Dissection by Ultrasonic Energy Versus Monopolar Electrosurgical Energy in Laparoscopic Cholecystectomy

Department of General Surgery, St George's Hospital and Medical School, University of London, UK.
JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons (Impact Factor: 0.91). 01/2010; 14(1):23-34. DOI: 10.4293/108680810X12674612014383
Source: PubMed


Laparoscopic cholecystectomy is the gold standard for management of symptomatic gallstones. Electrocautery remains the main energy form used during laparoscopic dissection. However, due to its risks, search is continuous for safer and more efficient forms of energy. This review assesses the effects of dissection using ultrasonic energy compared with monopolar electrocautery during laparoscopic cholecystectomy.
A literature search of the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, and EMBASE was performed. Studies included were trials that prospectively randomized adult patients with symptomatic gallstone disease to either ultrasonic or monopolar electrocautery dissection during laparoscopic cholecystectomy. Data were collected regarding the characteristics and methodological quality of each trial. Outcome measures included operating time, gallbladder perforation rate, bleeding, bile leak, conversion rate, length of hospital stay and sick leave, postoperative pain and nausea scores, and influence on systemic immune and inflammatory responses. For metaanalysis, the statistical package RevMan version 4.2 was used. For continuous data, Weighted Mean Difference (WMD) was calculated with 95% confidence interval (CI) using the fixed effects model. For Categorical data, the Odds Ratio (OR) was calculated with 95% confidence interval using fixed effects model.
Seven trials were included in this review, with a total number of 695 patients randomized to 2 dissection methods: 340 in the electrocautery group and 355 in the ultrasonic group. No mortality was recorded in any of the trials. With ultrasonic dissection, operating time is significantly shorter in elective surgery (WMD -8.19, 95% CI -10.36 to -6.02, P<0.0001), acute cholecystitis (WMD -17, 95% CI -28.68 to -5.32, P=0.004), complicated cases (WMD -15, 95% CI -28.15 to -1.85, P=0.03), or if surgery was performed by trainee surgeons who had performed <10 procedures (P=0.043). Gallbladder perforation risk with bile leak or stone loss is lower (OR 0.27, 95% CI 0.17 to 0.42, P<0.0001 and OR 0.13, 95% CI 0.04 to 0.47, P=0.002 respectively), particularly in the subgroup of complicated cases (OR 0.24 95% CI 0.09 to 0.61, P=0.003). Mean durations of hospital stay and sick leave were shorter with ultrasonic dissection (WMD -0.3, 95% CI -0.51 to -0.09, P=0.005 and WMD -3.8, 95% CI -6.21 to -1.39, P=0.002 respectively), with a smaller mean number of patients who stayed overnight in the hospital (OR 0.18, 95% CI 0.03 to 0.89, P=0.04). Postoperative abdominal pain scores at 1, 4, and 24 hours were significantly lower with ultrasonic dissection as were postoperative nausea scores at 2, 4, and 24 hours.
Based on a few trials with relatively small patient samples, this review does not attempt to advocate the use of a single-dissection technology but rather to elucidate results that could be used in future trials and analyses. It demonstrates, with statistical significance, a shorter operating time, hospital stay and sick leave, lower gallbladder perforation risk especially in complicated cases, and lower pain and nausea scores at different postoperative time points. However, many of these potential benefits are subjective, and prone to selection, and expectation bias because most included trials are unblinded. Also the clinical significance of these statistical results has yet to be proved. The main disadvantages are the difficulty in Harmonic scalpel handling, and cost. Appropriate training programs may be implemented to overcome the first disadvantage. Cost remains the main universal issue with current ultrasonic devices, which outweighs the potential clinical benefits (if any), indicating the need for further cost-benefit analysis.

Download full-text


Available from: Walid Sasi
  • Source
    • "Unlike electrosurgery devices based on joule heating [19]-[21], the PT-based USVD devices feature outstanding hemostasis and efficient dissections with minimal lateral thermal damage and low smoke generation. Furthermore, it has no risk of electrical current flowing through the patient [22]. The PT has both longitudinal and transverse resonant modes. "
    [Show abstract] [Hide abstract]
    ABSTRACT: This paper presents a novel cost-effective automatic resonance tracking scheme with maximum power transfer (MPT) for piezoelectric transducers (PT). The conventional approaches compensate the PT with complex power factor correction schemes or drive it in resonance using intricate loops with limited operating range. The proposed tracking scheme is based on a band-pass filter (BPF) oscillator, exploiting the PT’s intrinsic resonance point through a sensing bridge. It guarantees automatic resonance tracking and maximum electrical power converted into mechanical motion regardless of process variations and environmental interferences. Thus, the proposed BPF oscillator-based scheme was designed for an ultrasonic vessel sealing and dissecting (UVSD) system, where accurate PT displacement regulation over a wide range of loads is required. An amplitude control for a switching power stage was developed to regulate the output mechanical motion and provide different power levels for the specific surgical functions such as sealing and dissecting. A proportional-integral (PI) compensator was developed to ensure stable operation under various loading conditions. The sealing and dissecting functions were verified experimentally in chicken tissue and glycerin.
    Full-text · Article · May 2015 · IEEE Transactions on Industrial Electronics
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To compare the potential for postoperative laparoscopic adhesion formation utilizing either monopolar cautery or ultrasonic energy and to determine whether there is added benefit with the addition of a suspension of hyaluronate/carboxymethylcellulose in saline versus saline alone. Injuries were induced in rabbits by using monopolar cautery on 1 uterine horn and adjacent sidewall and ultrasonic energy on the opposite. Hyaluronate/carboxymethylcellulose or saline was added to every other animal. Autopsies were performed after 3 weeks. Clinical and pathologic scoring of adhesions was performed by blinded investigators. A very significant difference occurred in pathologic adhesion scores favoring the ultrasonic scalpel when the animals were treated with saline. However, a borderline significant difference was found in pathologic scores favoring the ultrasonic scalpel compared to the monopolar cautery. There was no significant difference in clinical adhesion scores between the 2 modalities. No significant difference in either score was found with the addition of hyaluronate/carboxymethylcellulose or saline with either instrument. No benefit was found for adhesion prevention with hyaluronate/carboxymethylcellulose. Although no reduction was achieved in clinical adhesions, the ultrasonic scalpel resulted in fewer histologic signs of tissue inflammation in the early postoperative period, suggesting that further clinical adhesions might develop over time with cautery.
    Full-text · Article · Jul 2011 · JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Laparoscopic surgery is a less invasive treatment option for tumors in the intraabdominal organs; however, the safety and indication of laparoscopic or laparoscopy assisted pancreaticoduodenectomy (LPD) is still controversial. We attempted LPD in four cases for intraductal papillary mucinous neoplasm (IPMN) located in the pancreatic head and we report the surgical records and short-term outcome. LPD was carried out in four patients including three patients with the combined type IPMN and one with the branch type, based on the International Consensus Guidelines. None of the patients had invasive carcinoma based on preoperative imaging diagnosis. Laparoscopic procedures were performed until isolation of the pancreas head and duodenum, and final resection of PD and intestinal reconstruction were performed using small incision laparotomy (7-8cm). The mean total operating time was 882 minutes (820-932 minutes), mean blood loss was 925ml (610-1550ml) and red cell transfusion was not required in any patients. One patient underwent reoperation for bleeding at the pancreaticojejunostomy site at day 1. Mean duration until patients were able to walk was 3.5 days (2-6 days) and duration of use of analgesia was limited to within 7 days. Grade B pancreatic fistula was observed in one patient and jejunal ileus was observed in one patient. There were no deaths. LPD was safely performed and blood loss was limited, although the operating time was long. Postoperative recovery in patients without complications might be better than the conventional PD under laparotomy. Future study is necessary.
    Preview · Article · Jan 2012 · Acta medica Nagasakiensia
Show more