切口,入腹后置入连接好2个5 mm Trocar和1个10 mm Trocar所形成的三通道防漏气操作装置,制造气腹,以10 mm Trocar进入腹腔镜镜头,自2个5 mm Trocar各进入一把腹腔镜器械和5 mm超声刀,按常规腹腔镜操作方法完成胆囊切除术.结果 16例患者手术均获成功,手术时间为50～150 min,未放置引流管,术后无出血及胆汁漏等并发症发生.患者恢复良好,脐部无明显手术瘢痕.结论 经脐单孔腹腔镜胆囊切除术切口美观,安全可行.但操作难度较传统LC大,进一步完善脐部操作装置及手术器械,可望在一定程度上取代传统LC.     

Initial experience with laparoscopic cholecystectomy in a teaching hospital.

The safety of laparoscopic cholecystectomy and the necessary training are serious concerns. This report describes both the surgical experience and the training and credentialling process at a private community-based teaching hospital. All 140 laparoscopic cholecystectomies attempted during the initial 9-month experience (March to December 1990) of 11 surgeons are detailed. There were no deaths. Eight patients subsequently underwent open cholecystectomy, and another two patients required reoperation for complications, which included one common-duct transection. The mean operating time was 106 minutes, the mean hospital stay was 1.6 days and most patients resumed unrestricted activity within 1 week. Use of the laser in 49% of patients was of no discernible benefit. This early experience indicates that laparoscopic cholecystectomy is both safe and effective and should be considered the technique of choice for elective cholecystectomy.     

临时心脏起搏器在腹腔镜胆囊切除术围手术期中的应用

目的探讨伴有缓慢型心律失常患者腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中应用临时心脏起搏器的安全性. 方法 34例伴缓慢型心律失常的老年拟行LC患者,于术前安置临时心脏起搏器.LC术中应用超声刀切开、止血,不使用电刀. 结果 34例LC均获成功,无手术并发症,围手术期无严重心血管并发症发生. 结论围手术期安置临时心脏起搏器,术中使用超声刀可有效提高伴缓慢型心律失常的老年患者LC围手术期的安全性,减少严重心血管系统并发症的发生.     

腹腔镜"一钩到底法"快速胆囊切除术的临床应用研究

目的观察在腹腔镜快速胆囊切除术(LC)中采用"一钩到底法"的临床效果,分析技术要点和优点。 方法回顾性分析2010年12月至2013年10月间收治的1 303例行LC术的患者,其中685例患者术中应用"一钩到底法"(试验组),618例患者行传统LC术(对照组)。观察两组所用的手术时间、中转开腹手术数、术中胆管损伤数、术后并发症发生情况。 结果试验组的手术操作时间少于对照组,差异有统计学意义(t=12.58,P<0.05);两组术后均无出血现象,试验组无胆漏发生,且切口感染率低于对照组,但差异无统计学意义(χ²=0.018,P=0.893)。试验组的胆管损伤率(0.29%)和中转开腹率(0.73%)均少于对照组(0.16%、0.32%),但差异无统计学意义。 结论LC术中应用"一钩到底法"可以缩短手术操作时间,减少并发症的发生率,值得在临床上推广使用。