Bipolar Coagulation Research Articles

Bipolar Coagulation Aneurysm Dome Remodeling (Aneurysmorrhaphy) for Middle Cerebral Artery Aneurysms.

Adequate visualization of the proximal and distal vessels and clip reconstruction of the bifurcation with complete aneurysm neck exclusion are often difficult in the setting of bulbous small- and moderate-sized middle cerebral artery (MCA) aneurysms. We describe our experience with bipolar aneurysm dome remodeling in the setting of bulbous MCA aneurysms. The charts of the senior author’s (Aaron Cohen-Gadol) patients who underwent clip ligation of their MCA aneurysm (220 patients), and more specifically those whose aneurysm clipping was facilitated through bipolar coagulation remodeling (8 patients), were reviewed. Patient demographics, aneurysm characteristics, and postoperative angiographic results were analyzed. Eight patients with eight MCA aneurysms were treated through this technique over a six-year period. Their mean age was 53 years, and six of the eight patients were women. Two involved the anterior temporal artery, and the rest were at the M1 bifurcation or trifurcation. Three of the eight were ruptured; the mean aneurysm maximum diameter was 7 mm. Postoperative angiography demonstrated complete aneurysm obliteration in seven of eight patients; one patient had an asymptomatic mild stenosis of her anterior temporal artery’s origin, and another had a small neck remnant in the setting of a highly atherosclerotic neck. On the basis of this experience, dome coagulation remodeling of small- and moderate-sized bulbous aneurysms in the setting of poor proximal and distal vessel visualization was found to be safe for facilitating aneurysm clipping and offers more desirable clip deployment.

Application of meticulous anatomy skills with straight bipolar electric coagulation forceps in thyroid surgery

Objective: To compare the efficacies of the two techniques of "micro-hemostasis and micro-cutting" with straight bipolar electrocoagulation forceps and traditional clamp-ligation for hemostasia in thyroid surgery. Methods: A total of 228 patients who underwent surgical treatment for thyroid neoplasms in our hospital between January 2015 and December 2018 were retrospectively analyzed, including 50 males and 178 females, aged 23-68 years old. Of those, 150 cases as electric knife group received traditional thyroid surgery between January 2015 and December 2018 and 78 cases as bipolar electrocoagulation group received thyroid surgery by using the technique of bipolar electrocoagulation with meticulous anatomy between January 2018 and December 2018. The total operation time, single operation time, intraoperative hemorrhage, postoperative drainage volume on the first day, postoperative hoarseness and hypocalcemia were compared between the two groups. SPSS 16.0 was used to analyze the data. Results: The total operation time and intraoperative hemorrhage in the bipolar electrocoagulation group were significantly lower than those in the electric knife group ((59.33±18.29)min vs (77.21±25.39)min, (14.83±9.22)ml vs (36.86±11.80)ml, all P<0.01). The single operation time of the bipolar electrocoagulation group was shorter than that of the electric knife group((10.25±6.16) min vs (20.34±7.24)min, (16.25±7.15)min vs (35.68±8.25)min, (12.12±5.25)min vs (20.68±7.26)min, t value was 3.948,16.262,8.238, all P<0.01).There was no significant difference between the two groups in postoperative drainage volume on the first day (P>0.05) and the incidence of postoperative hoarseness (P>0.05), while the incidence of hypocalcemia in the bipolar electrocoagulation group(10.26%) was lower than that in the electric knife group(21.33%,χ(2)=4.353, P<0.05). Conclusions: The fine dissection for thyroid operation can be achieved by using straight bipolar electrocoagulation tweezers. The use of "micro-hemostasis" and "micro-cutting" technique with bipolar electrocoagulation tweezers can greatly reduce intraoperative bleeding, operation time and postoperative complication.

Monopolar electrosurgical tunneling combined with bipolar coagulation for bloodless resection of sessile benign skin lesions

Monopolar radiofrequency or electrosurgical probes and bipolar forceps can be used for the removal of pedunculated or sessile benign skin lesions. 1 Pangti R. Dixit A. Gupta S. Bipolar forceps of a high-power electrosurgical unit for precise removal of small benign skin lesions [e-pub ahead of print]. J Am Acad Dermatol. 2019; https://doi.org/10.1016/j.jaad.2019.03.026 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar However, broad pedunculated or sessile lesions are supplied by large blood vessels. The monopolar probe, in either cutting or coagulation mode, cannot sufficiently coagulate the large bleeders; thus, bloodless removal is not possible. The bipolar mode is good for bloodless removal of smaller lesions only because the terminals of the bipolar forceps do not work at a distance of more than 4 to 5 mm because of tissue resistance. 1 Pangti R. Dixit A. Gupta S. Bipolar forceps of a high-power electrosurgical unit for precise removal of small benign skin lesions [e-pub ahead of print]. J Am Acad Dermatol. 2019; https://doi.org/10.1016/j.jaad.2019.03.026 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Furthermore, the bipolar mode cannot cut the tissue on its own.

Selective fetal termination in monochorionic twin pregnancies - pregnancy outcome after bipolar cord coagulation and interstitial laser coagulation

Introduction/Objective. In this paper we present the perinatal outcome after selective fetal termination (SFT) in monochorionic (MH) twins done by bipolar cord coagulation (BCC) and interstitial laser coagulation (ILC). Methods. During a five-year period, SFT was done in 22 MH twins. BCC was done in 15 and ILC in seven cases. We registered the indication for SFT, gestational age at SFT, immediate postoperative death and late death of the co-twin, PPROM (preterm pre-labor rupture of membranes), gestational age at delivery/abortion, procedure-to-delivery interval, mode of delivery, neonatal body weight and 5-minute Apgar score. Results. Live birth was significantly higher after BCC than after ILC (86.7:57.1%). Gestational age at intervention was higher in BCC (20.2 ? 1.8 : 16.5 ? 1.7 weeks). Gestational age at delivery/abortion was lower for ILC (32.5 ? 4.8 : 27.5 ? 9.5 weeks); however, there was no difference when comparing live births only (33.8 ? 3.7 : 34.7 ? 4.5 weeks). There was no difference between procedure-to-delivery/abortion interval (86.7 ? 33.7 : 77.1 ? 73 days); however, the interval was significantly higher after ILC when comparing live births only (93.3 ? 33 : 133 ? 30.9 days). There was no difference in PPROM (26.7:14.3%); preterm delivery (69.2:50%); Cesarean section rate (84.6:75%); neonatal body weight (2174 ? 82.4 : 2475 ? 823 g); or Apgar score (7.7 ? 1.9 : 9.2 ? 1). Conclusion. There is no ideal method of SFT in MH twins. Success of each SFT method depends upon the correctly set indication, gestational age at the procedure, and the SFT technique. The risk of co-twin death is lower after BCC than after ILC. As in Narodni Front University Clinic for Gynecology and Obstetrics better results were achieved after BCC, this method became a standard for SFT in MH twins, except in cases of twin reversed arterial perfusion sequence before 16 weeks.

ESTIMATION TO EFFICIENCY OF THE MULTIFUNCTION METHOD ОF ENDOMETRIOSIS OVARIЕS TREATMENT

The aim: The aim of the study was to improve the results of treatment of patients with endometriosis by using a combination method of therapy. Materials and methods: For two years, 136 women of reproductive age who underwent laparoscopic surgeries for ovarian endometriosis were monitored: Group I (n = 24) did not receive any hormonal treatment in the perioperative period; Group II (n = 32) - received gonadotropin-releasing hormone agonists within 3 months after surgery; Group III (n = 80) prior to laparoscopic removal of the ovarian cyst used gonadotropin-releasing hormone agonists - Triptorelin 3.75 mg intramuscularly for 2 months, as well as three months after surgery. The control group consisted of 30 healthy women of reproductive age with regular menstrual periods. All patients underwent transvaginal ultrasound, counting the number of antral follicles before and after treatment. Serum hormone levels (FSH, prolactin, thyrotropic hormone, anti-Mullerian hormone, inhibin B) were determined by enzyme-linked immunosorbent assay on Cobas e-411 analyzer (Roche Diagnostics, Switzerland) on day 2-3 of the menstrual cycle and on day 2-3 of the first menstrual period after the end of treatment. Laparoscopic removal of the cyst was performed with exfoliation of the cyst, hemostasis on the wound surface of the bed of the cyst was performed with a bipolar electrocoagulator. Bipolar coagulation and resection of the ovarian tissue with no potential was used during surgical treatment of the ovaries, which made it possible to preserve the intact portion of the ovary as much as possible. Results: Analysis of ovarian reserve indices, namely number of antral foliculs, number of antral follicles, AMG, and inhibin B levels in all examined patients with ovarian endometriomas were significantly lower than those of the control group before the start of treatment: in the ovarian endometrial group group 1.26 times (p <0.01), inhibin B - 1.5 times (p <0.01), the number of antral follicles - 1.2 times (p <0.01), due to the development dystrophic changes of the follicular apparatus due to prolonged compression, hypoxia, fibrosis in the ovaries. Patients who planned pregnancy were advised to have an active sexual life before menstruation was restored. In 23 (46.9%) of 49 patients who had reproductive plans, pregnancy occurred without first menstruation after a course of gonadotropin-releasing hormone agonists, 12 (24.5%) women became pregnant during the first three menstrual cycles. Extracorporeal fertilization was recommended for women who did not have pregnancy within 6 months of surgery. For two years in women who did not plan pregnancy, recurrence of endometriosis was not observed. Conclusions: The combination of laparoscopic treatment with gonadotropin-releasing hormone agonists in patients with endometriosis with infertility allowed to restore reproductive function in 71.4% of women, which indicates the effectiveness of the treatment method used. In addition, it helps to achieve lasting remission and addresses the socio-social problems of women's health and maternity.

Comparative Characteristics of Hemostasis During Vaginal Hysterectomy

Aim. To compare the results of surgical treatment using bipolar hemostasis and traditional ligation of ligaments and blood vessels in vaginal hysterectomy.Material and methods. Fifty patients with benign uterine disease underwent vaginal hysterectomy using electrosurgery (n = 29) or conventional suture ligation (n = 21 controls).Results. Postoperative pain (especially on the fi rst day) was decreased in the electrosurgery group (5.50 ± 1.43 VAS points) as compared to the control group (7.64 ± 0.58 points), p &lt; 0.001. Intraoperative blood loss was signifi cantly lower in electrosurgery group (82.86 ± 22.58 ml) than in the control group (226.36 ± 129.12 ml), p &lt; 0.001. Operating time was signifi cantly shorter in the main group than in the controls (65.36 ± 20.9 min vs. 86.59 ± 40.19 min, p &lt; 0.05). On average, 2.75 ± 1.11 suture packages were used with bipolar coagulation, 6.00 ± 1.93 in the controls (p &lt; 0.001). Hospital stay was similar for both groups. Adverse event rates did not differ signifi cantly.Conclusions. Bipolar coagulation with the TissueSeal Plus proved to be more effi cient or identical to traditional suture ligation. Intraoperative blood loss, postoperative pain and the duration of the operation were less, while the complications were identical for both groups. In addition, bipolar coagulation was easier to use and cost effective. These fi ndings prove the feasibility and effectiveness of the use of electrosurgical techniques to perform hysterectomy and its further study

An alternative method of surgical treatment of ovarian endometriomas from the standpoint of preservation of the ovarian reserve

Hypothesis/aims of study. Ovarian endometriomas are a great danger to the female reproductive function. In addition to the negative impact of the disease itself on ovarian reserve, the reproductive capabilities of women are influenced by surgery on the ovaries and subsequent hormonal therapy. Ovarian reserve after cystectomy of the endometriomas suffers more than after removal of other benign ovarian tumors. The solution of the problem can be obtained using sclerotherapy during laparoscopy. The aim of this study was to assess the impact of sclerosing endometriomas during laparoscopy on the ovarian reserve.&#x0D; Study design, materials and methods. The study involved 36 patients aged 2535 years. Inclusion criteria were genital endometriosis, endometrioma of one of the ovaries with a volume of 15100 cm3, and pregnancy planning. Exclusion criteria were uterine fibroids, endometrial hyperplasia, polycystic ovary syndrome, and the previous operations on the ovaries and uterine tubes. The main group consisted of 18 patients who underwent sclerotherapy of an endometrioma during laparoscopy with a 70% ethanol solution. The comparison group comprised 18 patients who underwent cystovariectomy with bipolar coagulation of the tumor lining. Within 4 months after surgery, gonadotropin-releasing hormone agonists were administered. An ultrasound examination of the pelvic organs and determination of anti-Mllerian hormone (AMH) level were performed before surgery, after surgery, and after hormonal treatment.&#x0D; Results. In both study groups, AMH level decreased immediately after surgery: in the main group, it reduced by 1.4 times, in the comparison group by 2.4 times. After termination of therapy with gonadotropin-releasing hormone agonists and recovery of the menstrual cycle, AMH level increased slightly (it was 2.9 0.40 ng/ml in the main group, and 1.8 0.24 ng/ml in the comparison group). Within 12 months after surgery, pregnancy occurred in 44.4% of patients in the main group and in 33.3% of patients in the comparison group. Over 16 months of follow-up, not a single case of recurrence of the disease was subsequently detected.&#x0D; Conclusion. Sclerotherapy of endometriomas during laparoscopy is supposed to be an effective and promising technique aimed at preserving the ovarian reserve in this category of patients.

Posterior longitudinal ligament resection during microscopic anterior cervical discectomy: technique and safety consideration

BackgroundHerniation of the cervical disk material results in interruption of the posterior longitudinal ligament (PLL) in the majority of patients. Routine opening of the PLL during ACDF is a necessary step for complete removal of all disk fragments.ObjectivesSafety measures during PLL opening during microscopic anterior cervical discectomy and risk-free surgeryStudy designA retrospective clinical case seriesPatients and methodsThe study was conducted on 145 patients. The main symptom was radicular pain. Pre-operative identification of PLL was assessed by MRI. All patients were operated upon by ACDF. We started dissection off the midline in patients with intact ligament while we used the site of disruption to start and complete dissection in patients with interrupted ligament. Follow-up was done monthly.ResultsNinety-seven percent of patients underwent single level surgery. The most commonly operated level was C5-6. PLL was interrupted in 60.7% of patients. There was a statistically significant difference between median VAS in immediate, early, and late post-operative period. Bleeding was encountered in 46% of patients. Saline irrigation was a suitable method for hemostasis.ConclusionConventional MRI is the modality of choice for pre-operative identification of PLL. It is better to use the site of ligament interruption to start sharp dissection and to start lateral to the midline in intact ligament. Sharp dissection is better with curved knife. Thin foot plate Kerrison is suitable for excision of the remaining parts. Hemostasis using saline irrigation is better and non-risky than using bipolar coagulation.

Extirpation of a Ruptured Anterior Spinal Artery Aneurysm Accompanied by Dural Arteriovenous Fistula at the Craniovertebral Junction via a Posterolateral Approach: The Management of Extradural Venous Congestion.

Objective This study was aimed to discuss how to control extradural venous congestion with an increased pressure in cases of arteriovenous shunt disease of the craniovertebral junction. Design The study is presented through an operative video. Results A 77-year-old patient with subarachnoid hemorrhage had a dural arteriovenous fistula located at the C1–C2 level. Left vertebral angiography showed a fistula between the left C2 radiculomeningeal muscular artery and perivertebral plexus. Furthermore, right vertebral angiography showed a ruptured aneurysm at the aberrant branch of the anterior spinal artery originating from the contralateral vertebral artery (VA), possibly formed because of the concurrently increased pressure of the perimedullary veins. Aneurysm extirpation was planned through a posterolateral approach. To reduce venous bleeding during the approach, preoperative embolization of the radiculomeningeal muscular artery was performed. During surgery, the suboccipital triangle was exposed following layer-by-layer dissection of the suboccipital muscles ( Figs. 1 and 2 ). Subperiosteal dissection of the paravertebral plexus surrounding the VA around the C1 lamina was effective to avoid venous bleeding. A bloodless operative field was achieved, and key anatomical structures, such as the C2 nerve root, feeder, and V3 portion of the left VA, were clearly identified. With a sufficient amount of lateral exposure, the ruptured anterior spinal artery aneurysm was successfully extirpated with bipolar coagulation. The patient was discharged with no neurologic deficit. Fig. 1 ( A ) The initial CT scan showing the subarachnoid hemorrhage. ( B ) Left vertebral angiogram demonstrating a dural arteriovenous fistula at the craniovertebral junction. ( C ) Right vertebral angiogram showing an aneurysm (arrow) arising at the aberrant branch of the anterior spinal artery. ( D ) The postoperative angiogram demonstrating the extirpation of the aneurysm (arrowhead). Fig. 2 ( A ) Intraoperative photograph showing the subperiosteal dissection technique to protect the vertebral artery and minimize the bleeding from the paravertebral plexus. ( B ) The sufficient posterolateral exposure was obtained with minimal bleeding. C1, C1 lamina; C2, C2 lamina; Occ, occipital bone. Conclusion Controlling extradural venous congestion is essential to obtain a clear operative field in cases of arteriovenous shunt disease at the craniovertebral junction. The link to the video can be found at: https://youtu.be/fCT69WtAQbo .

Robotic-Assisted Laparoscopic Excision of C-Section Scar Ectopic Pregnancy with Bipolar Coagulation of Uterine Vessels

Video Objective To describe a technique of robotic-assisted laparoscopic excision of c-section scar ectopic pregnancy (CSP) with bipolar coagulation of uterine vessels. Setting CSP occurs when a gestational sac (GS) is located in the anterior uterine wall with diminished myometrium between the sac and the bladder, and a discontinuity in the anterior wall of the uterus adjacent to the GS, with an empty uterus and cervical canal. It is estimated that 4.2% of ectopic pregnancies are CSP. Laparoscopic bipolar coagulation of uterine vessels is mostly described in myomectomies: it aids in decreasing blood loss, preserves the uterus, and there are pregnancies and term pregnancies post-procedure reported in the literature, with approximately 40% early miscarriage rate. This is a video case report of a 35yo G6P3023 7weeks pregnant with CSP on sonogram, failed multidose regimen methotrexate and developed lower abdominal pain with vaginal bleeding. She was counseled on surgical treatment of CSP. Interventions In this video, we describe the surgical approach opted for this patient. The minimally invasive surgery was recommended considering decreased blood loss, postoperative pain and hospital stay. Considering her history of prior 3 c-sections, the robotic approach would offer better visualization for lysis of adhesions and greater instruments range of motion. In anticipation of bleeding of difficult control, bipolar coagulation of uterine vessels was planned preoperatively. Preoperative imaging was also crucial. It was noted firm adhesions from the bladder to the lower uterine segment, carefully dissected off until identification and removal of GS, confirmed with frozen section. The hysterotomy was repaired with barbed suture. Excellent hemostasis with minimal blood loss (EBL 20ml) noted. Patient did well postoperatively, with beta HCG followed to zero. Conclusion Robotic-assisted laparoscopic excision of CSP should be considered as a valuable treatment option, and preparedness is paramount.

Clinical anatomy study of superior mesenteric vessels and its branches

Objective: To examine the anatomical relationships of tributaries to superior mesenteric artery and vein in surgical procedures. Methods: A prospectively designed observational trial, registried to Chinese Clinical Trial Registry, ChiCTR 1800014610, was conducted in Department of General Surgery, Peking Union Medical College Hospital from July 2016 to Decmeber 2018 to record the relationships of ileocolic artery and vein, right colic artery and vein, middle colic artery and vein, and combinations to assemble Henle's trunk, during the laparoscopic operation of radical right colectomy for right colon malignancies. The length of middle colic artery, length of Henle's trunk, and distance from Henle's trunk to the inferior margin of pancreatic head to duodenum were measured during operation. A total of 100 patients, 52 male and 48 female, with right colon cancer, who underwent radical right colectomy, were enrolled in present study from July 2016 to December 2018, with age of (61.0±12.3) years (range: 31 to 82 years), and body mass index of (23.3±3.5) kg/m(2) (range: 16.0 to 34.2 kg/m(2)). Results: The ileocolic artery and vein presented as rates of 97.0% (97/100, 95%CI: 91.5% to 99.4%, the same below) and 98.0% (98/100, 93.0% to 99.8%), respectively. The ileocolic vein ran ventrally in 51 of 97 patients (52.6%, 42.7% to 62.5%). The right colic artery, which raised from superior mesenteric artery directly, was found in 42 of 100 patients (42.0%, 32.3% to 51.7%); and the right colic vein drained directly into superior mesenteric vein in 19 of 100 patients (19.0%, 11.3% to 26.7%). The presence of middle colic artery and vein were 95.0% (95/100, 90.7% to 99.3%) and 90.0% (90/100, 84.1% to 95.9%) respectively. The average length of middle colic artery, from its origin to bifurcation into right and left branches, was (2.6±1.6) cm (range: 0.1 to 7.2 cm). All the dissected middle colic vein drained into superior mesenteric vein (87.8% (79/90), 81.0% to 94.6%) and Henle's trunk (12.2% (11/90), 5.4% to 19.0%). Henle's trunk was found in 93 of 100 patients (93.0%, 88.0% to 98.0%), with average length of (1.0±0.6) cm (range: 0.1 to 2.4 cm). The distance between Henle's trunk to the inferior margin of pancreatic head was (2.7±0.7) cm (range: 1.3 to 4.5 cm). More than half of the Henle's trunk were composed of 3 tributaries (54.8% (53/93), 40.8% to 61.2%). The most frequently discovered tributaries to form Henle's trunk were right gastroepiploic vein (98.0% (98/100), 93.0% to 99.8%), superior right colic vein (82.0% (82/100), 74.5% to 89.5%), and superior anterior pancreaticoduodenal vein (78.0% (78/100), 69.9% to 86.1%). In present study, the right branch of middle colic vessels was often found to run closely with Henle's trunk, veins drained from small intestine could be found to run over superior mesenteric artery to converge into superior mesenteric vein. There were 2 incidences, injuries to Henle's trunk and middle colic vein, happened during the operation, which were overcomed by bipolar coagulation and dividing the vessels. Conclusions: Ileocolic vessels and middle colic vessels could be used as landmarks for laparoscopic surgery based on their constant anatomical existence. In contrast, the chances are rare for the presence of right colic artery or right colic vein. Nearly half of the Henle's trunk was consisted of right gastroepiploic vein, superior right colic vein and superior anterior pancreaticoduodenal vein. Exceptional cautions should be made for the variations of the Henle's trunk during the operation.

Optimized SEEG-guided radiofrequency thermocoagulation for mesial temporal lobe epilepsy with hippocampal sclerosis

PurposeConcerns about the impact of open surgery for drug-resistant mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) have driven interest in minimally invasive techniques. Stereo-electro-encephalography guided radiofrequency thermocoagulation (SEEG guided RF-TC) offers an alternative choice but with currently limited efficacy. We developed a procedure for optimally extended thermocoagulative lesions and investigated the efficacy and safety for MTLE-HS in a preliminary observational study. MethodsFrom June 2016 to August 2017, twenty-two patients were selected for the present study. They met the criteria of unilateral MTLE-HS after noninvasive evaluation and then underwent implantation of a combination of SEEG electrodes to form a high-density focal stereo-array, including one electrode along the long axis of amygdalohippocampal complex and three orthogonal electrodes to widely sample mesial temporal structures. A unilateral epileptogenic zone of mesial temporal structures was confirmed in these 21 patients. SEEG-guided bipolar coagulations were performed between two contiguous contacts of the same electrode, or between two adjacent contacts of different electrodes. ResultsSurgical procedures were well tolerated, with no related complications. At the follow-up of 12 months, 20 patients (95.2%) experienced a >90% decrease in seizure frequency and 16 patients (76.2%) were free of disabling seizures (Engel class I). Among them, eight (38.1%) were classified as Engel class Ia and the other eight (38.1%) as Engel class Ib. Four others (19%) had rare disabling seizures (Engel class II). Only one (4.8%) experienced an Engel class III outcome. ConclusionOptimized SEEG-guided RF-TC is a promising complementary option for the treatment of MTLE-HS.

Ovarian function after the use of various hemostatic techniques during treatment for endometrioma: protocol for a randomized clinical trial

BackgroundLaparoscopic cystectomy is currently considered the gold standard for the treatment of ovarian endometrioma, resulting in an improvement in symptoms, a lower recurrence rate, and a higher pregnancy rate among infertile patients. However, this treatment is not free from risk, since it is associated with a reduction in ovarian reserve. There is still controversy in the literature regarding whether the cause of the reduction in ovarian reserve is due to damage caused by the coagulation energy during hemostasis or whether the procedure itself is the cause of the damage irrespective of the hemostatic method used. The aim of this study is to compare the effects of different hemostatic methods on the ovarian function of women subjected to laparoscopic surgery for ovarian endometrioma.MethodsAn open-label randomized clinical trial to be conducted at the Lauro Wanderley University Hospital between December 2017 and August 2020. Eighty-four patients will be randomly allocated to three groups according to the hemostatic technique used during laparoscopic surgery for ovarian endometrioma: bipolar coagulation; laparoscopic suture; and hemostatic matrix. Ovarian function will be assessed by serum anti-Müllerian hormone measurement and by performing an antral follicle count using ultrasound before surgery and one, three, and six months after surgery. The internal review board of the Medical Sciences Center, Federal University of Paraíba approved the study protocol under reference CAAE 71621717.9.0000.8069.DiscussionBearing in mind the need for more randomized clinical trials to clarify this issue, we hope to contribute with data that will determine whether there is any difference between hemostatic methods despite the rational use of bipolar energy or whether the procedure itself explains the ovarian damage irrespective of the hemostatic technique used.Trial registrationClinicalTrials.gov, NTC03430609. Registered on XX.10/31/2017.ISRCTN Registry, ISRCTN11469394. Registered on XX.17/12/2017.Unique Protocol ID: U1111–1203-2508.

Treatment of a Distillery Wastewater in a Bipolar-Mode Electrocoagulation System: Performance Evaluation and Kinetic Analysis

This work investigates the performance of a bipolar mode electro coagulation system with multiple electrodes. The objective is to remove recalcitrant total organic carbon (TOC) and total phosphorus (TP) from distillery wastewater. The design surface area to volume (S/V) ratio considered for the study was 76.5/m. The effects of the process variables, such as initial pH, retention time and current density, were evaluated on the performance of the reactor. The percentage removal of pollutants increased with an increase in current density and time. The treatment efficiency was found to be at near neutral pH. The results of the experiment revealed that the efficiencies of removing the pollutants were found to be 73% and 85% for TOC and TP, respectively. The reactions followed first-order kinetics for both TOC and TP removal from distillery wastewater. The mass transfer coefficient, K values were found to be higher at near neutral pH. The correlation between the current density and mass transfer coefficients for both the pollutants was deduced and the energy consumption was found to be 12 kWh/cu m.

Vein of Galen arteriovenous malformation: Unedited microneurosurgery

Background:Vein of Galen arteriovenous malformations (VGAVMs) are vascular malformations of the pineal region between a persistent embryological median prosencephalic vein of Markowski and the arterial choroidal system by a direct (mural type) or indirect (choroidal type) communication. Angiographic evaluation of VGAVMs usually describes a limbic arch between the anterior and posterior cerebral arteries throughout a pericallosal artery, and the classic “ε” shape configuration of the thalamostriate veins drainage into a subtemporal or a lateral mesencephalic vein due to the underdevelopment of the straight sinus, sigmoid sinus, and jugular bulbs. Moreover, falcine dural channels join the pouch of the malformation with the posterior third of the superior sagittal sinus and less frequently with the cavernous sinus, inferior petrosal sinus, and facial veins. At present, endovascular therapy is the standard management for these lesions. However, under failure of endovascular procedures such in this case, microsurgical management of VGAVMs under an experienced neurosurgical team might be paramount.Case Description:The patient with a choroidal type VGAVM and multiple failed endovascular procedures underwent sitting praying position and midline supracerebellar infratentorial approach. Strong retraction with stitches and proper hemostasis of a highly vascular dura was achieved after transverse sinus-based opening. Accurate microsurgical dissection between the superior cerebellar surface and the tentorium allowed a supracerebellar approach over the vermis and along the midline recognizing the venous pouch of the VGAVM instead of the absent straight sinus. Water dissection allowed us to differentiate the cleavage plane between the VGAVM and surrounding structures maintaining an impeccable surgical field as well. Under high microscopic magnification, arterial feeders of the malformation coming from the posterior cerebral artery were recognized. Intraoperative angiography and reevaluation of the preoperative imaging helped us to confirm a safety approach before coagulation and cut those vascular feeders. Throughout an open-close and short bursts bipolar coagulation techniques preventing attachment of conventional bipolar tips within the vascular structure and without permanent use of water irrigation, the vessels were carefully dissected, coagulated, and sectioned. Along with our experience, we believe that this standard coagulation technique applied in all vascular malformation surgeries is safe and effective. A remaining small plexiform malformation associated with the vein of Galen malformation was coagulated and isolated. A new intraoperative angiography determined complete microsurgical occlusion of the VGAVM. Careful homeostasis based on electrocoagulation and surgical was achieved. Finally, we performed a microsurgical wound closure as a conventional technique in Helsinki neurosurgery.Conclusion:This unedited video offers all detailed aspects that a neurosurgeon as the senior author JH considers essential when performing an efficient and safe surgery for a VGAVM.Videolink:http://surgicalneurologyint.com/videogallery/vein-of-galen-avm.

Effect of Laparoscopic Suturing Versus Bipolar Coagulation on Ovarian Reserve in Patients Undergoing Endometriotic Ovarian Cystectomy.

Effect of Laparoscopic Suturing Versus Bipolar Coagulation on Ovarian Reserve in Patients Undergoing Endometriotic Ovarian Cystectomy.

New technologies for low-grade glioma surgery

Brain surgery has come far from the primitive methods used thousands of years ago. In the last hundred years alone, we have come across countless breakthroughs like the invention of bipolar coagulation, the surgical microscope, microsurgical techniques and a large variety of surgical instruments. The latest years have brought us neuro-navigation, intra-operative imaging techniques and brain activity monitoring. Low-grade glioma surgery, in particular, has taken advantage a lot from all these new methods, bringing great benefits for the patients: the safe extent of resection has grown progressively and tumours located in eloquent areas that were thought until recently to be inoperable, have started to be removed in safe conditions. The purpose of this paper is to present these new technologies as a recap for neurosurgical professionals.

Selective fetal reduction in monochorionic twins: Preliminary experience

Objective:In complicated mono-chorionic twin pregnancies, vaso-occlusive techniques like bipolar cord coagulation (BPCC), radiofrequency ablation (RFA), interstitial laser ablation (ILA) of cord and fetoscopy guided cord coagulation with lasers are the methods proposed for selective fetal reduction. This study brings forth preliminary data of selective fetal reduction procedures at a tertiary care center in India.Material and Methods:This was a prospective observational study of 31 patients with complicated mono-chorionic twin pregnancies. Methods used were ILA, RFA and BPCC. Outcome measures included overall co-twin survival after selective feticide, survival rates with each method, miscarriage (defined as all fetal loss before 24 weeks), early fetal death (<24 hours after procedure) and late fetal death (>24 hours after the procedure) of co-twin.Results:Technical success was achieved in 30/31 (96.8%) of pregnancies. Over all take home baby rate was 63.3%. Live birth rates were 50%, 71.4% and 75% with ILA, RFA and BPCC respectively.Conclusion:Data from initial cases of selective fetal reduction in complicated mono-chorionic twins suggests that these procedures are feasible but are associated with high adverse perinatal outcome.

The Impact on Ovarian Reserve of Different Hemostasis Methods in Laparoscopic Cystectomy: A Systematic Review and Meta-analysis.

The objective of this review was to analyze the impact on ovarian reserve of the different hemostatic methods used during laparoscopic cystectomy. The studies were identified by searching electronic databases (MEDLINE, Embase, Cochrane, LILACS) and scanning reference lists of articles. We selected clinical trials that assessed the influence of hemostatic techniques on ovarian reserve in patients with ovarian cysts with benign sonographic appearance submitted to laparoscopic cystectomy by stripping technique. The included trials compared different laparoscopic hemostatic techniques: suture, bipolar electrocoagulation, ultrasonic energy and hemostatic sealants. The outcomes evaluated were level of serum anti-Mullerian hormone (AMH) and antral follicle count (AFC). The possibility of publication bias was evaluated by funnel plots. Twelve trials involving 1,047 patients were evaluated. Laparoscopic suture was superior to bipolar coagulation when evaluating serum AMH and AFC, in the 1st, 3rd, 6th and 12th month after surgery. In the comparison between bipolar and hemostatic sealants, the results favored the use of hemostatic agents. The use of ultrasonic energy was not superior to the use of bipolar energy. We recommend suture for hemostasis during laparoscopic cystectomy.

INFLUENCE OF SURGICAL INTERVENTION ON PATIENTS WITH OVARIAN APOPLEXY IN THE ASPECT OF OVARIAN RESERVE PRESERVATION

&#x0D; &#x0D; &#x0D; Ovarian apoplexy is the women’s disease of reproductive age, 75% of which are under the age of 30 years old, about 30% undergo surgery, and 40-62% of them are subjected to repeated surgeries because of disease recurrence [3, 10]. Goal of study: improvement of surgical treatment of the patients with ovarian apoplexy for maximal preservation of ovarian reserve.Materials and methods. A total of 120 women were included in the study. These include 55 patients with ovarian apoplexy, who underwent laparoscopic surgery for the first time. These patients were included in the prospective study and divided into two groups, depending on the hemostasis method used during the surgery. Group 1 included 30 patients with hemostasis, which was carried out using bipolar coagulation, group 2 included 25 patients, whose bleeding from the ovary was stopped by applying sutures. In each group, the patients were selected with the “blind” method. The study included patients with stable hemodynamic parameters before surgery and duration of hospitalization of not more than 24 hours. The comparison group consisted of 45 patients with laparoscopic confirmation of pain form of the ovarian apoplexy, who underwent conservative treatment. Study results and their discussion. Patients with ovarian apoplexy with stable hemodynamic parameters should undergo surgery using laparoscopic access, which allows to clarify the diagnosis, stop bleeding, prevent development of sexually transmitted infections and carry out surgical correction of the associated pathological processes of the internal genital organs. Stop of bleeding at the patients with ovarian apoplexy with bipolar electrosurgery is faster (shorter duration of surgery by 13 minutes), but this leads to more significant decrease in ovarian reserve (Anti-Mullerian hormone (AMH) by 30%, antral follicle count (AFC) by 10%) than use of hemostatic sutures (AMH by 22%, PAF by 8%) (p &lt;0.05). In order to maximize the maintenance of the ovarian reserve at surgeries by women with ovarian apoplexy, it is always better to carry out hemostasis by enucleating the cyst capsule within healthy tissues and saturation with absorbable synthetic areactive sutures on the ovarian wound following by intracorporal knot tying. Regardless of the hemostasis, used during surgical treatment of ovarian apoplexy by patients of the age of 36 years old and older, there is a greater decrease in ovarian reserve (AMH by 30%, AFC by 20%) than at patients whose age is less than 35 years old (AMH by 20%, AFC by 12%) (p &lt;0.05). By patients with implemented fertility function regardless of age and by all patients under the age of 35, undergoing surgery because of ovarian apoplexy for the first time, bipolar coagulation is permissible to stop bleeding. At implementation of bipolar hemostasis of patients with ovarian apoplexy, point coagulation of bleeding vessels should be performed, avoiding damage to surrounding tissues.&#x0D; &#x0D; &#x0D;