Electrosurgical Devices Research Articles

ВОПРОСЫ БЕЗОПАСНОСТИ ПАЦИЕНТОВ ПРИ ПРИМЕНЕНИИ ЭЛЕКТРОХИРУРГИЧЕСКИХ ТЕХНОЛОГИЙ

n the organization of modern surgical practice, one of the main and undoubtful trends is to ensure and control the safety of patients undergoing surgery, which, in turn, serves as the basis for the proper level of quality of medical care. The development of modern surgery is inconceivable without the use of the latest technologies. But along with their high efficiency, there are also certain dangers. A wide range of equipment used in surgery requires deep knowledge of medical personnel on its safe use. It should be noted that the increase in the volume of new technologies will only increase. This is primarily associated with the progress in surgery. The article discusses the basics of monopolar and bipolar electrocoagulation. The possible effects of electrocoagulation depending on the settings of high-frequency electrosurgical devices are described. The causes of alternative electrical current output from the patient's body and electrical burns are considered. The variants and procedure for installing neutral electrodes are presented. The features of electric shock during laparoscopic surgeries are described. The recommendations for electrical safety of patients during surgical interventions are given.

Tailored lateral internal sphincterotomy (T-LIS) for chronic anal fissure by LigaSure Small Jaws©: a comparison with other non-conservative treatments for anal fissures

An anal fissure is a small tear in the thin tissue (mucosa) that lines the anus. Anal fissures typically cause pain and bleeding with bowel movements. The cause is not fully understood, but low intake of dietary fiber may be a risk factor. Chronic anal fissure was defined as a split or ulceration in the posterior or anterior anoderm for at least 6 weeks: have distinct anatomic features such as muscle fibers visible in the wound. Anal fissures can be attributed to constipation or repeated straining: a hard fecal bolus cut the mucosa of anal canal that is relatively thigh at sphincter level management and optimal treatment of the disease is controversial. Many studies recommend conservative and medical treatment modalities as the initial treatment options since they are non-invasive and do not have risks such as anal sphincter injury. Lateral internal sphincterotomy (LIS) is considered the gold standard for treatment of chronic anal fissure. Nonetheless, anal incontinence is one of the worrisome complications of LIS. Fissurectomy is another option among those techniques which address the issues with LIS. LigaSure© (Valleylab) is a bipolar electrosurgical device designed to deliver high current and very low voltage to tissue. It monitors tissue impedance between the jaws of the instrument and continuously adjusts the delivery of energy. The use of LigaSure Small Jaw was never reported for anal fissures in literature. We have applied the use of this device to a group of patients complaining for chronic anal fissure in order to verify if there is any advantage to perform it compared to traditional technique (blade, scissors, electrocautery).

Reprocessing capabilities of newly approved devices for use in surgery

IntroductionSingle-use medical devices used in surgery can create environmental waste and increased costs. Reprocessed medical devices may reduce cost and environmental impact. This study investigated the reprocessing capabilities of newly FDA-approved devices in surgery. MethodsDevices were identified using the publicly-available FDA Releasable 510(k) Database from 2018 to 2023 using the instrument product codes for laparoscope, general, and plastic surgery (GCJ); and electrosurgical (GEI) devices. GCJ and GEI devices were categorized based on usage, and the number of devices (total, single, and reprocessed) were extracted. Costs were obtained from public websites. ResultsThere were 658,510(k) applications for surgical devices, representing 3.8 % (658/16723) of total applications. Reprocessing capabilities existed for 29 % of GCJ devices and 14 % of GEI devices. Among GCJ devices, 5 (56 %) laparoscopy and 16 (38 %) camera devices had reprocessing capabilities. For GEI devices, 7 (50 %) laparoscopic and 5 (50 %) cable devices had reprocessing capabilities. Only one (6 %) tissue ablation device had reprocessing capabilities. The average cost of GCJ and GEI single-use devices ($11314; $8554, respectively) was less than reprocessed counterparts ($17206; $16134, respectively). ConclusionReprocessing capabilities for newly approved surgical devices are variable and overall limited. To enhance adoption of reprocessing in surgical practice, future efforts will likely be needed to expand the reprocessing potential of new surgical devices.

Robotic liver parenchymal transection using the SynchroSeal

BackgroundThere is much heterogeneity in the instrumentation used for parenchymal transection in minimally invasive liver surgery. Instruments specifically designed for robotic parenchymal transection of the liver are lacking. We aim to gain insight into the safety and effectiveness of the SynchroSeal (Intuitive Surgical, Inc., Sunnyvale, CA), a novel bipolar electrosurgical device, in the context of liver surgery.MethodsThe present study is a post-hoc analysis of prospectively collected data from patients undergoing robotic liver resection (RLR) using the SynchroSeal in two high-volume centres. The results of the SynchroSeal were compared with that of the previous generation bipolar-sealer; Vessel Sealer Extend (Intuitive Surgical, Inc., Sunnyvale, CA) using propensity score matching, after excluding the first 25 Vessel Sealer procedures per center.ResultsDuring the study period (February 2020–March 2023), 155 RLRs meeting the eligibility criteria were performed with the SynchroSeal (after implementation in June 2021) and 145 RLRs with the Vessel Sealer. Excellent outcomes were achieved when performing parenchymal transection with the SynchroSeal; low conversion rate (n = 1, 0.6%), small amounts of intraoperative blood loss (median 40 mL [IQR 10–100]), short hospital stays (median 3 days [IQR 2–4]), and adequate overall morbidity (19.4%) as well as severe morbidity (11.0%). In a matched comparison (n = 94 vs n = 94), the SynchroSeal was associated with less intraoperative blood loss (48 mL [IQR 10–143] vs 95 mL [IQR 30–200], p = 0.032) compared to the Vessel Sealer. Other perioperative outcomes were similar between the devices.ConclusionThe SynchroSeal is a safe and effective device for robotic liver parenchymal transection.

Development of a high-frequency electrosurgical device and analysis of the results of post-registration clinical trials in comparison with world analogs

Development of a high-frequency electrosurgical device and analysis of the results of post-registration clinical trials in comparison with world analogs

Simultaneous sealing and bisection of porcine renal blood vessels, ex vivo, using a continuous-wave, infrared diode laser at 1470 nm

Electrosurgical and ultrasonic devices are used in surgical procedures for hemostatic sealing and bisection of vascular tissues. Previous benchtop studies alternatively demonstrated successful infrared laser sealing and cutting of blood vessels, in a sequential, two-step approach. This study describes a smaller, laparoscopic device compatible design, and simultaneous approach to sealing and bisection of vessels, with potential optical feedback. A 1470-nm infrared diode laser sealed and bisected 40 porcine renal arteries, ex vivo. A reciprocating, side-firing, optical fiber, housed in a transparent square quartz optical chamber (2.7 × 2.7 × 25 mm outer dimensions), delivered laser energy over an 11 mm scan length, with a range of incident powers (41–59 W) and treatment times (5–21 s). Vessel diameters ranged from 2.5 to 4.8 mm. Vessel burst pressure measurements were performed on each cut end (n = 80) with success indicated by pressures exceeding 360 mmHg. All vessel ends were successfully sealed and bisected (80/80). The highest incident power, 59 W, yielded short treatment times of 5–6 s. Peak temperatures on the external chamber surface reached 103 oC. Time to cool down to body temperature measured 37 s. Infrared lasers simultaneously seal and bisect blood vessels, with treatment times comparable to, and temperatures and cooling times lower than reported for conventional devices. Future work will focus on integrating the fiber and chamber into a standard 5-mm-outer-diameter laparoscopic device. Customization of fiber scan length to match vessel size may also reduce laser energy deposition, enabling lower peak temperatures, treatment times, and cooling times.

PlasmaBlade versus Electrocautery for Deep Inferior Epigastric Perforator Flap Harvesting in Autologous Breast Reconstruction: A Comparative Clinical Outcome Study.

(1) Background: DIEP-based breast reconstruction necessitates wide undermining at the abdominal donor site, creating large wound areas. Flap harvesting is usually conducted using electrosurgical dissection devices. This study sought to compare the clinical outcomes in patients after using the PEAK PlasmaBlade (PPB) versus monopolar electrocautery (MPE). (2) Methods: This retrospective cohort study included 128 patients with DIEP-based breast reconstruction. Patient characteristics and information on the postoperative course were collected and a comparative evaluation was conducted. (3) Results: The MPE group exhibited significantly (p* = 0.0324) higher abdominal drainage volume (351.11 ± 185.96 mL) compared to the PPB group (279.38 ± 183.38 mL). A subgroup analysis demonstrated that PPB significantly reduced postoperative wound fluid in patients with BMI > 30 kg/m2 (p* = 0.0284), without prior neoadjuvant chemotherapy (p** = 0.0041), and among non-smokers (p = 0.0046). Furthermore, postoperative pain was significantly (p**** < 0.0001) lower in the PPB cohort. (4) Conclusions: This study confirms the non-inferiority of the PEAK PlasmaBlade to conventional electrocautery for abdominal flap harvesting. The PPB demonstrated advantages, notably reduced drainage volume and lower postoperative pain levels. Recognizing patient subsets that benefit more from the PPB highlights the importance of personalized device selection based on patient characteristics.

Hysteroscopic Metroplasty Using Holmium: YAG Laser for Treatment of Septate Uterus

To demonstrate the safety, efficacy, and ease of hysteroscopic metroplasty using holmium:YAG (Ho:YAG) laser for treatment of septate uterus. Stepwise demonstration of surgical technique with narrated video footage. Septate uterus is the most common type of uterine anomaly. The incidence of uterine septum in women presenting with infertility and recurrent abortions is 15.4% [1,2]. Hysteroscopic septal incision is associated with improvement in live-birth rate in these women [3]. Hysteroscopic metroplasty for septate uterus can be done with the use of scissors and energy sources such as monopolar and bipolar electrosurgery and lasers. Ho:YAG laser is commonly used by urologists for various surgeries because of its "Swiss Army Knife" action of cutting, coagulation, and vaporization [4]. Ho:YAG laser is known for its precision. It causes lesser depth of tissue injury and necrosis and minimal collateral thermal damage compared with the electrosurgical devices and other lasers used for hysteroscopic surgery [5-8]. This is advantageous in hysteroscopic metroplasty given that it reduces the risk of uterine perforation during surgery and hence uterine rupture in the subsequent pregnancy. Reduced collateral damage to the surrounding endometrium helps promote early endometrial healing and prevent postoperative intrauterine adhesions. A 28-year-old patient with history of 2 spontaneous abortions came to our hospital for investigations. 3D transvaginal sonography of the patient showed presence of partial septate uterus with a fundal indentation of 1.5 cm (Supplemental video 1). Diagnostic hysteroscopy followed by septal incision using Ho: YAG laser was planned. We used a 2.9 mm BETTOCCHI Hysteroscope (Karl Storz SE & Co.) with a 5 mm operative sheath. Normal saline was used as the distending medium and the intrauterine pressure was maintained at 80 to 100 mm Hg. The procedure was done under total intravenous anesthesia using propofol injection. Vaginoscopic entry into the uterus (without any cervical dilatation) showed evidence of a partial uterine septum with tubal ostia on either side of the septum. A 400 micron quartz fiber was passed through a laser guide into the 5-Fr working channel of the operative hysteroscope. Ho:YAG laser (Auriga XL 50-Watt, Boston Scientific) with power settings of 15 watts (1500 mJ energy at 10 Hz) was used. Incision of the septum was started at the apex of the septum in the midline and continued in a horizontal manner from side to side toward the base (Supplemental video 2). Incision of the septum is continued till the tip of the hysteroscope can move freely from one ostium to the other (Supplemental video 3). The operative time was 12 minutes. There were no intra- or postoperative complications. Postoperative estrogen therapy was given for 2 months in the form of estradiol valerate 2 mg (tablet, Progynova, Zydus Cadila) 12 hourly orally for 25 days and medroxyprogesterone acetate 10 mg (tablet, Meprate, Serum Institute of India, Ltd) 12 hourly orally added in the last 5 days [9]. 3D transvaginal ultrasound was done on day 8 of menses. It showed a triangular uterine cavity with a very small fundal indentation of 0.37 cm. A second look hysteroscopy that was done on day 9 of menses showed an uterine cavity of good shape and size [10]. Few fundal adhesions were seen and they were incised using Ho:YAG laser. The patient conceived 5 months after the primary surgery and delivered by cesarean section at 38 weeks, giving birth to a healthy baby of 2860 grams. There were no complications during her pregnancy and delivery. A comparative study is essential to prove its advantages over other energy sources for this surgery. Hysteroscopic metroplasty using Ho:YAG laser for treatment of septate uterus is a simple, precise, safe, and effective procedure. VIDEO ABSTRACT.

A novel discrete linkage-type electrode for radiofrequency-induced intestinal anastomosis

Introduction For decades, radiofrequency (RF)-induced tissue fusion has garnered great attention due to its potential to replace sutures and staples for anastomosis of tissue reconstruction. However, the complexities of achieving high bonding strength and reducing excessive thermal damage present substantial limitations of existing fusion devices. Materials and methods This study proposed a discrete linkage-type electrode to carry out ex vivo RF-induced intestinal anastomosis experiments. The anastomotic strength was examined by burst pressure and shear strength test. The degree of thermal damage was monitored through an infrared thermal imager. And the anastomotic stoma fused by the electrode was further investigated through histopathological and ultrastructural observation. Results The burst pressure and shear strength of anastomotic tissue can reach 62.2 ± 3.08 mmHg and 8.73 ± 1.11N, respectively, when the pressure, power and duration are 995 kPa, 160 W and 13 s, and the thermal damage can be controlled within limits. Histopathological and ultrastructural observation indicate that an intact and fully fused stomas with collagenic crosslink can be formed. Conclusion The discrete linkage-type electrode presents favorable efficiency and security in RF-induced tissue fusion, and these results are informative to the design of electrosurgical medical devices with controllable pressure and energy delivery.

Applications of electrothermal bipolar vessel sealing devices in transoral head and neck surgery

AbstractObjectiveElectrothermal bipolar vessel sealing devices are electrosurgical devices that seal tissues and blood vessels up to 7 mm in diameter. This paper discusses our experience using electrothermal bipolar vessel sealing devices in transoral head and neck surgery.MethodsElectrothermal bipolar vessel sealing devices were used in five patients with lesions of varying size and type within the pharyngo-larynx. These were treated transorally by the otolaryngology department at the Royal Adelaide Hospital. Either the Medtronic LigaSure or BiZact devices were used for transoral resection, debulking or division of these lesions.ResultsElectrothermal bipolar vessel sealing devices were considered helpful in four out of the five cases. Success was dependent on suitable transoral access. A single unsuccessful case reflected the LigaSure jaw's inability to engage a large tumour effectively.ConclusionElectrothermal bipolar vessel sealing devices can be safely deployed transorally to treat lesions of the upper aero-digestive tract in selected patients. Further studies investigating additional indications would broaden applications of this approach.

Concurrent laparoscopic highly selective vagotomy with closure of duodenal ulcer perforations show good clinical results as primary repair alone.

To compare clinical and operative results between laparoscopic primary repair (LPR) alone and LPR with highly selective vagotomy (LPR-HSV) in patients with duodenal ulcer perforation. Clinical data from patients who underwent either LPR or LPR-HSV by resecting both sides of the neurovascular bundle using an ultrasonic or bipolar electrosurgical device for duodenal ulcer perforations, between 2010 and 2020, were retrospectively collected. Between-group differences in continuous and categorical variables were statistically analysed. Data from 184 patients (mean age, 49.6 years), who underwent either LPR (n = 132) or LPR-HSV (n = 52) were included. The mean operation time was significantly longer in the LPR-HSV group (116.5 ± 39.8 min) than in the LPR group (91.2 ± 33.3 min). Hospital stay was significantly shorter in the LPR-HSV group (8.6 ± 2.6 days) versus the LPR group (11.3 ± 7.1 days). The mean postoperative day of starting soft fluid diet was also significantly shorter in the LPR-HSV group (4.5 ± 1.4 days) than in the LPR group (5.6 ± 4 days). No between-group difference in morbidity rate was observed. The learning curve of the HSV procedure showed a stable procedure time after 10 operations. LPR with HSV may be a safe and feasible procedure for selective cases who are at high risk for ulcer recurrence.

Risk mitigation to healthcare workers against viral and bacterial bioaerosol load in laparoscopic surgical exhaust with a new flow mode in hollow fiber membranes-based filter

Laparoscopy of COVID-19-infected/suspected patients needs to be performed with the utmost care due to the chances of virus carryover through the pneumoperitoneum gas. In this study, polysulfone/polyvinyl-pyrrolidone hollow fiber membranes (HFMs) were fabricated by phase inversion process, and these HFMs were bundled into a module consisting of tortuous, circular-helical arrangement. Further, copper (Cu) and zinc (Zn) nanoparticles (NPs), known to have antimicrobial and antiviral properties, were flow-coated on the lumen side of the HFMs. To test functional efficiency, the modules were challenged with wet aerosol and bioaerosols. Wet aerosol removal efficiency was ∼98%. Bioaerosol-containing bacteria E. coli strain K-12, showed 2.6 log (∼99.8%), and 2.1 log (∼99.3%) removal efficiency for Cu NPs and Zn NPs coated HFMs modules, respectively, and 1.6 log (∼97%) removal for plain (uncoated) HFMs. Bioaerosols containing SARS-CoV-2 surrogate virus (MS2 bacteriophage) showed ∼5–7 log reduction of bacteriophage for plain HFMs, 3.9 log, and 2.3 log reduction for Cu and Zn coated HFMs, respectively. The flow of aerosols entirely through the HFM lumen helps in attaining a low ΔP of < 1 mm Hg, thus rendering its usefulness, particularly for exhausting pneumoperitoneum gases where high upstream pressures could lead to barotrauma. Statement of environmental implicationSurgical smoke is generated during minimally invasive surgical (MIS) procedure such as laparoscopy when electrosurgical devices are used to cut any tissues. This smoke is a hazard as it contains toxic volatile compounds, mutagens, carcinogens, bacteria, and virus-laden aerosols. Infection to healthcare professionals through the bioaerosols containing smoke is well reported in literature. The limitation of using hypochlorite and pleated/HEPA filter, led us to design a low pressure drop bioaerosol filter, which can remove smoke, tissue fragments, and COVID-19 virus. It provides a much safer operation theatre environment during MIS procedures as well as in general for bioaerosol removal.

Implementation of an Electrosurgical Checklist in a Podiatry Unit in Relation to a Case of Inadvertent Burns during Hallux Valgus Surgery

Iatrogenic burns are unpleasant and sometimes difficult to explain to patients. Podiatric surgeons routinely use electrosurgical devices to cut and coagulate tissue during surgical procedures. Although advances in technology have made electrosurgery increasingly safer for patients and personnel, its use is still poorly understood by the surgical community, and the hazards associated with its use still exist presently. Human error, direct or indirect transfer of electricity to a conductive device, or device malfunction can cause serious adverse events, including burns, electrical shocks, and or fires. Here, we report a rare case of a 43-year-old man who suffered severe burns during hallux valgus surgery. The surgeon and the nursing staff did not notice any injuries during the surgical intervention. This unusual clinical case serves to highlight the importance of implementing protocols to prevent injuries related to the use of electrosurgery. Based on this report, a specific checklist was implemented to prevent adverse events related to electrosurgery in our podiatric surgery unit to reduce the risk of electrosurgical complications. The implementation of the checklist can be useful to help health professionals improve patient safety during surgery and avoid potential medico–legal liability claims.

A retrospective comparative study of hemorrhoidal artery ligation versus ligasure hemorrhoidectomy for the third degree hemorrhoidal disease

BackgroundHemorrhoidal disease (HD) is the most common disease of the anorectal region. Excision of pathological hemorrhoidal structures by providing bipolar energy transfer with Ligasure, which is basically an electrosurgical device, is one of the treatment methods Ligasure hemorrhoidectomy (LH). In another method applied for the first time by Morinaga, the vascular plexus is provided by Doppler-guided ligation of the hemorrhoidal arteries (ADHL). In our study, we aimed to compare and evaluate the results of these two minimally invasive treatment methods. Materials and methodsPatients treated with ADHL and LH for HD in our Surgery Clinic were included in the study. Demographic data, complaints, number of hemorrhoidal structures, location, complications, operation time, bleeding during and after the operation, length of hospital stay, postoperative pain scoring, and postoperative results were evaluated from the patient files. ResultsThe number of patients included in the study was 91. While 54 patients were treated with ADHL (group 1), 37 patients (group 2) were treated with LH. Although the gender distribution between the groups was similar, there was male predominance in both groups. The mean operative time was shorter in group 1. The number of packages was 2.7 in group 1 and 2.4 in group 2. The mean hospital stay was 1.5 days in the ADHL-treated group, compared to.3.05 days in the LH group. In the postoperative period, bleeding was not observed after an average of 1.4 days in group 1, while this period was 4.9 days in group 2. While recurrence occurred in 4 patients in the ADHL group, recurrence developed in 3 patients who underwent LH. ConclusionADHL and LH techniques have advantages and disadvantages over each other. Although the ADHL technique seems to be superior to LH in terms of post-defecation pain and shorter hospital stay, prospective randomized controlled studies are needed to determine which method should be chosen in which patient.

Aesculap Caiman Articulating Electrosurgical Device

Aesculap Caiman Articulating Electrosurgical Device

Effect of longitudinal-bending elliptical ultrasonic vibration assistance on electrosurgical cutting and hemostasis

Electrosurgical devices are widely used for tissue cutting and hemostasis in minimally invasive surgery (MIS) for their high precision and low trauma. However, tissue adhesion and the resulting thermal injury can cause infection and impede the wound-healing process. This paper proposes a longitudinal-bending elliptical ultrasonic vibration-assisted (EUV-A) electrosurgical cutting system that incorporates an ultrasonic vibration in the direction of the cut by introducing an elliptical motion of the surgical tip. Compared with a solely longitudinal ultrasonic vibration-assisted (UV-A) electrosurgical device, the EUV-A electrode contacts the tissue intermittently, thus allowing for a cooler cut and preventing tissue accumulation. The experimental results reveal that the EUV-A electrode demonstrates better performance than the UV-A electrode for both anti-adhesion and thermal injury through in vitro experiments in porcine samples. The tissue removal mechanism of EUV-A electrosurgical cutting is modeled to investigate its anti-adhesion effect. In addition, lower adhesion, lower temperature, and faster cutting are demonstrated through in vivo experiments in rabbit samples. Results show that the EUV-A electrode causes lower thermal injury, indicative of faster postoperative healing. Finally, efficacy of the hemostatic effect of the EUV-A electrode is demonstrated in vivo for vessels up to 3.5 mm (equivalent to that of electrocautery). The study reveals that the EUV-A electrosurgical cutting system can achieve safe tissue incision and hemostasis.

Antiadhesion Superhydrophobic Bipolar Electrocoagulation Tweezers with High Conductivity and Stability.

Irregularly shaped electrosurgical devices face significant challenges in electrosurgery due to serious blood and tissue adhesion. Superhydrophobic surfaces inspired by lotus leaves have attracted great attention for their promising antiadhesion properties. However, there are few methods for efficiently preparing superhydrophobic irregularly shaped bipolar electrocoagulation tweezers (BETs). Herein, we propose a simple and environmentally friendly method to fabricate antiadhesion superhydrophobic surfaces on BETs. The superhydrophobicity is obtained by combining laser texturing to form rough structures and low surface energy modification via stearic acid. The formation mechanism of superhydrophobicity is investigated through analyzing microstructures and chemical compositions by scanning electron microscopy, white-light interferometry, and X-ray photoelectron spectroscopy. The functionalized BET surfaces exhibit excellent water repellency with a contact angle of 159.6°, a roll-off angle of 1°, and a surface energy of 14.3 mJ/m2, possessing excellent antiadhesion properties against blood, chicken breast tissue, and pork tissue. Compared with ordinary BETs, the mass of blood, pork tissue, and chicken breast tissue adhered to the superhydrophobic BET is reduced by 97.70, 70.34, and 75.35%, respectively. Moreover, the superhydrophobic BETs have excellent conductivity and maintain good antiadhesion properties after low-temperature storage for 2 weeks, after being impacted by sand and blood and 30 cycles of tape peeling tests. With outstanding antiadhesion performance, the superhydrophobic BET may have promising application prospects in the electrosurgery field.

Sutureless Thyroidectomy Using Electrosurgical Devices

Sutureless Thyroidectomy Using Electrosurgical Devices

Formaldehyde Reduction in an Operating Room Setting: Comparison of a Catalytic Surgical Vacuum Device With a Traditional Smoke Evacuator.

Introduction Electrosurgery exposes healthcare workers to volatile organic compounds (VOCs) including formaldehyde. Adopting electrosurgical devices that catalytically transform formaldehyde to benign substances has the potential to improve safety in surgical settings. Materials and methods We compared the efficiency of formaldehyde removal of two medical devices.The first was a novel surgical vacuum (SV) device containing ultra-low particulate air (ULPA) filtration, activated carbon and catalytic transition metal oxide.The second was a commonly utilized handpiece evacuator (HE) that contained only mechanical filtration and activated carbon granules. Both devices were exposed to formalin vapor. Results The time weighted average (TWA), median and peak concentrations of detected formaldehyde at the outflow of the SV unit were 90% lower than the corresponding values detected at the outflow of the HE device (p = 0.0034). When catalytic material was added to the HE device, the detected formaldehyde concentration at the outflow was reduced by 55%(p = 2.9 x 10-15). Conclusions The catalytic SV device has the potential to considerably reduce formaldehyde levels in operating room (OR) environments.

Indocyanine Green–Assisted Retrograde Ureterolysis in Robotic Transvaginal NOTES for the Management of Stage IV Endometriosis with Obliterated Cul-de-sac

To explore the use of indocyanine green (ICG) in highlighting ureteral anatomical landmarks for the successful and safe execution of robotic-assisted transvaginal NOTES hysterectomy with resection of deeply infiltrated endometriosis. Stepwise demonstration with narrated video footage. An academic tertiary care hospital. Our patient is a 38-year-old G4P1031 with a symptomatic enlarged uterus secondary to adenomyosis and uterine myomas, dense adhesions between the posterior uterus, and left uterosacral ligament. Stage IV endometriosis with obliterated cul-de-sac is a challenging procedure in the surgical management of endometriosis. Ureterolysis is the key step to performing this surgery successfully and safely; however, the routine dissection of ureters from the sacral promontory level to the uterine artery is challenging in obliterated cul-de-sacs with pelvic side wall adhesions with the proximal ureter at greatest risk [1-4]. Using the ICG firefly technique allowed us to rapidly identify and safely dissect the ureter through robotic transabdominal endometriosis surgery [5,6]. The angle of approach in transvaginal NOTES surgery for hysterectomy with obliterated cul-de-sac endometriosis leads to far more difficulty in identifying the ureter at the beginning of surgery [3]. Therefore, an obliterated cul-de-sac was associated with a potentially increased risk of ureteral injury and bowel injury. We used ICG to help identify the ureter at the beginning of the case leading to reducing the risk of surgical complication, in which the concept of ureterolysis from the level of the uterine artery to the bifurcation of common iliac vessels in vNOTES surgery will be referred to as "vNOTES retrograde ureterolysis." With the cystoscope in place, a ureteral catheter was inserted into the right ureter and 5 cc of ICG was injected, and the same procedure was done on the left [1,5]. Bovie electrosurgical device was used to incise circumferentially around the cervix. The bladder was dissected off the pubovesical cervical fascia anteriorly and posteriorly with a combination of the Bovie as well as blunt and sharp dissection. Bilateral uterosacral and cardinal ligaments, as well as uterine arteries, were then clamped, transected with Mayo scissors, and secured. Entry into the anterior cul-de-sac was completed, and a stitch using 0 vicryl was used to tag the anterior peritoneum to the anterior vaginal cuff.Posterior entry was attempted unsuccessfully. The Gelpoint mini device was then placed, and the Da Vinci XI robot was docked. Bilateral ureters were identified and dissected out of bilateral pelvic sidewalls using the firefly mode at the level of the uterine artery. The ureters were easily dissected away from the uterus. The left broad ligament was then cauterized and transected using the vessel sealer. The plane between the uterus and the rectum was identified laterally, and the rectum was taken down from the uterus from the right to the left side.Bilateral broad ligaments were then cauterized and transected using the vessel sealer, followed by cauterization and transection of the round ligaments, utero-ovarian ligaments, and mesosalpinx bilaterally. The vaginal cuff angles were secured with a figure-of-eight stitch of 0 vicryl, and the vaginal cuff was then closed in a running fashion with 0 V-Loc.The patient was discharged in one day with reports of minimal pain (Videos 1-3). Robotic-assisted NOTES hysterectomy with deeply infiltrated endometriosis resection is feasible and safe with ICG-assisted ureteral labeling in a case of obliterated cul-de-sac. The unique green color labeling of ureters offers a prominent landmark in assisting the ureteral dissection while avoiding ureteral and bowel injury, resulting in the possibility of using vNOTES surgery in challenging cases.