Comparison of ultrasonically activated scalpel versus conventional division for the pancreas in distal pancreatectomy

Purpose: The goal of this study was to compare the benefits and complications of using an ultrasonically activated scalpel and conventional division of the pancreas in patients undergoing a distal pancreatectomy. Methods: A retrospective review was performed of all patients who underwent distal pancreatectomy at the Department of Surgery, Koshigaya Municipal Hospital. In the ultrasonically activated scalpel (US) group (n = 11), the pancreas was divided using coagulation shears. The stump of the pancreas was left open without parenchymal suturing. In the conventional surgical division (CV) group (n = 20), the pancreas was cut with a knife and the stump was oversewn with interrupted mattress sutures. The main pancreatic duct was ligated in all patients in both groups. The postoperative courses in the two groups were then compared in terms of postoperative serum amylase levels and the incidence of pancreatic fistulas. Results: The postoperative serum amylase levels were significantly lower in the US group than in the CV group (P < 0.01 on the day of operation). The incidence of pancreatic fistulas was also significantly lower in the US group (0%) than in the CV group (30%) (P = 0.04). Conclusions: The use of the ultrasonically activated scalpel was found to reduce the incidence of pancreatic fistula in distal pancreatectomy. Furthermore, the use of this device without any clamping or parenchymal suturing may reduce the damage to the remnant pancreas. Received: December 22, 2000 / Accepted: March 9, 2001     

Hepatic resection using the harmonic scalpel

We describe herein our technique of performing extensive resection of the liver by blunt dissection in combination with excision using a harmonic scalpel. A ball coagulator was inserted at 3-cm intervals along the proposed cutting line in the liver, and the liver parenchyma between these holes was then cut using coagulation shears. Regardless of the condition of the liver, good coagulation and cutting were achieved using the harmonic scalpel without vascular occlusion when dividing the shallow layer of the liver, and no complications in association with the harmonic scalpel, such as postoperative bleeding, bile leakage, or abscess formation at the cut margins, occurred. In the deep layer below the main trunk of the hepatic vein, blunt dissection was used, since it was difficult to achieve sufficient control of bleeding from large vessels using the harmonic scalpel alone. Therefore, when used in combination with other techniques, the harmonic scalpel appears to be an effective device for liver surgery that minimizes bleeding and decreases the vascular clamping time. Received: October 14, 1999 / Accepted: May 30, 2000     

超声刀在腹腔镜肠粘连松解术中的应用

目的 探讨超声刀在腹腔镜肠粘连松解手术中的应用。方法 应用超声刀行腹腔镜肠粘连松解术治疗粘连性肠梗阻29例。结果 29例均顺利完成手术，无中转开腹。2例因肠管间广泛致密粘连而致分离中肠管破裂，但均在腹腔镜下修补成功。手术时间30～150min。术后无肠漏、出血或腹腔感染等并发症。术后3～7d出院，随访1～24个月，未见有腹痛、腹胀等复发症状。结论 与电刀相比，超声刀的应用使腹腔镜肠粘连松解手术安全性更高，创伤更小，手术时间更短．而且使术后肠粘连肠梗阻复发的机会更少。     

超声刀在腹腔镜胃肠手术中的使用技巧

超声刀作为当今外科手术中最常用的能量工具之一．被认为是影响传统外科发展的革命性产品。凶其在切割、止血、分离等方面的优势，越来越多的腹腔镜外科医生在胃肠手术巾使用超声刀进行相应操作。然而，胃肠手术操作具有相对特殊性．涉及游离胃或肠周系膜结缔组织、裸化离断特定血管等操作，超声刀的合理使用就显得尤为重要。基于在腹腔镜胃肠手术中使用超声刀过程中积累的有限体会与经验，本文总结了超声刀使用的“几种刀法”，以期对初学者合理使用有所帮助。     

A new technique for pancreaticogastrostomy for the soft pancreas: the transfixing suture method

Background/Purpose Pancreatic anastomotic leakage remains a persistent problem after pancreaticoduodenectomy (PD). The presence of soft, nonfibrotic pancreatic tissue is one of the most important risk factors for pancreatic leakage. Accordingly, we devised a pancreas-transfixing suture method for pancreaticogastrostomies in patients with a soft, nonfibrotic pancreatic remnant. Methods The pancreas-transfixing method was applied in 103 consecutive patients after either standard PD (49 patients) or pylorus-preserving pancreaticoduodenectomy (PPPD) (54 patients) for malignant or benign disease. Of these 103 patients, 65 had a soft, nonfibrotic pancreatic remnant. For the pancreaticogastrostomy technique, an ultrasonically activated scalpel was used for transecting the pancreas. The inner layer involves a duct-to-mucosa anastomosis with an internal stent and the outer layer involves a single row of pancreas-transfixing sutures between the pancreatic remnant and the posterior gastric wall. Results Operative mortality was zero and morbidity was 22%. Only two patients (2%) developed pancreatic leaks; both resolved nonoperatively with the continuation of closed drainage. Conclusions This technique is simple and appears to reduce the risk of pancreatic leakage, possibly by decreasing the risk of suture injury of the pancreas and by embedding the transected stump into the wall of the stomach. This novel pancreaticogastrostomy technique is an effective reconstructive procedure, especially for patients with a soft, nonfibrotic pancreas.     

Hemostasis with the ultrasonically activated scalpel

In patients with implanted pacemaker/cardioverter defibrillator (ICD), the use of electrocautery can lead to serious pacemaker dysfunction. The ultrasonically activated scalpel, however, which has been introduced mainly for the use in laparoscopic surgery, could potentially avoid the outlined problem, since no electrical current flows while in use. This hypothesis was tested in a pacemaker patient undergoing laparoscopic cholecystectomy. During the procedure, no abnormal rhythms or ECG interferences were detected while working in close vicinity to the device. Thus, the ultrasonically activated scalpel provides adequate hemostasis and does not bear the risk of pacemaker dysfunction. Received: 12 January 1999/Accepted: 20 January 1999     

Piezosurgery for osteotomies in orbital surgery: Our experience and review of the literature

INTRODUCTIONPiezoelectric bone surgery, simply known as Piezosurgery^®, is a new promising technique for bone cutting based on ultrasonic microvibrations that allows to perform precise and thin osteotomies with soft tissue sparing.PRESENTATION OF CASEA 45-years-old woman presenting with progressive left ocular pain, diplopia on the lateral left gaze, and visible exophthalmos was admitted to our department. CT scan and MRI images documented a left supero-lateral orbital lesion. A left lateral orbitotomy using the piezoelectric scalpel was performed. The tumour (lacrimal gland lymphoma) was completely removed with no injuries to the orbital structures and with a perfect realignment of the bone stumps.DISCUSSIONHigh powered pneumatic osteotome are commonly used to perform craniotomies. Large bone cutting groove and high temperatures developing at the contact site could produce an uneasy bone healing. The use of a piezoelectric scalpel allows to realize precise and thin osteotomies, facilitating craniotomy's borders ossification and avoiding injuries to non-osseous structures.CONCLUSIONWidely used in Oral and Maxillofacial Surgery, Piezosurgery^® can also be useful in neurosurgical approaches in order to obtain a faster bone flap re-ossification, a better aesthetic result, and a lower risks of dural layer and soft tissue damage.     

Usefulness of ultrasonically activated scalpel for pulmonary resection in video-assisted thoracoscopic surgery

We evaluated the reliability and efficacy of the ultrasonically activated scalpel (Harmonic Scalpel) for pulmonary resection in video-assisted thoracoscopic surgery (VATS). Fifty-six cases of primary or metastatic lung cancer with history of lobectomy or segmentectomy from July 2003 to June 2006 were investigated. The ultrasonically activated scalpel was used to separate aborted lobulation and segment in the surgery. The outcome of the operation using the ultrasonically activated scalpel revealed the mean operation time of 224.5 minutes and mean blood loss volume of 116.7 ml. The chest drainage catheter was removed at the postoperative day 3.4 and hospitalization lasted 10.4 days on average. By means of statistical analysis, no significant differences were noted when compared with the cases using surgical stapler to separate the lobules or segments of the lungs. Histopathological results showed destruction of alveolar structures and denaturation of cells at the cut surface of the resected lung through the use of the ultrasonically activated scalpel. This method resulted in good lung expansion and preservation of the residual lung volume. Furthermore, it prevented postoperative air leakage by appropriate treatment to the cut surfaces of the residual lung. Indeed, the method appears to be useful in the separation of lung tissues in severe aborted lobulation and segmentectomy by VATS.     

BBT—UT-3300型超声刀在肝胆手术中的应用

目的探讨超声刀在复杂肝胆手术中的临床应用效果。方法对2008年7月至2009年8月60例行肝切除术、胆道探查术、脾切除联合贲门周围血管离断术病人,随机分为超声刀组和对照组,各30例,超声刀组运用超声刀行分离止血及脏器切除,对照组运用常规方法施行手术。两组均观察术中出血量、手术输血量、并发症发生率等。结果超声刀组与对照组相比,术中出血量显著减少[（107±115）ml与（354±3.76）ml,P〈0．05];手术输血量显著减少[{102±123）ml与（356±131）ml,P〈0．01];手术时间显著缩短[（170±36）min与（221±54）min,P〈0．05];并发症发生率低（16．7％与26．7％,P〈0．05）。结论运用超声刀行复杂肝胆手术可有效提高手术安全性,降低手术风险。     

腹腔镜联合纵隔镜在食管癌根治术中的应用

目的:探讨腹腔镜联合纵隔镜在食管癌根治术中的应用价值。方法:运用超声刀和L igaSure行腹腔镜下游离胃术、腹腔镜联合纵隔镜经后纵隔食管癌切除、胃食管左颈吻合8例,其中食管中段癌3例、食管下段癌5例,TNM分期为T1~3N0~1M0。结果:全组无手术死亡,无中转开胸或开腹手术,术中无输血,手术时间180~220m in,平均200m in,术中出血量50~150m l,平均l00m l,纵隔淋巴结清扫0~8枚,平均3.2枚,腹部淋巴结清扫0~6枚,平均1.4枚,术后胃肠功能恢复时间3~4d,平均3.7d,术后住院时间10~19d,平均12d。结论:对于中下段无外侵(≤T3)的食管癌患者在腹腔镜联合纵隔镜下行食管癌根治术可以提高手术的安全性,缩短手术时间,减少术中出血,减轻手术创伤,具有良好的推广应用价值。     

USE OF THE HARMONIC SCALPEL FOR NEPHRON SPARING SURGERY IN RENAL CELL CARCINOMA

Purpose

The harmonic scalpel is a new tool for excising and coagulating tissue with ultrasound using higher frequencies than an ultrasonic aspirator. We evaluated the usefulness of the harmonic scalpel in nephron sparing surgery.

Materials and Methods

We used the harmonic scalpel to incise the renal parenchyma during nephron sparing surgery in 10 patients with renal cell carcinoma.

Results

Bleeding from the renal parenchyma was minimal but hemostasis of the larger vessels was not obtained even when the harmonic scalpel was used at maximal coagulation power. The cut surface of the kidneys, especially the vessels, were more clearly recognized than if an utrasonic aspirator had been used, enabling hemostasis by figure-of-8 suture.

Conclusions

The harmonic scalpel is useful for obtaining a clear parenchymal stump and hemostasis during nephron sparing surgery, although complete hemostasis of the arcuate or larger vessels cannot be achieved.     

Use of an ultrasonic osteotome device in spine surgery: experience from the first 128 patients

Introduction

The ultrasonic BoneScalpel is a tissue-specific device that allows the surgeon to make precise osteotomies while protecting collateral or adjacent soft tissue structures. The device is comprised of a blunt ultrasonic blade that oscillates at over 22,500 cycles/s with an imperceptible microscopic amplitude. The recurring impacts pulverize the noncompliant crystalline structure resulting in a precise cut. The more compliant adjacent soft tissue is not affected by the ultrasonic oscillation. The purpose of this study is to report the experience and safety of using this ultrasonic osteotome device in a variety of spine surgeries.

Methods

Data were retrospectively collected from medical charts and surgical reports for each surgery in which the ultrasonic scalpel was used to perform any type of osteotomy (facetectomy, laminotomy, laminectomy, en bloc resection, Smith Petersen osteotomy, pedicle subtraction osteotomy, etc.). The majority of patients had spinal stenosis, degenerative or adolescent scoliosis, pseudoarthrosis, adjacent segment degeneration, and spondylolisthesis et al. Intra-operative complications were also recorded.

Results

A total of 128 consecutive patients (73 female, 55 male) beginning with our first case experience were included in this study. The mean age of the patients was 58 years (range 12–85 years). Eighty patients (62.5 %) had previous spine surgery and/or spinal deformity. The ultrasonic scalpel was used at all levels of the spine and the average levels operated on each patient were 5. The mean operation time (skin to skin) was 4.3 h and the mean blood loss was 425.4 ml. In all cases, the ultrasonic scalpel was used to create the needed osteotomies to facilitate the surgical procedure without any percussion on the spinal column or injury to the underlying nerves. There was a noticeable absence of bleeding from the cut end of the bone consistent with the ultrasonic application. There were 11 instances of dural injuries (8.6 %) and two of which were directly associated with the use of ultrasonic device. In no procedure was the use of the ultrasonic scalpel abandoned for use of another instrument due to difficulty in using the device or failure to achieve the desired osteotomy.

Conclusions

Overall, the ultrasonic scalpel was safe and performed as desired when used as a bone cutting device to facilitate osteotomies in a variety of spine surgeries. However, caution should be taken to avoid potential thermal injury and dural tear. If used properly, this device may decrease the risk of soft tissue injury associated with the use of high speed burrs and oscillating saws during spine surgery.     

超声刀在不同类型肝切除术中的应用选择

目的比较开放手术中超声刀法和钳夹法离断肝实质以及开放手术对比腹腔镜手术中应用超声刀离断肝实质对于控制出血的效果。方法收集2019年1月至2019年6月在复旦大学附属华山医院普外科同一手术小组因肝脏肿瘤接受肝脏切除手术的263例病人的临床病理资料。观察开放手术中超声刀法和钳夹法离断肝实质的两组病人,以及开放手术和腹腔镜手术中应用超声刀离断肝实质的两组病人,比较其手术时间、术中出血量、肝门阻断时间、术后肝功能恢复和并发症的发生情况。结果组间比较,病人基本的临床病理资料差异均无统计学意义;其手术时间、肝门阻断时间、术后肝功能恢复以及术后并发症发生率方面差异也无统计学意义。开放超声刀组术中出血量明显多于腹腔镜超声刀组[(285±76)ml比(207±53)ml,P=0.02]。虽然总体比较开放超声刀组和开放钳夹法组两组之间的术中出血量没有明显差别[(285±76)ml比(251±58)ml,P=0.27],但是分层分析显示在肝硬化较重的S2~S4级病人中,开放超声刀组的术中出血量明显多于开放钳夹法组[(323±82)ml比(263±63)ml,P=0.03];在脂肪肝病人中,开放超声刀组的术中出血量也明显多于开放钳夹法组[(309±81)ml比(259±71)ml,P=0.04]。结论超声刀在腹腔镜下使用较开放手术更能体现其优势,开放手术中肝硬化和脂肪肝较重的病人不推荐使用超声刀。     

国产超声刀在普外科开放手术中的临床应用：附视频

目的探讨国产超声刀在普外科开放手术应用中的有效性及安全性。方法将2008年9月至2010年2月60例行开放手术的患者,随机分为试验组和对照组,各30例。试验组运用国产BBT超声手术系统,对照组运用美国强生超声刀,观察并比较两组患者组织切割时间、血管凝同时间、术中出血量、术后住院天数、术后腹腔引流管引流量等指标。结果试验组和对照组之间术中出血量无明显差异[（89．50±27．65）mlvs5（95．23±22．95）ml,P=-0．298],而且术后住院时间【（17.3±8．8）dvs（16．1±9．9）d,P=0．6041及术后腹腔引流[（180．6±61．0）ml口s（174．9±44．4）ml,P=0．674]在两组之间差异均无统计学意义;但与对照组相比,试验组的组织切割平均时间[（6．95±1．41）s vs（4．32±1．11）s,P〈O．05]和血管凝同时间[（6．00±0.314）s vs（2．68±0．123）s,P〈0．001]要长。结论国产BBT超声手术系统安全有效,符合临床使用的要求,可以在临床推广运用。     

The plasma scalpel: A new thermal knife

A new thermal knife, the plasma scalpel, capable of simultaneous division of tissue and coagulation of blood vessels, is described. A high temperature argon gas plasma (unrelated to blood plasma) is created by passing the gas through a direct current arc, ionizing the gas and elevating its temperature to 3000°C. A small plasma cutting jet is formed by a nozzle at the tip of the handpiece. Liver resections and muscle transections performed in a canine model, and full thickness burn excisions in a pig skin model showed effective division of tissue and significantly less blood loss when compared to the steel scalpel. Wound healing studies of histologic comparisons and wound breaking strength were performed for steel, plasma, laser, and electrosurgical scalpel incisions in the skin of mice and rats. All thermal knife wounds showed localized tissue damage at the edges of the incision, but the events of healing began at the same time. Compared to the steel scalpel, there was a three to six day delay in the onset of healing, but healing occurred in the normal fashion and all thermal knife wounds reached the same healed breaking strength as the steel scalpel wounds. Clinically, the plasma scalpel has been used for 138 procedures in 96 patients. The majority of cases have been transection of muscle, hepatic resection or debridement, or soft tissue debridement. Muscle transection data for the plasma scalpel compared to the electrosurgical scalpel has shown virtually no blood loss with a shorter time to hemostasis for the plasma scalpel. The plasma scalpel has proved to be an effective thermal knife, capable of simultaneous division and coagulation. Further development work and proof of its efficacy in the clinical setting are necessary to establish the plasma scalpel and adequately demonstrate its proper role in surgery.     

Pancreatic transection using a sharp hook-shaped ultrasonically activated scalpel

Background and aims  The operative mortality and morbidity associated with pancreatic surgery has been decreasing; however, pancreatic fistula remains a major cause of a potentially fatal complication. Although different devices and techniques have been proposed to reduce of the postoperative pancreatic fistula, none has gained unanimous acceptance. We herein describe a new technique for pancreatic transection using a sharp hook-shaped ultrasonically activated scalpel (UAS). Materials and methods  Between December 2004 and June 2006, 32 patients who had undergone pancreatectomies performed using the sharp hook-shaped UAS (Ethicon Endo-Surgery, Cincinnati, OH, USA) were studied. Results  The incidence of pancreatic fistula in these patients was 6.3% (2/32). Both cases underwent a distal pancreatectomy. No patient had systemic organ failure induced by postoperative pancreatic fistula, and conservative drainage management improved the pancreatic fistula. No pancreatic fistulas developed in patients who underwent pancreaticoduodenectomy with a duct-to-mucosa anastomosis pancreaticojejunostomy after pancreatic transection using the sharp hook-shaped UAS. Conclusion  Pancreatic transection using the sharp hook-shaped UAS is an easy and useful method that facilitates detection of the main pancreatic duct with minimal blood loss. It may contribute to lower morbidity and mortality after pancreatic resection.     

腹腔镜胆囊切除术中超声刀直接处理胆囊动脉(附800例报告)

目的探讨超声刀直接处理胆囊动脉的临床价值. 方法回顾分析1999年7月至2002年12月采用超声刀直接凝固切断胆囊动脉的腹腔镜胆囊切除术800例临床资料. 结果所有病例均顺利完成手术,无一例术中或术后胆囊动脉残端出血;病理切片镜下见超声刀的热作用足以使胆囊动脉壁组织发生变性,管腔闭塞. 结论腹腔镜胆囊切除术中超声刀直接处理胆囊动脉安全可靠.     

心脏起搏器植入患者腹腔镜手术超声刀临床应用的研究

目的 :研究安装心脏起搏器患者腹腔镜手术及应用超声刀前后血液动力学变化 ,并探讨应用腹腔镜手术及超声刀的可行性及安全性。方法 :选择心脏起搏器植入患者 12例 ,腹腔镜手术过程中使用超声刀进行组织分离、切割、止血和管道闭合。分别于手术前 30min、麻醉后 10min(气腹前 )、气腹后 15min、超声刀应用后 5min及手术后 30min监测血液动力学指标 (心率、动脉收缩压、平均动脉压、脉搏血氧饱和度 )并进行比较。结果 :腹腔镜手术中安装心脏起搏器患者麻醉后 10min、气腹后 15min、超声刀应用后 5min及手术后30min指标与手术前 30min相比 (1)心率、平均动脉压均增快及升高 ;(2 )动脉收缩压、脉搏血氧饱和度相比均有下降 ;(3)患者心率、动脉收缩压、平均动脉压、脉搏血氧饱和度于气腹后 15min与手术前 30min比较差异有显著性 (P <0 0 5 ) ;(4 )患者心率、动脉收缩压、平均动脉压、脉搏血氧饱和度于麻醉后 10min、超声刀应用后 5min及手术后 30min指标与手术前 30min比较差异无显著性 (P >0 0 5 )。结论 :安装心脏起搏器患者腹腔镜手术及超声刀使用过程中可出现血液动力学变化 ,与无心脏疾病患者腹腔镜手术一致 ,表明腹腔镜手术中应用心脏起搏器及超声刀未引起血液动力学的特殊改变 ,其变化与麻醉、二氧化     

Clipless cholecystectomy: broadening the role of the harmonic scalpel.

BACKGROUND: The ultrasonically activated (Harmonic) scalpel has proven to be an effective, efficient, and safe instrument for dissection and hemostasis in both open and laparoscopic surgical procedures. To date, the primary use of the Harmonic scalpel in laparoscopic cholecystectomies has been for the division of the cystic artery and liver bed dissection. Advancements in the Harmonic scalpel blade tip now provide for the reliable ultrasonic division and closure of the cystic duct. METHODS: In a personal, prospective series involving 100 consecutive patients undergoing laparoscopic cholecystectomies, the Harmonic scalpel was used as the sole instrument for division of the cystic duct and artery as well as dissection of the liver bed. Two patients with large cystic ducts (over 5 mm) received an additional ductal ligature. RESULTS: No patients developed postoperative hemorrhage or bile leakage. CONCLUSION: The Harmonic scalpel provides complete hemobiliary stasis for most patients and is a safe alternative to standard clip or ligature closure of the cystic duct. Furthermore, there may be a cost savings inherent in a procedure utilizing a single disposable instrument.     

Cutting lung parenchyma using the harmonic scalpel—an animal experiment

Objective: Applicability of harmonic scalpel in lung surgery was investigated using an animal model. Methods: Air tightness, control of bleeding and features of tissue regeneration were compared in a 4-week time frame of investigation in animals in which either surgical stapler or harmonic scalpel were used for pulmonary resection. Results: No significant differences between the two methods were found on a clinical and histopathological basis. Conclusions: Complete lack of granuloma formation at the resection line and in its vicinity consequently restitutio ad integrum demonstrate the advantage of the harmonic scalpel over the stapler in the circumstances investigated. Overall the vibration transmission method was shown not to be inferior to the standard methods in peripherial lung tissue resection.