Monopolar Dissection Research Articles

Does the use of monopolar energy as the preferred mode of dissection effectively reduce seroma formation in laparoscopic total extra peritoneal hernioplasty? A prospective double-blinded randomized control trial.

Seroma is a commonly encountered sequela after hernia repair. Tremendous effort has been spent to investigate the effective way to prevent this "complication" including the modification of surgical technique, use of per-peritoneal drainage, etc. There were debates about the use of monopolar diathermy versus blunt dissection in laparoscopic TEP in the prevention of seroma formation. This randomized study aims to compare the effects of using 2 techniques in laparoscopic TEP on pre-peritoneal drain output and seroma formation. From 1.9.2018 to 30.9.2019, all male and female patients presented with the first occurrence, unilateral inguinal hernia anticipated for laparoscopic TEP were enrolled into the study after informed consent. Patients were randomized into "monopolar dissection preferred" (MDP) group and "blunt dissection-preferred" (BDP) group just before commencing of operation after general anesthesia. Surgeons were instructed to use monopolar energy as main dissection method for the whole operation if possible (MDP), whereas blunt dissection is the preferred choice in BDP group, but the use of monopolar energy was allowed if needed. Total energy time was measured by a specially designed homemade device attaching to the monopolar pedals as accurate as to millisecond (ms). Pre-peritoneal drains were inserted for drainage and removed 23h after operation. Drainage output, total operating time, energy time, clinical and ultrasonic seroma sizes at day 1, day 6, 1-month post operations, recurrence are compared between 2 groups. A total of 103 patients where included. There was no significant difference in age, gender, co-morbidities, side of hernia, mean defect size, operating time, fixation adjuncts, or postoperative stay. The drain volume in BDP group is 71.13 ± 31.42mL while it in MDP group is 56.36 ± 21.46mL. The MDP group had significantly fewer drain output at 23h post operation (p = 0.007) and lower seroma incidence on days 6 (p = 0.036). Overall incidence of seroma formation was 12% on postoperative day 1, 11% on postoperative day 7. No statistically differences in postoperative pain score or complications were observed at the first week, 1- and 3-months' post operation. There was no correlation with energy time to the drain output. No recurrence was found in subsequent follow-up. Pre-peritoneal drainage is clinically safe in laparoscopic totally extra-peritoneal hernioplasty and can effectively reduce the size and incidence of seroma. The seroma formation can be further reduced by appropriate use of monopolar energy as preferred dissection approach in lap TEP. Due to limitation in measuring the actual energy time, the result should be further validated by randomized multi-centers trial on its potential benefit in hernia repair by a more accurate measuring device on energy used.

Secondary tonsillar hemorrhage requiring surgical intervention: Analysis of 1429 tonsillectomy cases on single surgeon experience

Objective: Determination of risk factors affecting secondary tonsillar hemorrhage of the requiring surgical intervention. Material and Method: 1429 tonsillectomy cases performed with three different dissection techniques (dissection and snare, bipolar and monopolar dissection) by a single surgeon were examined retrospectively.  Age, sex, surgical knowledge, indications and postoperative tonsillar hemorrhage day of the patients were recorded. Patients who were operated on for hemorrhage were evaluated statistically in terms of technique used, age, sex and indications. Findings: A total of 25 cases of a secondary hemorrhage cases requiring surgical intervention were detected. The relationship between age and bleeding was statistically significant (p=0.003). Hemorrhage frequency requiring surgical intervention was significantly higher in patients with recurrent tonsillitis than in patients with tonsillar hypertrophy (p = 0.001). 19 of the 25 patients who were operated on for hemorrhage were in the group of tonsillectomy patients due to recurrent tonsillitis. There was no meaningful relationship in terms of sex. The hemorrhage rate in the dissection and snare technique was 1.74% (12 patients), the hemorrhage rate in bipolar dissection was 2.78% (9 patients), and the monopolar dissection- hemorrhage rate was 0.96% (4 patients). There was no statistically significant difference between the results (p = 0.170). It was determined that the hemorrhage required surgery at most was between 6th and 10th days. Conclusion: While there was no significant relationship between the incidence of secondary tonsillar hemorrhage requiring surgery and gender and dissection techniques, it has been observed that the risk was increased in patients operated due to recurrent tonsillitis and older age group.

Lower-pole intracapsular tonsillectomy in obstructive sleep apnea patients

Conclusion: Lower-pole intracapsular tonsillectomy (LPIT) is a valuable surgical technique capable of decreasing post-operative bleeding in obstructive sleep apnea (OSA) patients.Objective: This study performed LPIT to simultaneously reduce post-operative bleeding of lower pole and prevent recurrent tonsillitis of upper pole and compared its effects to extracapsular tonsillectomy (ET).Methods: ET was performed in the extracapsular plane, with complete monopolar dissection. In LPIT, the upper pole of palatine tonsil was removed by electrocautery with the extracapsular plane, followed by removal of the lower-pole by plasma ablation with the intracapsular plane. Post-operative bleeding incidence, bleeding site, and degree of pain were compared between the two groups.Results: Three hundred and forty-seven patients diagnosed of OSA with polysomnography were enrolled. ET was performed in 152 patients and LPIT in 195 patients. There were no significant differences in post-operative pain between the two groups. The LPIT group showed significantly lower total bleeding incidence than the ET group (4.1% vs 9.2%; p = .05). In particular, lower-pole bleeding incidence was lower in the LPIT group than the ET group (1.0% vs 5.3%; p = .02).

Survey-based analysis of fundamental tasks for effective use of electrosurgical instruments

Despite widespread use of electrosurgical instruments, there are no widely accepted tasks for training and evaluation of technical skills. The purpose of this study is to propose a set of tasks and report experts' evaluations of the proposed tasks for validity, technical skills versus knowledge requirements, and utility for future privileging curricula. A set of seven hands-on tasks involving electrical energy were identified based on the fundamental use of surgical energy (FUSE) curriculum of the Society of American Gastrointestinal and Endoscopic Surgeons. A web-based survey was developed based on the seven identified tasks, with seven questions asked for each task. These questions rated candidate tasks on their suitability for validation studies, the role of manual skills, and the appropriateness of including the task in privileging curricula. Members of the FUSE committee were sent the web-based survey, and responses were recorded. Of the 27 members of the FUSE committee, 16 responded to the survey. A total of 775 Likert-style responses were recorded and quantified to a 1-5 range. Overall, responses within task-question pairs had a mean standard deviation of 0.83, suggesting general agreement. Tasks requiring bi-manual dexterity scored higher than single-handed tasks on a combined, four-question Likert-scale index for task validation (p < 0.0001), and a two-question index for manual skills (p < 0.0001). Survey responses indicated general agreement that the identified tasks represent important technical skills and are consistent with actions in the operating room. Bimanual tasks were favored for validation purposes over single-handed tasks. The traction and monopolar dissection and monopolar coaptation tasks had the highest agreement with validation-oriented questions (97 and 87 %, respectively).

Intraoperative Use of FloSeal with Adenotonsillectomy to Prevent Adverse Postoperative Outcomes in Pediatric Patients

The purpose of this study was to compare postoperative complications associated with monopolar dissection adenotonsillectomy, with and without the application of FloSeal at the completion of the procedure. Retrospective cohort study. Tertiary care pediatric hospital. This was a retrospective cohort study of 800 cases of adenotonsillectomy. Two cohorts of patients were identified based on whether or not FloSeal was used intraoperatively during the completion of the monopolar dissection adenotonsillectomy. Outcomes that were measured included: (1) age, (2) sex, (3) diagnosis, (4) primary hemorrhage, (5) secondary hemorrhage, (6) return to operating room, and (7) dehydration. All binomial outcomes measured were subjected to chi-square and t tests. Age and gender were similar between the 2 groups. Chronic tonsillitis was the primary indication more often in the control group; this was statistically significant. Primary hemorrhage occurred in 1 subject from each group (0.28%); secondary hemorrhage occurred in 11 subjects from the FloSeal group (3.22%) and 7 from the control group (1.87%). Both outcomes were not statistically different between the 2 groups. Return to operating room showed no statistically significant difference between groups. The need for postoperative admission for dehydration failed to show statistical significance between groups. In our experience, the application of FloSeal hemostatic matrix after monopolar adenotonsillectomy demonstrates no additional reduction in postoperative adverse events encountered in the pediatric population. Specifically, our data failed to demonstrate statistically significant reduction of: (1) primary hemorrhage, (2) secondary hemorrhage, (3) return to operating theatre, or (4) dehydration.

Factors influencing histopathology-assessed TME quality after low anterior rectal resection: Results of a prospective multicenter observational trial.

3547 Background: Total mesorectal excision (TME) has become standard of care in rectal cancer surgery, leading to a massive reduction in local recurrence rate. However, incomplete TME is associated with an increase in local recurrences. To date, there are no reliable data on clinical factors predicting incomplete TME in patients undergoing rectal cancer surgery. We used the data set of the German Quality Assurance in Rectal Cancer Surgery prospective multicenter observational trial to investigate this issue under routine clinical care conditions. Methods: This is a retrospective analysis of a prospectively gathered data set involving >300 German hospitals of all levels of care. Patients undergoing low anterior rectal resection for rectal cancer between 01/01/05 and 12/31/09 were included. Multivariate analysis using a stepwise logistic regression model was performed in order to identify factors predicting suboptimal TME as determined at postoperative histopathology. Risk factors analyzed included age, BMI, tumor distance from the anal verge, neoadjuvant therapy, duration of surgery, surgeon experience, laparoscopic vs. open approach, dissection technique, intraoperative complications, and pT stage. Results: A total of 6,179 patients were included. Due to missing data for one or more parameters 1,573 patients had to be removed from the data set, leaving 4,606 patients for analysis. pT stage >2 (OR 1.22), tumor distance from the anal verge <8 cm (OR 1.27), advanced age (>65 years, OR 1.24; >80 years, OR 1.59), presence of intraoperative complications (OR 2.06), monopolar dissection technique (OR 1.44), and low experience of the operating surgeon (OR 1.20) were identified as being independently associated with moderate or poor TME quality. Conclusions: This is the largest analysis of factors predicting incomplete TME to date. Since good TME quality is a prerequisite for a low recurrence rate, rectal cancer surgery should be performed or supervised by experienced colorectal surgeons. Monopolar pelvic dissection technique should be avoided. On the other hand, laparoscopic approach and use of neoadjuvant therapy do not seem to increase the risk for incomplete TME.

Dissection versus diathermy for tonsillectomy

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2001 and previously updated in 2003.Tonsillectomy is a commonly performed surgical procedure. There are several operative methods currently in use, but the superiority of one over another has not been clearly demonstrated. To compare the morbidity associated with tonsillectomy by two different techniques - dissection and diathermy. We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3), PubMed, EMBASE, CINAHL, Web of Science, BIOSIS Previews, ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 1 October 2010, following a previous update search in 2003. Randomised controlled trials of children and adults undergoing tonsillectomy or adenotonsillectomy by dissection or diathermy techniques. Two review authors selected studies, extracted data and assessed risk of bias independently. Two studies (254 participants) are included in the review. The overall risk of bias in the included studies was low, although we excluded pain data from one study due to unclear risk of bias. One study compared monopolar dissection diathermy with conventional cold dissection in children and the other compared microscopic bipolar dissection with cold dissection in children and adults. These studies demonstrate reduced intraoperative bleeding, but increased pain in the diathermy group. There was no difference in the rate of secondary bleeding overall, although the power of both studies to detect a small difference was insufficient. There are insufficient data to show that one method of tonsillectomy is superior. There is evidence that pain may be greater after monopolar dissection. Large, well designed randomised controlled trials are necessary to determine the optimum method for tonsillectomy.

Dissection versus diathermy for tonsillectomy.

Tonsillectomy is a commonly performed surgical procedure. There are several operative methods currently in use, but the superiority of one over another has not been clearly demonstrated. To compare the morbidity associated with tonsillectomy by two different techniques - dissection and diathermy. Cochrane Controlled Trials Register, Medline (1966-2000), Embase (1974-2000). Reference lists were scanned for additional material. Randomised controlled trials of children and adults undergoing tonsillectomy or adenotonsillectomy by dissection or diathermy techniques. Trials were assessed for methodological quality according to the method outlined in the Cochrane Reviewers Handbook. The reviewers assessed each trial and extracted data independently. Twenty-two potential studies were identified for further assessment. Twenty trials were not included because they did not meet the inclusion criteria for randomisation methods, controls or outcome criteria. Two trials met the inclusion criteria, one comparing monopolar dissection diathermy with conventional cold dissection in children, and the other comparing microscopic bipolar dissection with cold dissection in children and adults. These studies demonstrate reduced intraoperative bleeding, but increased pain in the diathermy group. There was no difference in the rate of secondary bleeding overall, although the power of both studies to detect a small difference was insufficient. There are insufficient data to show that one method of tonsillectomy is superior. There is evidence that pain may be greater after monopolar dissection. Large, well designed randomised controlled trials are necessary to determine the optimum method for tonsillectomy.

Leiomioma do esôfago removido por videolaparoscopia

This report describes a leiomyoma of the inferior third section of the esophagus removed during laparoscopic cholecystectomy. The patient is a woman 55-years-age, carrying esophageal myoma of 40 mm in diameter wide, situated in the posterior wall of the lower esophagus. Indications for surgery were based mainly on the growth of the mass (6 mm when discovered 7 years previously, increased to 40 mm). Recently the patient returned suffering from pain, which could be attributed to his litiasic cholecystopaty. A small degree of low disphagia could also be observed. Radiologic imaging, direct endoscopic examination and endoscopic ultrasound showed that the mioma protruded on to the oesophagic lumen, discreetly diminishing there. A laparoscopic esophageal myomectomy was indicated at the same session of the laparoscopic cholecystectomy. Once the pneunoperitoneum was installed, five ports were placed as if for a hiatus hernia surgery. The cholecystectomy was uneventful. Next, an esophagoscopy was performed so as to determine the precise area covering the base of the tumour; at the right-lateral site. Longitudinal and circular fibres of the esophagus was severed over the lesion and the enucleation of the tumour was performed alternating the monopolar dissection, bipolar and hidrodisection. Control-endoscopy was carried out to verify mucosa integrity. Four suture points with poliglactine 3-0 string so as to close the musculature followed this. One suture was placed in for diminution of the size of the esophagean hiatus. Total time of intervention: two hours (30m for the cholecystectomy and one hour and thirty minutes for the myomectomy). Postoperative period: uneventful. Disappearance of the disphagia was observed. Radiologic transit control with water-soluble contrast at 4th post-operative day: good passage. Diagnosis from laboratory of pathology: conjunctive tumour formed by muscle non-striated cells: leiomyoma. The patient was re-examined on the two-month postoperative follow-up. General conditions were good and there were no complain of dysphagia. Neither there were any symptoms of gastro-esophageal reflux.