Monopolar Electrocautery Research Articles

Re: Video-assisted left inguinal lymphadenectomy for penile cancer

The concept of endoscopic inguinal dissection for penile cancer was proposed by Bishoff et al. from San Antonio, Texas, USA in 2003 with the dissection of 2 cadaveric models. After some modifications, the first case in clinical scenario was successfully operated at ABC Medical School, Sao Paulo, Brazil in 2003 by Tobias-Machado et al which nominate their procedure as VEIL (video endoscopic inguinal lymphadenectomy) (1). In order to achieve the maximum benefits of the minimally invasive approach, regarding mor-bidity reduction, the ABC Medical School technique was based in 10 major steps and we would like to emphasize 3 of them: distal lymphatic tissue ligation at the femoral triangle vertex, proximal control of visualized lymphatics with clips and ligation of the proximal portion of the lymphatic tissue at the deep portion of the femoral channel (2). We are concerned about these issues because in the presented video no lymphatic clipage was documented, the tissue was sectioned using only monopolar electro-cautery. This can increase the post-operative complications related to the lymphatic tissue, thereby reducing the benefits of minimally invasive procedure. It is fundamental to stress that no energy source (electric, ultrasonic, ligasure) can adequately seal lymphatic vessels. One other interesting observation is that monopolar energy can be used but control is needed when it is utilized near the skin to prevent an isquemic event. The present video demonstrates the dissection in the correct plane (under Scarpa´s fascia) to maintain some fat under the skin. A randomized comparison with open surgery in nonpalpable inguinal nodes patients showed a reduced overall complication rate of endoscopic technique (20 X 70%) specially related to skin events (0 x 40%) (3). The same number of nodes could be obtained comparing the approaches. Five year follow-up series showed cancer specific survival of 100% for negative inguinal nodes and 80% for positive nodes suggesting that VEIL is oncological effective (4). Veil is having a growing international acceptance but experience is yet small. Actually about 20 centers around the world performed the endoscopic procedure with success and very similar re-sults. Some centers are applying endoscopic surgery for other tumors as melanoma, vulvar and anal cancers. Actual results lead us to think that this technique has the potential to reduce post-operative morbidity (2-6). Nevertheless we would like to congratulate Britto et al who demonstrated the reproducibility of the method at the Federal University of Rio Grande do Norte, it could be consider especially impor-tant because VEIL can be of great value in a region which has a high incidence of penile cancer.

Endourological management in a newborn with incomplete bladder duplication

We report an unusual case of a newborn with incomplete bladder duplication and a complete sagittal septum. This malformation was associated with dysplasia of the right kidney, right cryptorchidism, single urethra, and no other genital or gastrointestinal anomalies. At birth, we found severe ureterohydronephrosis in a solitary left kidney caused by the collapse of the left bladder when the right bladder was filled. We performed a neonatal puncture of the bladder septum. At 3 months of life, the patient underwent complete resection of the septum by cystoscopy with monopolar electrocautery. There are no previously reported cases of a newborn with obstructed uropathy. This is the first reported case of incomplete bladder duplication with endourological management.

Is Monopolar Electrocautery Safe and Effective for Control of the Cystic Artery During Laparoscopic Cholecystectomy?

Laparoscopic cholecystectomy is one of the most common surgical procedures. Here we report our experience with the use of monopolar electrocautery to control the cystic artery during laparoscopic cholecystectomy. Data regarding the site, number, size, and method of control of the cystic artery during laparoscopic cholecystectomy were prospectively collected. Other data collected included the operative time, intraoperative difficulties, and postoperative complications. The study included 158 laparoscopic cholecystectomies. Two arteries were controlled in 25 patients (15.8%) and one artery in 122 patients (77.2%), while the cystic artery was not identified in 11 patients (7%). The artery was graded as small, medium, and large in 43, 72, and 32 patients, respectively. Patients with unidentified cystic artery were excluded from our data analysis. The artery was controlled using monopolar electrocautery in 114 patients (77.5%) and by metal clips in 33 patients (22.5%). The cystic artery was controlled lateral to the cystic lymph node in the majority of patients (68%). Neither bleeding nor bile duct injury was encountered throughout the study period. Electrocautery is safe and effective for control of the cystic artery during laparoscopic cholecystectomy. A future randomized study is needed to confirm the findings of the present study.

The 6th Russian School of Colorectal Surgery meeting

The capital of Russia these days is a metropolis with 12 million people. Two million people daily enter and leave Moscow! The last time we participated in this meeting was 3 years ago. Our first impression this time was that the meeting had tripled in size under the leadership of Prof. V.P. Tsarkov. He and his team spread their arms and gave a warm welcome to more than 1,500 participants. In the early spring of this year,for the sixth time, the Russian School of Colorectal Surgery offered a very interesting and busy program. The conference was divided into 2 days and two important and fascinating topics. The first day was dedicated to benign pathology of the rectum and pelvic floor. Hemorrhoidal disease was a popular topic for live surgery and problem solving. G. Millito, M. Janic, and S. Regadas demonstrated hemorrhoidectomy with Ligasure, hemorrhoidectomy with monopolar electrocautery, and stapled hemorrhoidopexy. It was concluded that surgical hemorrhoidectomy should be reserved for patients who do not respond to outpatient treatment and those who have large external hemorrhoids, or combined internal and external hemorrhoids with significant prolapse (grades III–IV). E. Rullier performed laparoscopic ventral rectosacropexy for descending perineum syndrome with new mesh and a new method for securing it. This session was chaired by M. Pescatori and moderated by V.P. Tsarkov, I. Nechai, D. Khubezov, and V. Egiev, all of whom stimulated the discussion with their comments. The following session consisted of lectures on another interesting topic: diagnosis and treatment of pelvic floor dysfunctions. With his fascinating presentation, M. Pescatori opened another perspective on this problem and spoke about the iceberg syndrome and treatment solutions. S. Regadas gave a masterly lecture based on several years of experience with a novel 3-D dynamic anorectal ultrasoound technique for the assessment of perineal descent. A.A. Popov made an important contribution with his talk on pelvic floor descent from a gynecologist’s point of view. The session closed with an interesting lecture by J. Korcek on transvaginal procedures in the treatment of rectocele and pelvic floor syndrome. The next day in the Congress Hall of the Hotel Radisson Slavyanskaya, the seats were rapidly taken and even standing room was at a premium as the hall filled with curious surgeons. Live surgery began in two operating theatres simultaneously. R. Bergamaschi, A. Parvajz, and V.P. Tsarkov masterfully demonstrated their techniques in laparoscopic and open colectomy. The next session was devoted to new perspectives in the treatment of colon cancer. The series of lectures began with R. Bergamaschi examining the issue of laparoscopic colon cancer surgery as a new standard of care, followed by E. Rullier speaking about issues in laparoscopic treatment of colon cancer and then E. Tiret, who covered the current standards of care. C.G. Fu presented an impressive case series of hand-assisted laparoscopic surgery. The session closed with a very interesting lecture by K. Maeda on the pros and cons of lymph node dissection in colon cancer. The last session was dedicated to various themes: from a surgical view of colon cancer metastases, presented by V.P. Tzarkov, through questions about when and how to treat dehiscence of colonic anastomoses, discussed by Y. Panis. A. Zakharenko described some very complicated cases of colon cancer. A. Parvajz stressed the importance of a training program for surgeons in the colorectal field. A young yet very experienced hepaticobiliary surgeon from Liverpool, S. Fenwick, gave an exciting talk on new hope for the treatment of liver metastatic colorectal cancer. An impressive master class on the first day was given by S. Regadas, with a helping hand from the staff of the Department of Colorectal and Pelvic Floor Surgery of the Russian National Center of Surgery. This very successful meeting wound to an end on the evening of the second day, as the Moscow river flowed into the night, quietly singing “Kalinka”.

The use of harmonic scalpel in spinal surgery with contraindication to the use of monopolar electrocautery: a case report in a 14-year-old girl with a primary generalized dystonia and a 100° thoracic scoliosis

Many techniques are reported to decrease blood loss in children and adolescents undergoing extensive spinal surgeries. The reduction of blood loss and subsequent reduction of allogenic blood transfusion is a desired outcome in such surgical programs. In patients with severe neuromuscular scoliosis, this becomes a greater concern due to a variety of factors such as the need for extensive surgical exposure and the longer intraoperative time [18]. A lot of pharmacological, anesthetic, and surgical techniques including preoperative autologous blood donation [1], human recombinant erythropoietin [17, 27], intraoperative blood salvage techniques, and topical and systemic hemostatic agents [8, 20] are employed to reduce intraoperative and postoperative bleeding. The extensive use of monopolar electrocautery has been proposed as a safe and rapid technique to perform posterior exposure of the spine [18]. No significant differences with operative times, intraoperative blood loss, and postoperative hemoglobin levels have been demonstrated in orthopedic patients using bipolar sealer devices for intraoperative haemostasis [3, 11, 13]. In some patients with implanted pacemaker of brain stimulator, electrocautery has a potential risk of serious implanted hardware dysfunction [2, 6, 19, 24, 25]. In these patients, the use of harmonic scalpel, using high-frequency mechanical vibrations to cut and coagulate at the same time, could be an alternative technique to the use of monopolar electrocautery [14, 16]. We report the case of a 14-year-old girl previously treated for a severe acquired dystonia by pallidal bilateral stimulation. The presence of brain stimulators contraindicated the use of monopolar electrocautery for a requested extensive scoliosis surgery. In this case, the successful use of harmonic scalpel is reported and discussed.

Feasibility of transanal minimally invasive surgery for mid-rectal lesions

Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery. We assessed the feasibility of TAMIS for lesions located in the mid rectum. From July 2010 to October 2011, 16 consecutive patients with rectal pathology underwent TAMIS. After a single-incision laparoscopic surgery port was introduced into the anal canal, pneumorectum was established with a laparoscopic device, followed by transanal excision with conventional laparoscopic instruments, including graspers, monopolar electrocautery, and needle drivers. Clinicopathological findings, surgical procedure results, and perioperative outcomes were determined prospectively. Of the 16 patients, 11 had rectal cancers (3 T1 lesions and 8 after preoperative chemoradiotherapy), 4 had neuroendocrine tumors, and 1 had a mucocele. The median length of the lesions from anal verge was 7.5 cm (range 4-10 cm). All procedures were completed laparoscopically without conversion to conventional transanal approach. The median operating time was 86 min (range 33-160 min), and the median estimated blood loss was 15 ml (range 0-150 ml) with no patient requiring intraoperative transfusions. There was no surgical morbidity or mortality, but one patient died during follow-up due to synchronous advanced gastric cancer. The median postoperative hospital stay was 3 days (range 2-6 days). TAMIS seems to be a feasible and safe treatment option for lesions located in the mid rectum.

Ultrasonic scalpel causes greater depth of soft tissue necrosis compared to monopolar electrocautery at standard power level settings in a pig model

BackgroundUltrasonic scalpel (UC) and monopolar electrocautery (ME) are common tools for soft tissue dissection. However, morphological data on the related tissue alteration are discordant. We developed an automatic device for standardized sample excision and compared quality and depth of morphological changes caused by UC and ME in a pig model.Methods100 tissue samples (5 × 3 cm) of the abdominal wall were excised in 16 pigs. Excisions were randomly performed manually or by using the self-constructed automatic device at standard power levels (60 W cutting in ME, level 5 in UC) for abdominal surgery. Quality of tissue alteration and depth of coagulation necrosis were examined histopathologically. Device (UC vs. ME) and mode (manually vs. automatic) effects were studied by two-way analysis of variance at a significance level of 5%.ResultsAt the investigated power level settings UC and ME induced qualitatively similar coagulation necroses. Mean depth of necrosis was 450.4 ± 457.8 μm for manual UC and 553.5 ± 326.9 μm for automatic UC versus 149.0 ± 74.3 μm for manual ME and 257.6 ± 119.4 μm for automatic ME. Coagulation necrosis was significantly deeper (p < 0.01) when UC was used compared to ME. The mode of excision (manual versus automatic) did not influence the depth of necrosis (p = 0.85). There was no significant interaction between dissection tool and mode of excision (p = 0.93).ConclusionsThermal injury caused by UC and ME results in qualitatively similar coagulation necrosis. The depth of necrosis is significantly greater in UC compared to ME at investigated standard power levels.

Is harmonic scalpel during laparoscopic cholecystectomy superior than clips and cautery technique?

The standard laparoscopic cholecystectomy is usually performed using a monopolar electrocautery for dissection and clips for occlusion of the cystic duct and cystic artery. Some pitfalls are associated with the use of the monopolar cautery and clips, therefore other alternative techniques have been described. Ultrasonically activated devices have been used for dissection and cystic duct ligation during laparoscopic cholecystectomy (LC) with encouraging results, however it does not gain widespread acceptance among surgeons. The aim of the present study was to compare the surgical outcome of LC performed by the harmonic scalpel to that peiformed by the conventional diathermy and clips. Material and methods: This prospective randomized comparative study included 30 patients (group A) in whom LC was conducted using the conventional method by clipping both the cystic duct and artery with dissection of gallbladder from liver bed by monopolar electrocautery (clips and cautery method = CCM), and 30 patients (group B) who were operated on using laparoscopic harmonic scalpel (LHS) for closure and division of cystic duct and artery and for dissection of gallbladder from liver bed. Our primary end point was the biliary complications; however other intraoperative and postoperative parameters were included: bleeding, duration of operation, postoperative pain, and other complications. Results: Demographic data was similar in both groups. The operative duration was shorter in LHS than CCM (56.3 min vs. 63.3 respectively, p < 0.01), with a significant less incidence of gallbladder peiforation (6.66% vs. 20%, p < 0.001).No postoperative bile leak was encountered in LHS, but it occurred in 3% of patients in CCM No patient developed post operative bleeding in both groups however the amount of postoperative drainage was significantly less in LHS (29 vs. 47.7, p = 0.001). Most of patients were discharged from hospital on 2nd postoperative day; however the delayed discharge was statistically higher in CCM (16.6% vs. 6.66%, p < 0.01). Conclusion: LHS is a reliable, effective and safe tool in LC. It is a good alternative to standard monopolar electrocautery dissection with clipping of cystic duct and artery. It provides a shorter operative duration, less incidence of gallbladder perforation, and less hospital stay. Abbreviations: CCM= Clip and cautery method, LC= Laparoscopic cholecystectomy, LHS= laparoscopic harmonic scalpel, HFMC= high frequency monopolar cautery, BDI= bile duct injury, CBC= complete blood picture, INR= international normalized ratio, LFT= liver function test, UIS= ultrasonography.

Miniature surgical robot for laparoendoscopic single-incision colectomy

This study aimed to demonstrate the effectiveness of using a multifunctional miniature in vivo robotic platform to perform a single-incision colectomy. Standard laparoscopic techniques require multiple ports. A miniature robotic platform to be inserted completely into the peritoneal cavity through a single incision has been designed and built. The robot can be quickly repositioned, thus enabling multiquadrant access to the abdominal cavity. The miniature in vivo robotic platform used in this study consists of a multifunctional robot and a remote surgeon interface. The robot is composed of two arms with shoulder and elbow joints. Each forearm is equipped with specialized interchangeable end effectors (i.e., graspers and monopolar electrocautery). Five robotic colectomies were performed in a porcine model. For each procedure, the robot was completely inserted into the peritoneal cavity, and the surgeon manipulated the user interface to control the robot to perform the colectomy. The robot mobilized the colon from its lateral retroperitoneal attachments and assisted in the placement of a standard stapler to transect the sigmoid colon. This objective was completed for all five colectomies without any complications. The adoption of both laparoscopic and single-incision colectomies currently is constrained by the inadequacies of existing instruments. The described multifunctional robot provides a platform that overcomes existing limitations by operating completely within one incision in the peritoneal cavity and by improving visualization and dexterity. By repositioning the small robot to the area of the colon to be mobilized, the ability of the surgeon to perform complex surgical tasks is improved. Furthermore, the success of the robot in performing a completely in vivo colectomy suggests the feasibility of using this robotic platform to perform other complex surgeries through a single incision.

Post‐operative pain following coblation or monopolar electrocautery tonsillectomy in children: a prospective, single‐blinded, randomised comparison

To compare post-operative pain following tonsillectomy by either coblation or monopolar electrocautery in children. A parallel-designed, prospective, single-blinded, randomised trial. Ambulatory surgical facility. Eighty otherwise healthy paediatric patients undergoing coblation or electrocautery tonsillectomy by a fellowship-trained paediatric otolaryngologist. (i) The number of post-operative days with severe pain based on subjective qualification by the caretaker, (ii) post-operative days with pain rated ≥ 5 on a scale of 1-10, (iii) post-operative days requiring oral paracetamol/acetaminophen with codeine solution and (iv) post-operative days until resumption of a regular diet were assessed and recorded daily using a post-operative pain survey as a form of daily diary that was returned at the 2-week follow-up visit. Patients were consecutively enrolled into two groups of 40 patients. Average ages were 5.2 years for coblation tonsillectomy and 6.0 years for electrocautery tonsillectomy. The average number of post-operative days with severe pain was 4.2 for coblation and 5.9 for electrocautery (P = 0.006), days rating pain ≥ 5 were 3.6 for coblation and 4.8 for electrocautery (P = 0.037), days of codeine use were 2.5 for coblation and 2.9 for electrocautery (P = 0.324), and days until resumption of a regular diet were 5.2 for coblation and 6.2 for electrocautery (0.329). Coblation tonsillectomy may reduce post-operative pain and the time until resumption of a regular diet compared to electrocautery tonsillectomy.

Effects of a Tissue Sealing-Cutting Device Versus Monopolar Electrocautery on Early Pilonidal Wound Healing: A Prospective Randomized Controlled Trial

Monopolar electrocauterization produces thermal effects on neighboring tissues, causing tissue damage. Recently, tissue sealing-cutting devices, which are easy to use and achieve simultaneous selective sealing and cutting with less production of heat, have been used. The aim of this study was to investigate the effects of a tissue sealing-cutting device vs monopolar electrocautery on wound healing in the early postoperative period after pilonidal sinus surgery. This study was a prospective randomized clinical trial. This study was conducted at Military Hospital, Eskisehir, Turkey. In total, 128 patients with chronic pilonidal disease were randomly assigned into 2 clinically comparable groups between December 2009 and June 2010. Pilonidal sinus excision was performed with monopolar electrocautery in the control group (n = 64) and with a tissue sealing-cutting device in the study group (n = 64). Data regarding wound healing, demographic variables, history, physical examination findings, defect dimensions, and scores for a visual analog scale were recorded. The main outcomes measured were surgical site infection, early wound failure (dehiscence), and unhealed wound rate. : Wound infection and dehiscence rates were significantly lower (P = .01 and .02), but the duration of surgery was significantly longer (P < .01) in the tissue sealing-cutting group. The unhealed wound rate was 12.5% in the electrocautery group and 4.7% in the tissue sealing-cutting group (P = .01). When the distance from the lowest margin to the anus was 5 cm or less, wound infection and dehiscence rates were lower in the tissue sealing-cutting group (P < .01 and .03). We could not obtain data regarding the cost-effectiveness of the instruments. A tissue sealing-cutting device in pilonidal sinus surgery yields better wound healing than monopolar electrocautery.

Postoperative pain after adult tonsillectomy with plasmaknife compared to monopolar electrocautery

Monopolar cautery is the most commonly used technique for tonsillectomy. The aim of the present study is to compare postoperative pain using a new technology, PlasmaKnife tonsillectomy (PKT), in comparison with monopolar cautery tonsillectomy (MCT). Prospective, randomized, single-blinded, self-controlled study using paired organs. Thirty-two adult patients, aged 18 to 30 years, scheduled for tonsillectomy for recurrent tonsillitis were included. Patients were randomly assigned to undergo PKT on one side and MCT on the opposite side. The primary outcome was self-rated daily pain assessed by using a 10-point scale. Patients were provided 21-day pain diaries and were phoned twice weekly by a research assistant to assess pain and remind them to complete diaries. Secondary outcomes included comparisons of operative time, blood loss, and postoperative complications. Repeated measures analysis of variance comparing PKT to MCT during the 21-day postoperative period revealed no difference in postoperative pain between the two groups (P = .131). In addition, total operative time (P = .276) and blood loss (P = .418) did not differ significantly between PKT and MCT. Adult subjects undergoing PKT do not experience less postoperative pain in comparison to MCT.

Comparison of the effects of different electrocautery applications to peripheral nerves: an experimental study

This study was designed to investigate the effects of bipolar and mononopolar electrocauterization on peripheral nerve tissue. The comparison on the deleterious effects of the different cautery modalities and the importance of probe tip placement are evaluated using electrophysiological, electron microscopic and biochemical assessment parameters. Ninety-eight male Wistar albino rats, each weighing 250-275g, were randomly divided into 14 groups. Each group consisted of seven animals. Monopolar and bipolar electrocautery were performed at 15 watts. The application was performed either directly on the nerve or 1mm lateral to the longitudinal axis of the nerve for 'near the nerve groups', respectively. The electrophysiological findings showed that the mean amplitudes were at the lowest value in the first day for all the groups. At the end of the 3rd week, we recognised that the electrophysiological recovery continued. Electron microscopic evaluation showed myelin disruption in all groups. Myelin disruption of healthy neurons was at the highest level in the 1st day of application in accordance with the electrophysiological findings. Biochemical evaluation revealed statistical significance between the control and the two of the 'near the nerve groups' (GIII and GV) for NO (nitrite and nitrate) serum level. The data of the present study might suggest that electrocautery, independent of the type and form of application, may result in significant damage in histological and electrophysological basis. Although the relative proportions cannot be ascertained, the time course of recovery suggests that both axon and myelin damage have occurred. The probable electrocautery damage may be of substantial importance for the situation that the nerves are displaced by tumor masses or atypical neural traces.

Energy source instruments for laparoscopic colectomy

Colectomy is a common procedures for both benign and malignant conditions. Increasingly more colectomy has been performed laparoscopically and there are several available instruments being used for this procedure. Of which three common dissecting instruments are: monopolar electrocautery scissors (MES), ultrasonic coagulating shears (UCS) and electrothermal bipolar vessel sealers (EBVS). The aim is to assess the safety and effectiveness of these instruments. Studies were identified from PubMed, EMBASE, Cochrane Controlled Trials Register, Cochrane Colorectal Cancer Group Trials Register. Major journals were specifically hand searched. All randomised controlled trials were included. All patients underwent elective laparoscopic or laparoscopic-assisted right, left or total colectomy or anterior resection for either benign or malignant conditions were included in the study. Two reviewers independently selected studies from the literature searches, assessed the methodological quality of the trials and extracted data. The three primary outcomes were: overall blood loss, complications and operating time. Six randomised controlled trials including 446 participants. Two trials compared three types of instruments (MES vs UCS vs EBVS). One trial compared MES and UCS. One trial compared UCS and EBVS. One trial compared 5 mm versus 10 mm EBVS. One trial compared the technique of laparoscopic staplers and clips versus EBVS in pedicle ligation during laparoscopic colectomy. The limitation of this review is the heterogeneity of the trials included. The measured outcomes were covered by one to three studies with small number of participants. With this in mind, there was significant less blood loss in UCS compared to MES. The operating time was significantly shorter with the use of EBVS than MES. No difference between UCS and EBVS apart from EBVS appeared to be handling better than UCS in one study. Haemostatic control was better in UCS and EBVS over MES. No definite conclusion on the cost difference between these three instrument but this would lie in the balance between the instrument cost and the operating time. The handling of 5 mm EBVS was better than 10 mm and its main advantage was trocar flexibility. Laparoscopic staplers/clips used for pedicle ligation in colectomy associated with more failure in vessel ligation and cost more when compared to EBVS. The limitations of this review is the small number of trials and heterogeneity of the studies included. With the current evidence it is not possible to demonstrate which is the best instrument in laparoscopic colectomy. Hopefully more data would follow and subsequent updates of this review could become more informative.

Our initial experience with robotic hepato‐biliary‐pancreatic surgery

The authors performed Asia's first robotic surgery in March 2000 and a clinical trial was launched in the following year in order to obtain governmental approval for the da Vinci(®) Surgical System. Fifty-two robotic surgeries were performed at Keio University Hospital, of which the authors performed 28 hepato-biliary-pancreatic surgeries. In robotic laparoscopic cholecystectomy, articulated monopolar electrocautery scalpels are flexible, enabling precise dissection around the gall bladder and clipless ligation of the cystic artery and cystic ducts. For laparoscopic hepatectomy, hepatic parenchyma was safely resected without hemorrhage by Glisson's pedicles ligation and bipolar hemostatic forceps. We review robotic laparoscopic cholecystectomy and hepatectomy and discuss the potential and future outlook for robotic hepato-biliary-pancreatic surgery.

Comparison of Postoperative Pain in Pediatric Patients Undergoing Coblation Tonsillectomy versus Cautery Tonsillectomy

To compare postoperative pain scores between monopolar electrocautery and coblation subcapsular tonsillectomy. Prospective double-blind randomized study. Tertiary care children's hospital. Between December 2004 and April 2008, 61 children, ages 4 to 20 years (mean age, 10 years; SD, 4 years), were randomized to have one tonsil removed by electrocautery and the other tonsil removed by coblation. Subjects used the FACES scale to rate pain on each side immediately postoperatively, 2 days postoperatively, and 2 weeks postoperatively. Postoperative hemorrhage was also tracked. Coblation tonsillectomy resulted in statistically less pain than electrocautery immediately after surgery, but this difference was not clinically significant. Pediatric pain is similar following monopolar electrocautery or coblation subcapsular tonsillectomy.

876 Development of an EUS-Guided High-Intensity Focused Ultrasound Endoscope

876 Development of an EUS-Guided High-Intensity Focused Ultrasound Endoscope

Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique

Roux-en-Y gastric bypass excludes the biliary and pancreatic tree from traditional endoscopic evaluation and treatment. As the number of former bypass patients accrues, the need to assess and treat this subset of patients for biliary and pancreatic disease will increase. The authors describe their technique, indications, and outcomes for this group of patients. Data were collected by a retrospective chart review of the experience two surgeons had with laparoscopically assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP) from July 2004 to October 2008 at a single institution. This review identified 22 cases. The operating surgeon performed the entire procedure. The indications were suspected sphincter of Oddi dysfunction in 18 patients and recurrent pancreatitis in four patients. Adhesions were lysed, and a purse-string suture was placed on the anterior portion of the stomach. A gastrotomy was made with monopolar electrocautery, and a 12 mm trocar was inserted. It was secured with a purse-string suture. A side-viewing duodenoscope was inserted through this port. An intestinal clamp was placed on the biliopancreatic limb. The intended interventions were sphincter of Oddi manometry, sphincterotomy, placement of a pancreatic duct stent, and injection of botulinum toxin if indicated. Laparoscopic access to the remnant stomach was sufficient for ERCP in 21 cases. One patient required conversion to an open procedure. A total of 12 patients had undergone prior open upper abdominal surgery. One retroperitoneal perforation was noted, with precut sphincterotomy and cannulation of the minor duodenal papilla and no clinical repercussions. Manometry was performed for 18 patients. The pancreatic duct cannulation rate for manometry was 89%, and the rate of bile duct cannulation for manometry was 94%. The manometry studies for 12 patients yielded abnormal results. Eight patients had transient improvement, and three patients had long-term improvement or resolution of symptoms after the index procedure. With additional treatment, two of the transient responders had long-term resolution of symptoms. The findings demonstrate that gastric bypass patients with biliary pain can be successfully evaluated endoscopically by laparoscopic transgastric ERCP for sphincter of Oddi dysfunction. The rate for technical success and complications does not appear to be significantly greater than for standard ERCP. A few helpful techniques were noted during this experience. Comparison of efficacy with that of a prior study was limited.

Secondary Endoscopic Pyelotomy in Children with Failed Pyeloplasty

To assess the results of secondary endopyelotomies (SEP) that were performed in our center in children who had earlier failed pyeloplasty. Eleven secondary endopyelotomies were done between 2005 and 2010 in 10 patients (5 boys and 5 girls, mean age 6.8 years), with a follow-up time of >6 months. The primary procedure was an open/laparoscopic pyeloplasty (n = 10) or a ureterocalicostomy (n = 1). In all cases, endopyelotomy was done by means of a monopolar electrocautery hook using the standard pediatric resectoscope. In 10 patients, SEP was done percutaneously, and in 1 patient it was done in a retrograde fashion. The mean operation time was 69 minutes. After a mean follow-up of 20 months, 70% of patients were free of complaints (n = 7), which was defined as a resolution of complaints, resolution of hydronephrosis, and improvement of renal wash-out curve and function. In 4 renal units, reintervention had to be considered; in one of these, a re-pyeloplasty has already been performed. The mean postoperative hospital stay was 2.8 days. No intraoperative complications occurred. In 1 patient, postoperative leakage around the nephrostomy drain occurred but resolved spontaneously. SEP is a fairly safe method to treat recurrent ureteropelvic junction-stenosis after failed pyeloplasty in children. However, because it seems to be less affective than the open redo pyeloplasty, it cannot be considered as a gold standard procedure and as such should be thoroughly discussed with the patient and parents.

Periprosthetic Femoral Condyle Fracture After Total Knee Arthroplasty and Saline-Coupled Bipolar Sealing Technology

Saline-cooled bipolar radiofrequency technology has emerged as an effective method to reduce bleeding during total knee arthroplasty (TKA). No significant osseous complications have been previously reported, and animal studies have revealed no difference in bone healing, strength, or osteonecrosis compared to conventional monopolar electrocautery. This article presents 4 cases of early postoperative periprosthetic femoral condyle fractures after extensive use of saline-cooled bipolar radiofrequency requiring revision TKA. Preoperative, intraoperative, and postoperative details from 4 patients who underwent early TKA revision for periprosthetic femoral condyle fractures were retrospectively reviewed. The senior author (M.M.) had not experienced similar condyle fractures postoperatively in over 2,500 primary TKAs performed over 2 decades. The cases described here were performed between July 2009 and November 2009, shortly after increasing the usage of saline-cooled bipolar radiofrequency on the synovium overlying the femoral condyles for hemostasis. No other change in surgical technique or implant that occurred during this time was observed. The senior author has significantly decreased his use of saline-cooled bipolar radiofrequency and has seen no recurrence of these complications.