A Comparative Study of Laparoscopic Extraperitoneal Laparoscopy With the Use of Ultrasonically Activated Shears

Abstract

Previous studies have demonstrated the efficacy and safety of extraperitoneal laparoscopic lymphadenectomies. The rate of peri- and postoperative complications with these procedures is below 15%. One of the most common postoperative complications, lymphocele, occurs in 3.8% to 21 % of patients, and can be symptomatic or nonsymptomatic. Nonsymptomatic lymphoceles require no treatment. Although the incidence of symptomatic lymphocele has decreased with the use of systematic preventive marsupialization, this procedure does not seal the lymphatic vessels and thus does not prevent lymphatic leakage during lymph nodes dissection. A device employing ultrasonic energy, the ultrasonically activated shears (the harmonic scalpel) has been investigated for management of symptomatic lymphoceles after pelvic lymphadenectomy in patients with gynecological malignancies. This device achieves both coagulation and cutting without instrument exchanges. In a small number of studies, use of the ultrasonic shears has reduced the occurrence of lymphoceles and accomplished sealing, thereby reducing lymphatic leakage. The aim of this study was to investigate the effectiveness of the ultrasonic shears in reducing the occurrence of symptomatic lymphoceles in patients who had undergone para-aortic laparoscopic lymphadenectomies (PALLs) in a prospective setting. The postoperative complications of PALLs were also investigated. A total of 98 patients who had received PALLS were divided into 2 groups. The ultrasonic group was comprised of 36 patients receiving PALLs that were performed with the activated shears. Outcomes in the study group were compared with a historical control group comprised of 62 patients receiving PALLs performed with the standard coagulation procedure. There were no statistically significant differences in the following perioperative and postoperative parameters between the ultrasonic group and control group: Operating time (129.9 ± 38.1 vs. 109.8 ± 38.1 minute, P = 0.22), hospital stay (5.1 ± 2.7 vs. 4.48 ± 3.6 days, P = 0.34), lymph nodes removed (19.8 ± 9.7 vs. 21.1 ± 8.8, P = 0.50) and positive lymph nodes (1.03 ± 2.9 vs. 0.89 ± 2.0, P = 0.78). In addition, no difference in blood loss occurred. No patients in the study group, but 7 patients in the control group experienced symptomatic lymphoceles that required medical treatment (P = 0.03). Four control patients had radiologic drainage and 1 received surgical drainage. The rate of peri/postoperative complications was 9%, which is comparable with rates of PALL reported in major studies. These findings are consistent with those of a number of major studies showing that the ultrasonically activated shears are effective for the performance of PALL. These and previous data suggest to the investigators that combined use of the shears together with systematic preventive marsupialization may significantly lower the frequency of postoperative symptomatic lymphoceles and other complications.