Management of Retrobulbar Hematoma

Retrobulbar hemorrhage is regarded as one of the most feared conditions in otolaryngology -- its onset can be rapid and can result in irreversible blindness. While a rare occurrence, the otolaryngologist should be compulsive about recognizing this entity, as he or she may be faced with managing this condition either as a consultant, or as one of his or her personal surgical complications. Regardless, prompt recognition and swift action can prevent catastrophic visual loss. This article presents a stepwise discussion of the surgical management of retrobulbar hematoma.

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Laryngeal trauma with and without tracheal separation

External laryngotracheal trauma is a rare occurrence and requires specialized evaluation and management. Airway compromise from laryngotracheal injury can be catastrophic. The stability of an airway must be ensured with rapid and repeated clinical evaluation. Additionally, bedside and operative endoscopy combined with radiographic studies should guide treatment planning. Repair may include open reduction and internal fixation of laryngeal fractures, endolaryngeal mucosal repair (via either endoscopic or open approaches), endoluminal stenting or open repair of laryngotracheal separation.

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Introduction

Dear Readers,

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Coalescent Mastoiditis

Coalescent mastoiditis occurs as bone is remodeled and resorbed from pressure necrosis, inflammation, and increased osteoclastic activity in the setting of an acute otologic infection. This finding necessitates treatment with antibiotics and surgery, which typically involves pressure equalizing tube placement and mastoidectomy. Herein, we review diagnostic and treatment considerations as well as surgical technique in the management of acute coalescent mastoiditis.

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Comparison of Sensory Changes Following Superomedial and Inferior Pedicle Breast Reduction

Abstract

Background

More attention is focused on sensory outcomes following breast reduction operations. We conducted this prospective, non-randomized study to compare two commonly used breast reduction techniques, superomedial pedicle and inferior pedicle, regarding sensation of the nipple-areolar complex.

Methods

We prospectively assigned 60 patients with macromastia into the superomedial pedicle group (SMP group, n = 30) or the inferior pedicle (IP group, n = 30) group. Six patients who withdrew from the study and another six patients who did not attend return visits were excluded. Algometry was used to measure the sensation of breast skin, cardinal points of the areola and the nipple. Two-point discrimination was also measured on the areola. Measurements were performed before surgery, at 3 weeks, and 6 months postoperatively.

Results

There were 20 patients in the SMP group and 28 patients in the IP group. The mean ages of the patients were 43.2 ± 12.7 and 45.9 ± 10.8 years, respectively (p = 0.438). The mean BMI of the patients were 32.4 ± 6.7 and 30.4 ± 5.3 kg/m², respectively (p = 0.257). The mean weights of resected tissues were 802.5 (280–2180) versus 773.7 (349.5–1425.0) g, respectively (p = 0.900). Although breast sensation did not change in the SMP group, sensation in the upper medial and lower lateral portions of breast skin was reduced in the IP group. Two-point discrimination test results did not change in either group. The amount of changes in algometry and two-point discrimination tests were similar in both groups.

Conclusion

Both superomedial and inferior pedicle breast reduction techniques are safe and reliable in terms of sensory changes.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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Evaluation of A Well-Known Technique with Ultrasound: Dorsal Grafting in Rhinoplasty

Abstract

Objective

We aimed to evaluate the survival of a well-known camouflage technique using ultrasound imaging of the graft through the nasal dorsum and supratip.

Material and Method

Twenty-two patients (8 women and 14 men) who underwent primary rhinoplasty performed by the same surgeon in Isparta, Turkey, between December 2013 and February 2015, were evaluated in this retrospective study. We used the remaining pieces of harvested septal cartilage during rhinoplasty as autologous graft material and venous blood mixture as a scaffold in a Turkish Delight fashion. We used a 10- to 14-MHz broadband linear ultrasound probe (Toshiba Aplio MX ultrasound system, Toshiba Medical Systems, Tustin, California). The mean total skin thickness values through bone (nasal dorsum) and cartilage (upper lateral cartilage) were calculated for each patient. Data were recorded for statistical analysis. We evaluated the patients pre- and postoperatively on the seventh day, first month, sixth month, and just before the end of the first year using ultrasonography. We made detailed ultrasonographic images of the skin and the underskin through the bone sculpture and compared the measurements. All patients were scanned at the same time of day to exclude diurnal variation of dermal edema. Patients who presented for primary functional rhinoplasty were included in the study.

Results

Nasal dorsum cartilage was significantly thicker on the seventh postoperative day, but the difference was not statistically significant in the sixth month after surgery compared with baseline values. There was no statistically significant difference between preoperative measures and measures in the sixth month. The difference in supratip thickness was significantly greater on the seventh postoperative day, and there was a large difference at the first month compared with preoperative values, but this did not reach significance. There was no significant difference in supratip thickness between pre- and postoperative values at the sixth month.

Conclusion

This method can be easily performed to reduce visual and tactual irregularities on the dorsum of the nose and can promote perfection on the dorsal esthetic line, but it is not sufficient for augmentation.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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Optimal Positioning of the Nipple–Areola Complex in Men Using the Mohrenheim-Estimated-Tangential-Tracking-Line (METT-Line): An Intuitive Approach

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Comparison of Sensory Changes Following Superomedial and Inferior Pedicle Breast Reduction

Abstract

Background

More attention is focused on sensory outcomes following breast reduction operations. We conducted this prospective, non-randomized study to compare two commonly used breast reduction techniques, superomedial pedicle and inferior pedicle, regarding sensation of the nipple-areolar complex.

Methods

We prospectively assigned 60 patients with macromastia into the superomedial pedicle group (SMP group, n = 30) or the inferior pedicle (IP group, n = 30) group. Six patients who withdrew from the study and another six patients who did not attend return visits were excluded. Algometry was used to measure the sensation of breast skin, cardinal points of the areola and the nipple. Two-point discrimination was also measured on the areola. Measurements were performed before surgery, at 3 weeks, and 6 months postoperatively.

Results

There were 20 patients in the SMP group and 28 patients in the IP group. The mean ages of the patients were 43.2 ± 12.7 and 45.9 ± 10.8 years, respectively (p = 0.438). The mean BMI of the patients were 32.4 ± 6.7 and 30.4 ± 5.3 kg/m², respectively (p = 0.257). The mean weights of resected tissues were 802.5 (280–2180) versus 773.7 (349.5–1425.0) g, respectively (p = 0.900). Although breast sensation did not change in the SMP group, sensation in the upper medial and lower lateral portions of breast skin was reduced in the IP group. Two-point discrimination test results did not change in either group. The amount of changes in algometry and two-point discrimination tests were similar in both groups.

Conclusion

Both superomedial and inferior pedicle breast reduction techniques are safe and reliable in terms of sensory changes.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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Evaluation of A Well-Known Technique with Ultrasound: Dorsal Grafting in Rhinoplasty

Abstract

Objective

We aimed to evaluate the survival of a well-known camouflage technique using ultrasound imaging of the graft through the nasal dorsum and supratip.

Material and Method

Twenty-two patients (8 women and 14 men) who underwent primary rhinoplasty performed by the same surgeon in Isparta, Turkey, between December 2013 and February 2015, were evaluated in this retrospective study. We used the remaining pieces of harvested septal cartilage during rhinoplasty as autologous graft material and venous blood mixture as a scaffold in a Turkish Delight fashion. We used a 10- to 14-MHz broadband linear ultrasound probe (Toshiba Aplio MX ultrasound system, Toshiba Medical Systems, Tustin, California). The mean total skin thickness values through bone (nasal dorsum) and cartilage (upper lateral cartilage) were calculated for each patient. Data were recorded for statistical analysis. We evaluated the patients pre- and postoperatively on the seventh day, first month, sixth month, and just before the end of the first year using ultrasonography. We made detailed ultrasonographic images of the skin and the underskin through the bone sculpture and compared the measurements. All patients were scanned at the same time of day to exclude diurnal variation of dermal edema. Patients who presented for primary functional rhinoplasty were included in the study.

Results

Nasal dorsum cartilage was significantly thicker on the seventh postoperative day, but the difference was not statistically significant in the sixth month after surgery compared with baseline values. There was no statistically significant difference between preoperative measures and measures in the sixth month. The difference in supratip thickness was significantly greater on the seventh postoperative day, and there was a large difference at the first month compared with preoperative values, but this did not reach significance. There was no significant difference in supratip thickness between pre- and postoperative values at the sixth month.

Conclusion

This method can be easily performed to reduce visual and tactual irregularities on the dorsum of the nose and can promote perfection on the dorsal esthetic line, but it is not sufficient for augmentation.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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Optimal Positioning of the Nipple–Areola Complex in Men Using the Mohrenheim-Estimated-Tangential-Tracking-Line (METT-Line): An Intuitive Approach

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Characterization of common bile duct injury after laparoscopic cholecystectomy in a high-volume hospital system

Abstract

Background

Despite the popularity of laparoscopic cholecystectomy, rates of common bile duct injury remain higher than previously observed in open cholecystectomy. This retrospective chart review sought to determine the prevalence of, and risk factors for, biliary injury during laparoscopic cholecystectomy within a high-volume healthcare system.

Methods

800 of approximately 3000 cases between 2009 and 2015 were randomly selected and retrospectively reviewed. A single reviewer examined all operative notes, thereby including all cases of BDI regardless of ICD code or need for a second procedure. Biliary injuries were classified per Strasberg et al. (J Am Coll Surg 180:101–125, 1995). Logistic regression models were utilized to identify univariable and multivariable predictors of biliary injuries.

Results

31.0% of charts stated that the Critical View of Safety was obtained, and 12.4% of charts correctly described the critical view in detail. Three patients (0.4%) had a cystic duct leak, and 4 (0.5%) had a common bile duct injury. Of the four CBDI, three patients had a partial transection of the CBD and one had a partial stricture. Patients who suffered BDI were more likely to have had lower hemoglobin, urgent surgery, choledocholithiasis, or acutely inflamed gallbladder. Multivariable analysis of BDI risk factors showed higher preoperative hemoglobin to be independently protective against CBDI. Acutely inflamed gallbladder and choledocholithiasis were independently predictive of CBDI.

Conclusions

The rate of CBDI in this study was 0.5%. Acutely inflamed conditions were risk factors for biliary injury. Multivariable analysis suggests a protective effect of higher preoperative hemoglobin. There was no correlation of CVS with prevention of biliary injury, although only 12.4% of charts could be verified as following the technique correctly. Better implementation of CVS, and increased caution in patients with perioperative inflammatory signs, may be important for preventing bile duct injury. Additionally, counseling patients with acute inflammation on increased risk is important.

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Comparison of 8 and 5 mm robotic instruments in small cavities

Abstract

Introduction

Robotic surgery has seen increasing use in the field of pediatric surgery. Our clinical experience suggested instrument size can impact on the surgical ability. This study aimed to compare the performance of robot-assisted laparoscopic skills in confined spaces using either 5 or 8 mm instruments.

Methods

A preclinical randomized crossover study design was implemented. 24 assessors performed three different reproducible drill procedures (M1: peg transfer, M2: circle cutting, M3: intracorporeal suturing). To assess surgical proficiency in confined working spaces, these exercises were performed with 5 and 8 mm instruments of the da Vinci^® Surgical Systems Si in a cubic box with 60 mm-sized edges. Each performance was recorded and evaluated by two reviewers using both objective structured assessment of technical skills (OSATS) and global evaluative assessment of robotic skills (GEARS) scores. Parietal iatrogenic impacts and instrument collisions were specifically analyzed using a dedicated scoring system.

Results

Regardless of their experience, trainees performed significantly better when using 8 mm instruments in terms of OSATS scores (20.5 vs. 18.4; p < 0.01) and GEARS scores (23.4 vs. 21.9; p < 0.01) for most items, except for "depth perception" and "autonomy." The 8 mm performances involved significantly less parietal box damage (4.1 vs. 3.4; p < 0.01), and tool collisions (4.1 vs. 3.2; p < 0.01).

Conclusions

In light of the better performances with 8 mm tools for specific tasks and parietal sparing constraints in restricted spaces, this study indicates that 5 mm instruments can be deemed to be less effective for reconstructive procedures in small children.

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Physiologic and psychological gender differences in bariatric surgery

Abstract

Background

Bariatric surgery is a safe and effective treatment for clinically severe obesity, but inequity in male and female utilization is well recognized. Approximately 20% of patients undergoing bariatric surgery are male. This paper aims to describe differences in outcomes by gender and to understand the physiologic and psychological differences that may explain this gender gap.

Methods

We examined 61,708 patients from the Michigan Bariatric Surgery Collaborative (MBSC) undergoing primary bariatric surgery between 2006 and 2016. Clinical data regarding demographics, comorbidities, and outcomes were compared by gender. Preoperative and 1-year postoperative surveys gathered psychological outcomes.

Results

This cohort was consistent with the national population with approximately 22% male patients. There were several significant differences between males and females at the time of surgery. Males tended to be older, have a higher BMI, be married, have lower self-reported depression scores, and have more comorbidities (all p < 0.05). Postoperatively, males suffered more serious complications than women (2.67 vs. 2.12, respectively, p < 0.05). At 1 year postoperatively, males were significantly more satisfied with their operation despite increased complications, decreased weight loss, and decreased rates of comorbidity resolution as compared to females (all p < 0.05).

Conclusions

Despite significantly lower weight loss and increased complication rates, males tend to have markedly higher satisfaction and psychological well-being scores than females. To improve outcomes in males, earlier referral to surgery may help to significantly reduce their risk. Conversely, increased attention to psychological support in the perioperative period for females may lead to improved psychological outcomes (i.e., body image, depression, psychological well-being).

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Impact of visual–spatial ability on laparoscopic camera navigation training

Abstract

Background

Technical limitations of minimally invasive surgery challenge both surgeons and camera assistants. Current research indicates that visual–spatial ability (VSA) has impact on learning of laparoscopic camera navigation (LCN). However, it remains unclear if complexity of LCN tasks influences the impact of VSA. The aim of this study was to examine the influence of VSA on LCN training within tasks of different complexity levels.

Methods

The present study was conducted as a monocentric prospective trial. VSA was assessed with a cube comparison test before participants underwent LCN training. LCN training consisted of three tasks with increasing complexity. Each task was performed four times and performance was assessed each time. Correlations and multivariate regression analysis were used to assess the influence of VSA on LCN skills.

Results

Seventy-one participants were included (35 males). Significant performance improvement and faster completion times were observed from the first to fourth trial of all three LCN training tasks. Significant positive correlations between VSA and performance on LCN task 3 were found (performance: r _s = 0.47; p < 0.001, time: r _s = −0.43; p < 0.001). Multivariate regression revealed that higher VSA resulted in greater reduction of time between the first trials of LCN training task 3 (B = −1.67, p = 0.031).

Conclusion

In the present study, all trainees improved LCN performance during the training. VSA seems to have impact on LCN performance and training progress particularly for complex LCN tasks. The relation of VSA and LCN performance was stronger for less experienced participants and in the beginning of the learning phase.

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Sleeve Gastrectomy: the first 3 Years: evaluation of emergency department visits, readmissions, and reoperations for 14,080 patients in New York State

Abstract

Introduction

The purpose of our study was to evaluate the indications for and incidence of both emergency department (ED) visits and hospital readmissions within the first postoperative year. We also sought to identify the rate of reoperation within the first 3 years following a SG operation in New York State (NYS).

Methods

The SPARCS database was examined for all SGs performed between 2011 and 2013. Using a unique identifier, patients were followed for at least 1 year. Patients were followed for reoperation and/or conversion to Roux-en-Y Gastric Bypass (RYGB), as well as for any other hospital-based encounter. Using primary diagnosis codes, the top five reasons for ED visits and readmission were identified.

Results

There were 14,080 SG between 2011 and 2013. Among all patients, just over one-third of patients visited the ED (33.9%). One in every ten of these visits resulted in readmission (9.5%), with 12.5% of the total postoperative patient population undergoing readmission within their first year after SG surgery. ED visits were unrelated to surgery in just over half of the patients (n = 4977; 53.88%). However, ED visits for abdominal pain (n = 1029; 11.14%), vomiting (n = 237; 2.57%), dehydration (n = 224; 2.43%), and syncope (n = 206; 2.23%) were attributed to surgery. The top five causes for readmission within the first year after SG were unrelated to surgery (n = 1101; 41.74%), complication related to bariatric surgery (n = 211; 8%), dehydration (n = 171; 6.48%), postoperative wound complication (n = 89; 3.37%), abdominal pain (n = 78; 2.96%). Overall, there was a low reoperation rate (0.32%); specifically, rates of sleeve revision and conversion to RYBG were 0.11 and 0.21%, respectively.

Conclusion

SG has increasing popularity in NYS. Although postoperative ED visits are high, SG has a low overall reoperation rate (0.32%), and of these patients, most undergo conversion to RYGB compared to sleeve revision. Overall 1-year readmission rates after SG are 12.5%.

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Improved immediate postoperative pain following laparoscopic inguinal herniorrhaphy using self-adhering mesh

Abstract

Background

Several synthetic meshes are available to reinforce the inguinal region following laparoscopic hernia reduction. We sought to compare postoperative pain of patients who underwent laparoscopic inguinal herniorrhaphy using self-adhering polyester mesh to those who had non-adhering, synthetic mesh implanted using absorbable tacks.

Materials and methods

This study is a retrospective review of patients who underwent primary laparoscopic inguinal herniorrhaphy at the Medical College of Wisconsin between October 2012 and July 2014. Clinical information and perioperative pain scores using the visual analog scale (VAS) were obtained to evaluate immediate pre and postoperative pain.

Results

A total of 98 patients (88 male) underwent laparoscopic inguinal herniorrhaphy during the study interval. Forty-two patients received self-adhering mesh and 56 patients received mesh secured with tacks. Patient demographics and comorbidities did not differ significantly between the two groups. There was no difference in preoperative VAS scores between groups. The self-adhering mesh patients had a lower mean VAS change score (less pain). Postoperative complications did not differ between groups apart from a higher observed incidence of seroma in the self-adhering mesh group (p = 0.04). No hernias recurred in either group during the study interval.

Conclusions

Self-adhering mesh in laparoscopic inguinal herniorrhaphy resulted in less immediate postoperative pain than tacked mesh as demonstrated by VAS score. Postoperative complications were similar between the two groups. The results of this study demonstrate that laparoscopic inguinal herniorrhaphy using self-adhering mesh is comparable to tacked mesh in regards to short-term complication rates, but show a favorable advantage in regards to immediate postoperative pain.

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Patient-specific mental rehearsal with interactive visual aids: a path worth exploring?

Abstract

Background

Surgeons of today are faced with unprecedented challenges; necessitating a novel approach to pre-operative preparation which takes into account the specific tests each case poses. In this study, we examine patient-specific mental rehearsal for pre-surgical practice and assess whether this method has an additional effect when compared to generic mental rehearsal.

Methods

Sixteen medical students were trained how to perform a simulated laparoscopic cholecystectomy (SLC). After baseline assessments, they were randomised to two equal groups and asked to complete three SLCs involving different anatomical variants. Prior to each procedure, Group A practiced mental rehearsal with the use of a pre-prepared checklist and Group B mental rehearsal with the checklist combined with virtual models matching the anatomical variations of the SLCs. The performance of the two groups was compared using simulator provided metrics and competency assessment tool (CAT) scoring by two blinded assessors.

Results

The participants performed equally well when presented with a "straight-forward" anatomy [Group A vs. Group B—time sec: 445.5 vs. 496 p = 0.64—NOM: 437 vs. 413 p = 0.88—PL cm: 1317 vs. 1059 p = 0.32—per: 0.5 vs. 0 p = 0.22—NCB: 0 vs. 0 p = 0.71—DVS: 0 vs. 0 p = 0.2]; however, Group B performed significantly better [Group A vs. B Total CAT score—Short Cystic Duct (SCD): 20.5 vs. 26.31 p = 0.02 η ² = 0.32—Double cystic Artery (DA): 24.75 vs. 30.5 p = 0.03 η ² = 0.28] and committed less errors (Damage to Vital Structures—DVS, SCD: 4 vs. 0 p = 0.03 η ²=0.34, DA: 0 vs. 1 p = 0.02 η ² = 0.22). in the cases with more challenging anatomies.

Conclusion

These results suggest that patient-specific preparation with the combination of anatomical models and mental rehearsal may increase operative quality of complex procedures.

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Barriers to laparoscopic colon resection for cancer: a national analysis

Abstract

Background

Level one evidence has shown that minimally invasive surgery (MIS) for colon cancer improves short-term outcomes with equivalent long-term oncologic results when compared to open surgery. However, the adoption of MIS for patients with colon cancer has not been universal. The goal of this study is to identify barriers to the use of MIS surgery in colon cancer resection across the United States.

Methods

The National Cancer Database was queried for all cases of colonic adenocarcinoma resection from 2010 to 2012. Patients undergoing an MIS approach were compared with those undergoing open surgery (OS). MIS was defined as either robotic or laparoscopic surgery. Patients with metastatic disease, surgery for palliation, or tumors >8 cm were excluded. Multivariable modeling was used to identify variables associated with the use of open surgery.

Results

After applying exclusion criteria, 124,205 cases were identified. An MIS approach was used in only 54,621 (44%) patients. In a multivariable model adjusting for stage and tumor size, a number of important factors were associated with decreased odds of a MIS approach including black race (OR .91; p < .0001), lack of insurance (OR .51; p < .0001), lower education (OR .88; p < .0001), lower income (OR .83; p < .0001), treatment at a community program (OR .86; p < .0001), and treatment at a low-volume center (OR .79; p < .0001). Utilization of MIS increased over the study period (2010: 38.7%, 2011: 44.0%, 2012: 49.1%; p < .0001).

Conclusions

MIS approach is utilized in less than half of all colon resections in this national database, which accounts for over 70% of all diagnosed cancers in the US. Significant variability exists among age, race, insurance status, socioeconomic status, region, and facility type. In light of the recognized benefits of the MIS approach, local and national policy should focus on narrowing these disparities and continuing the upward trend of MIS utilization.

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Long-term outcomes of patients with early gastric cancer found to have lesions for which endoscopic treatment is not indicated on histopathological evaluation after endoscopic submucosal dissection

Abstract

Background

Gastric cancer treatment guidelines recommend additional surgery as the standard treatment for lesions for which endoscopic submucosal dissection (ESD) is not indicated. However, the incidence of lymph-node metastasis is low in most patients.

Methods and materials

The study comprised 231 patients (231 lesions) who underwent ESD for early gastric cancer (EGC) in our hospital from September 2002 through March 2015 and were found to have lesions for which endoscopic treatment is not indicated on histopathological evaluation after ESD. The patients were divided into the additional operation group and the follow-up group, and long-term outcomes were studied retrospectively. Risk factors for metastasis and recurrence were also studied (capture rate, 98.7%).

Results

The median follow-up was 48 months. There were 174 men and 57 women with a median age of 72 years. The additional operation group comprised 118 patients, and the follow-up group comprised 113 patients. The rates of 5-year cause-specific survival and 5-year overall survival were significantly higher in the additional operation group (100 and 96.0%, respectively) than in the follow-up group (92.6 and 73.3%, respectively; p = 0.010, p < 0.001). In the follow-up group, 5 patients (4.4%) died of gastric cancer (p = 0.021). Among elderly patients 75 years or older, long-term outcomes did not differ significantly between the groups. Sixteen patients had metastasis or recurrence, and the presence of lymphatic involvement was an independent risk factor for metastasis, recurrence, or both (p = 0.003; odds ratio 10.594; 95% confidence interval 2.294–48.927).

Conclusions

In patients with EGC who are confirmed to have lesions for which endoscopic treatment is not indicated on histopathological evaluation after ESD, additional surgery should be aggressively performed if the patient can tolerate such treatment. In elderly patients aged 75 years or older and patients with serious underlying diseases, follow-up observation was suggested to be one option in patients who give informed consent after receiving an explanation of the risk of recurrence.

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Implementation of a novel efficacy score to compare sealing and cutting devices in a porcine model

Abstract

Background

In general surgery, minimally invasive laparoscopic procedures have been steadily increasing over the last decade. The application of advanced bipolar and ultrasonic energy devices for sealing and cutting of blood vessels plays a vital role in routine clinical procedures. The advantages of energy-based instruments are enhanced sealing capability combined with both fast sealing time and minimal thermal injury. The purpose of this study was to compare the safety and efficacy profiles of nine laparoscopic sealing and cutting devices in a porcine model, with a new scoring system.

Methods

Comparative studies in a porcine model were performed to assess vessel sealing, burst pressure, thermal spread, maximum heat, sealing/cooling time, and compression strength over the full jaw. Nine different devices from five manufacturers were tested in this study. The sealing and cutting devices (SCD) score has been developed to enable standardized comparisons of various devices. For this purpose, the most important parameters were identified through a consensus approach.

Results

All sealed vessels with different devices could withstand a median pressure of more than 300 mmHg (range 112–2046 mmHg). The time for the sealing procedure was 7.705 s (range 5.305–18.38 s) for the ultrasonic and 7.860 s (range 5.08–10.17 s) for the bipolar devices. The ultrasonic instruments reached a median temperature of 218.1 °C (range 81.3–349.75 °C) and the bipolar devices a temperature of 125.5 °C (range 94.1–133.35 °C). The tissue reached a median temperature of 61.9 (range 47.1–80.6 °C) after ultrasonic sealing and 76.7 °C (range 63.1–94.2 °C) after bipolar sealing. The median SCD score was 10.47 (range 7.16–13.72).

Conclusion

All the instruments used seemed safe for use on the patient. The SCD score allows an indirect comparability of the instruments.

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