Search

The use of energy-based tissue-sealing and cutting instruments is becoming more and more popular in visceral, urological, and gynecological surgery. For their safe and efficacious use in clinical practice, such instruments have to reliably seal vessels with a minimal sealing failure rate, cause minimal thermal damage to adjacent tissue, and have good cutting qualities.The efficacy and safety of the novel energy-based instrument for dissection, hemostasis and cutting (BiCision(®), ERBE) was compared to a commercially available device (EnSeal(®), Ethicon Endo-Surgery). We investigated vessel-sealing reliability (success rate), sealing quality and sealing time, lateral thermal damage cutting quality, tissue sticking to the instrument, burst pressure and delayed complications in an acute and chronic pig model after splenectomy, small bowel resection, nephrectomy, salpingo-oophorectomy, and sealing of peripheral vessels.For all parameters investigated, BiCision(®) was at least equivalent to EnSeal(®). BiCision(®) was even superior to EnSeal(®) with respect to the burst pressure in arteries (p = 0.044) and veins (p = 0.023) and the cut quality in all locations (arteries, p = 0.0009; veins, p = 0.043). The course of the 7-day chronic study was uneventful except for one animal that developed an intestinal obstruction. None of the animals showed any signs of postoperative bleeding. On second-look laparotomy at day 7, macroscopic inspection of the sealed tissue and vessels did not show any signs of complications or evidence that bleeding had occurred. Histologically, the integrity of vessel wall fusion, thermal alterations, and inflammatory reactions were comparable, confirming substantial equivalence.We demonstrated that the efficacy and quality of vessel sealing with BiCision(®) is at least equivalent to those of EnSeal(®) for vessel diameters up to 7 mm. Since EnSeal(®) has already been shown to be safe in clinical practice, BiCision(®) should be as reliable as EnSeal(®) under clinical conditions.

The aim of this study was to evaluate the feasibility of a totally stapled gastrojejunal anastomosis performed using one transabdominal 12-mm trocar and a gastroscope in a porcine model. The procedure was carried out on six domestic pigs weighing 45 kg using a hybrid technique with a gastroscope and a 12-mm Hasson trocar, positioned in the left hypochondrium. At the end of the procedure a mechanical circular 21-mm gastrojejunal anastomosis was performed by inserting the stapler through a small gastrotomy after enlarging the trocar incision. In all six cases the procedure was completed through a single 3 cm abdominal incision and without complications. The mean operating time was 2 h, and endoscopic investigation showed that the anastomoses were intact, patent, and airtight. Totally stapled gastrojejunal anastomosis using a hybrid NOTES—single 12-mm trocar approach is a feasible procedure in the porcine model. Further survival studies are warranted, particularly to evaluate the functional results of this procedure.

The use of staplers in gastrointestinal surgery is widespread, especially in advanced laparoscopic procedures. Staple line reinforcement with a buttress reduces bleeding and associated complications through a combination of factors. The intrinsic hemostatic properties of buttress materials have not been examined. This study examined the intrinsic hemostatic properties of two different types of material used in buttressing in an accepted hemostasis model that does not involve stapling or its effects by compression.An acellular collagen buttress (Veritas) and a synthetic polymer buttress (Duet) were compared to two commonly used hemostatic agents, Syvek and Surgicel, with gauze as control.In a swine capsular stripping hemostasis model, a 1 × 1 cm section of spleen capsule was removed and used as a source of bleeding, with one patch of material tested per bleeding site. A total of 51 wounds were created in five pigs (each patch n = 10, control n = 11). Hemostatic efficacy was assessed by quantitating the number of applications and total time needed for bleeding to stop.The mean time needed for hemostasis for Syvek and Veritas patches was significantly less than gauze, Duet and Surgicel (4.02, 4.51 vs. 8.97, 9.22, and 10.30 min respectively; p0.05). The Syvek and Veritas patches required significantly fewer applications than gauze, Duet™ and Surgicel (1.7, 2.2 vs. 4.1, 4.6, and 4.9 respectively; p0.01).The intrinsic hemostatic properties of different buttressing materials vary widely. In this study, a collagen buttress was significantly better at promoting hemostasis than the synthetic buttress material in a nonstapling model. This could be another factor to consider when choosing a buttress for staple line reinforcement.

Distorted haptic feedback by the surgical instrumentation is a major problem in minimally invasive surgery (MIS). Friction force generated by the rubber seal in the trocars masks the haptic information needed to perceive the properties and structure of the target tissue, resulting in an increased haptic perception threshold in naive subjects. This can lead to over application of forces in surgery. This paper examines the effect of surgical experience on the psychophysics of force perception and force application efficiency in MIS. A controlled experiment was conducted using a mixed design, with friction and vision as independent within-subjects factors, experience as a between-subjects factor, and applied force and detection time as dependent measures. Fourteen subjects (eight novices and six experienced surgeons) performed a simulated tissue probing task. Performance data were recorded by a custom-built force-sensing system. When friction was present, higher thresholds and longer detection times were observed for both experienced and inexperienced subjects. In all cases, experienced surgeons applied a greater force than novices, but were quicker to detect contact with tissue, resulting in higher force application efficiency. Surgeons seem to have adapted to the higher threshold in haptic perception by reacting faster, even while applying more force to the tissue, keeping within the limits of safety.

Recently, the laparosonic coagulating shears (LCS) have been used widely in laparoscopic surgery. In the current study, the usefulness of LCS for arterial division and hemostasis was examined in porcine arteries.Porcine arteries of several diameters (1, 3, and 5 mm) were removed and divided using LCS with different blade modes: shear, blunt, and flat. The division time and bursting pressure were registered. Additionally, divided sections stained by the Azan-Mallory method were observed microscopically.The division time was dependent on the blade modes used. With the flat mode, the bursting pressure of 5-mm arteries was significantly higher than the bursting pressure with shear and blunt modes. Histologically, cavitation and mild degeneration of the vessel walls occurred adjacent to the cutting edge.The LCS is a safe and useful device for arterial division and hemostasis for 5-mm arteries if an adequate blade mode is used.

Surgical resection is the gold standard for treatment of early-stage lung tumors. Different minimally invasive approaches are currently under investigation: In addition to conventional video-assisted thoracoscopic surgery (VATS), robotic technology with the da Vinci System has emerged over the past 10 years.In this series, 26 patients (12 women and 14 men; median age, 65 years) underwent a robotic lobectomy for early-stage lung tumors (clinical stage IA or IB) or centrally located metastases.The resected lobes included four left upper lobes, six left lower lobes, eight right upper lobes, and eight right lower lobes. Five intraoperative conversions to open thoracotomy were performed due to one major bleeding, two minor bleedings, one variant course of the pulmonary artery, and one extended resection. The postoperative complications included two prolonged air leaks, one colonic perforation, and one atrial fibrillation. The median hospital stay was 11 days (range, 7-53 days). One 30-day mortality (3.8%) occurred due to respiratory failure. The overall median operative time was 228 min (range, 162-375 min). For the first five patients, the posterior approach was used. Thereafter, the authors switched to an anterior approach, thus enabling an easier hilar dissection. Technical modification within this series also included the introduction of a new vessel sealing device.Robotic lobectomy was proved to be feasible and safe in our initial series in a learning curve setting. Changes in patient positioning and approach as well as technical modifications resulted in shorter operative times. A longer follow-up period and randomized controlled trials are necessary to evaluate a potential benefit over open and conventional VATS approaches.

Robotic technology has been postulated to improve performance in advanced surgical skills. We utilized a novel computerized assessment system to objectively describe the technical enhancement in task performance comparing robotic and laparoscopic instrumentation. Advanced laparoscopic surgeons (2–10 yrs experience) performed three unique task modules using laparoscopic and Telerobotic surgical instrumentation (Intuitive Surgical, Sunnyvale, CA). Performance was evaluated using a computerized assessment system (ProMIS, Dublin, Ireland) and results were recorded as time (s), path (mm) and precision. Each surgeon had an initial training session followed by two testing sessions for each module. A paired Student’s t-test was used to analyze the data. Ten surgeons completed the study. 8/10 surgeons had significant technical enhancement utilizing robotic technology. The ProMIS computerized assessment system can be modified to objectively obtain task performance data with robotic instrumentation. All the tasks were performed faster and with more precision using the robotic technology than standard laparoscopy.

Intestinal anastomotic healing requires apposition of the collagen containing submucosal layers of the opposing intestinal walls, which is traditionally achieved by staples or sutures. Recently, a feedback-controlled bipolar sealing system (LigaSure) has been successfully introduced to seal and transect vessels. Since this technology depends on fusion of collagen fibres which are abundantly present in the intestinal wall, the possibility to create intestinal anastomoses using this technology was investigated in the present study.For this purpose a new-generation radiofrequency (RF) generator and a prototype of the Ligasure Anastomotic Device (LAD) have been developed. The generator incorporates a closed loop control system which monitors tissue fusion, compares it with a mathematical model of ideal fusion based on the density and compliance of intestinal tissue and adjusts energy output accordingly. In total 8 anastomoses were created in a porcine model (4 pigs, 2 anastomoses each) and healing was assessed by macroscopic and histological examination.All seals were macroscopic intact both immediate after creation and at sacrifice at the 7th postoperative day. Between operations, pigs appeared healthy and had normal intestinal passage. Histological examination of the anastomoses revealed undisturbed healing with granulation tissue, newly synthesised collagen in the submucosa and re-epithelialization at the borders of the seals.These results confirm the feasibility to create experimental intestinal anastomoses using LigaSure technology. This may be an important step towards the development of new laparoscopic equipment combining dissecting and reconstructive properties within one single instrument.