Standard Electrosurgery Research Articles

First experiences with a diode laser in major gynecological laparoscopic procedures show lack of benefit and impaired feasibility

PurposeThe aim of this study is to evaluate feasibility and potential benefit of a diode laser in major laparoscopic procedures in gynecology.MethodsBetween 2018 and 2020, a total of 42 cases were enrolled in this study comparing standard electrosurgery with diode laser-supported therapy in laparoscopic supracervical hysterectomy (LASH), total laparoscopic hysterectomy (TLH), or laparoscopic myoma enucleation (LME). Dual wavelength 45 W diode laser light was used to cut and coagulate during laparoscopy in the prospective interventional arm consisting of 11 cases, while 31 matching patients who received conventional treatment with monopolar/bipolar current for the same interventions were retrospectively identified in our laparoscopy database. Recruitment in the prospective interventional laser diode arm was terminated after only 11 patients (instead of planned 50) due to intense hemorrhage and massive smoke development.ResultsA total of 42 cases were analyzed (11 LME, 19 LASH, and 12 TLH). Strong smoke development was evident in all 11 cases in the diode laser arm. It was necessary to convert to bipolar or monopolar current in all hysterectomies (n = 9) with initial diode laser implementation due to increased bleeding and smoke development. Conventional current sources had to be used in LMEs (n = 2) due to excessive bleeding and poor visibility during enucleation of the fibroid. A significant difference (p < 0.0001) was observed regarding smoke development when comparing the laser arm with the control arm.ConclusionWe found a 45-W diode laser to be inferior to electrosurgical techniques for major laparoscopic gynecologic surgeries regarding bleeding control and smoke development.

Lipids in surgical aerosol as diagnosis biomarkers for discrimination of lung cancer.

Introduction: Lung cancer is one of the most common malignancies worldwide, and the main effective treatment is surgical operation to cure this disease. This study assessed the feasibility of surgical aerosol for identification of lung cancer and adjacent normal tissue in surgery.Methods: In vitro experiments, the surgical aerosol was released when the tissue sample was being cut using a standard electrosurgery handpiece. Surgical smoke was dissolved in methanol by negative-pressure suction and then get to the neutral sprayer for analysis. Multivariate analysis was performed using partial least squares (PLS) analysis in MatLab 2011.Results: A total of 208 surgical aerosol database entries were obtained from 26 patients. In the cancerous aerosol, relative abundance (760.61, 782.39, and 789.68 m/z) was increased, while relative abundances of (756.41 m/z) was decreased compared with normal-tissue aerosol. After PLS analysis, mass–spectrometry (MS) data for the cancer aerosol showed clear differentiation from normal. Four significant peaks were identified by collision-induced dissociation experiments. The cancerous aerosol showed overexpression of phosphatidylserine (34:2), phosphatidylcholine (36:4), and triacylglycerol (46:2), while phosphatidylcholine (34:3) was decreased. Coupling PLS and extractiveelectrospray-ionization MS analysis of the surgical aerosol data of lung cancer were clearly distinguished from normal.Conclusion: The surgical aerosol might contain biomarkers for identification of lung cancer and normal tissue.

Wound healing and postsurgical complications in breast cancer surgery: a comparison between PEAK PlasmaBlade and conventional electrosurgery - a preliminary report of a case series.

PurposePEAK PlasmaBlade is a recent and distinctive type of electrosurgical device. Previous studies have already documented some meaningful advantages of this device over conventional electrosurgery. This study compared the use of PEAK PlasmaBlade to standard electrosurgery in mastectomy and breast conservative surgery. The purpose was to test the impact of PEAK PlasmaBlade on the wound-healing process and on postsurgical complications in breast cancer surgery.MethodsSixty patients undergoing breast cancer surgery were enrolled. The PEAK PlasmaBlade was used for 20 of those. A standard electrosurgical device was used for the other 40 patients. The 2 groups were homogenous in age, body mass index, comorbidities and type of surgery. We recorded wound complications, serum drainage amount and duration of stay, blood loss, time of surgery, length of hospital stay, and total number of medications required.ResultsThe 2 groups were not significantly different in terms of patient characteristics. A statistically significant reduction in incidence of seroma was observed in the PEAK group: only 10% versus 37.5% of the patients in the conventional electrosurgery group developed this complication (Fisher exact test, P = 0.034).ConclusionSeroma is the most important wound complication in breast surgery. The research of new instruments that might reduce its incidence is desirable. In order to validate or deny the results of this study, it is necessary to enroll more subjects and to consider the impact of this device on axillary lymph node dissection.

Healing comparison of porcine cutaneous incisions made with cold steel scalpel, standard electrosurgical blade, and a novel tissue dissector.

Background:Standard electrosurgery provides superior hemostasis compared to a cold steel scalpel, but inferior tissue healing. A novel electrosurgical blade with an advanced waveform, the MEGADYNE ACE BLADE™ 700 Soft Tissue Dissector (ACE), was designed to provide both excellent hemostasis and wound healing. This study compared ACE to scalpel and standard electrosurgery in a porcine model of wound healing.Methods:Skin incisions from six pigs were evaluated at time points of 0, 1, 2, 3 and 6 weeks after application of the three devices. Histopathology was performed on samples from each time point. For each non-initial time point, the healing incisions were photographed for later evaluation by expert graders, and excised for wound strength testing.Results:Time 0 photomicrographs showed a gradient of thermal tissue damage by initial incision, ranging from no damage made by the scalpel, minimal damage made by ACE, and twice the ACE damage made by a nonstick PTFE-coated electrosurgical blade. Histopathologic analysis at 6 weeks showed comparable dermal scar width measurements for scalpel and ACE incisions. Scars were wider for incisions made by standard electrosurgical blade. Wound strength was greater for scalpel and ACE than for standard electrosurgery. Cosmetic results at 6 weeks were not significantly different between scalpel and ACE incisions, while standard electrosurgical blade incisions were significantly inferior to ACE (odds ratio: 53.4, p<0.001).Conclusion:The MEGADYNE ACE BLADE™ 700 Soft Tissue Dissector represents a significant improvement in electrosurgical technology for skin incisions and dispels the traditional concerns of delayed healing and poor cosmetic result that have been attributed to using conventional electrosurgical blades for skin incisions.

A novel methodology for in vivo endoscopic phenotyping of colorectal cancer based on real-time analysis of the mucosal lipidome: a prospective observational study of the iKnife

BackgroundThis pilot study assessed the diagnostic accuracy of rapid evaporative ionization mass spectrometry (REIMS) in colorectal cancer (CRC) and colonic adenomas.MethodsPatients undergoing elective surgical resection for CRC were recruited at St. Mary’s Hospital London and The Royal Marsden Hospital, UK. Ex vivo analysis was performed using a standard electrosurgery handpiece with aspiration of the electrosurgical aerosol to a Xevo G2-S iKnife QTof mass spectrometer (Waters Corporation). Histological examination was performed for validation purposes. Multivariate analysis was performed using principal component analysis and linear discriminant analysis in Matlab 2015a (Mathworks, Natick, MA). A modified REIMS endoscopic snare was developed (Medwork) and used prospectively in five patients to assess its feasibility during hot snare polypectomy.ResultsTwenty-eight patients were recruited (12 males, median age 71, range 35–89). REIMS was able to reliably distinguish between cancer and normal adjacent mucosa (NAM) (AUC 0.96) and between NAM and adenoma (AUC 0.99). It had an overall accuracy of 94.4 % for the detection of cancer versus adenoma and an adenoma sensitivity of 78.6 % and specificity of 97.3 % (AUC 0.99) versus cancer. Long-chain phosphatidylserines (e.g., PS 22:0) and bacterial phosphatidylglycerols were over-expressed on cancer samples, while NAM was defined by raised plasmalogens and triacylglycerols expression and adenomas demonstrated an over-expression of ceramides. REIMS was able to classify samples according to tumor differentiation, tumor budding, lymphovascular invasion, extramural vascular invasion and lymph node micrometastases (AUC’s 0.88, 0.87, 0.83, 0.81 and 0.81, respectively). During endoscopic deployment, colonoscopic REIMS was able to detect target lipid species such as ceramides during hot snare polypectomy.ConclusionREIMS demonstrates high diagnostic accuracy for tumor type and for established histological features of poor prognostic outcome in CRC based on a multivariate analysis of the mucosal lipidome. REIMS could augment endoscopic and imaging technologies for precision phenotyping of colorectal cancer.

OC-102 A prospective, observational study of surgical and endoscopic rapid evaporative ionisation mass spectrometry (REIMS) for real time analysis of the colonic mucosal lipidome in colorectal cancer

Introduction REIMS permits real time analysis of tissue specific molecular information contained within an electrocautery smoke plume. 1 This study validated its diagnostic accuracy in colorectal cancer (CRC) and developed a novel endoscopic methodology. Method Patients undergoing elective surgery for CRC were recruited at St. Mary’s hospital London. 1. A standard electrosurgery handpiece using monopolar diatheramy on 30 W cutting mode (Valleylab TM ) was modified to allow aspiration of the electrosurgical aerosol to a Xevo G2-S iKnife QTof mass spectrometer (Waters Corporation). Ex-vivo analysis was performed and H&E staining and histological examination was carried out for validation. Multivariate analysis was performed using principal component analysis and linear discriminant analysis. Classification of each tissue type was performed using leave-one-patient-out cross-validation and receiver operating curves were generated. 2. Ex-vivo colorectal tissue was sampled using an endoscopic snare (Olympus Medical) modified to allow aspiration of the electrosurgical aerosol. Results 40 consecutive patients were recruited (22 male, median age 68 y, range 47–90). 23 tumour samples were analysed: 10 rectal adenocarcinomas and 13 colonic adenocarcinoma were analysed with TNM stages T2 (8), T3 (11) T4 (4), N0 (12), N1 (6) N2 (5), M0 (22), M1 (1). Distinction of malignant colorectal tissue was achieved with a classification accuracy of 94.4% and a sensitivity of 92.4%, Specificity 96.8% (ROC AUC 0.98). The diagnostic accuracy for dysplasia was 93.7% (Specificity 95.1%, sensitivity 85.7%, AUC 0.97). Distinction of tissue histology was possible based on membrane lipid ratios. Increases in glycerophospholipids (p = 0.0027), and triacylglycerols (p = 0.0004) were seen in healthy mucosa and increased prostaglandin D2 was found in malignant tissue (p = 0.0002). Endoscopic analysis was technically feasible and could identify colonic wall sub layers with a tissue classification accuracy of 88%. Discrimination of healthy colorectal tissue, adenomatous polyps and cancerous tissue (12 patients) was achieved with a tissue classification accuracy of 87.5%. Conclusion REIMS is able to diagnose dysplasia and malignant colorectal tissue with a high degree of accuracy in real time. This technology could improve the efficacy and safety of the endoscopic treatment of colon cancer. Disclosure of interest L. Muirhead: None Declared, J. Kinross Grant/ Research Support from: Imperial College BRC funding, Conflict with: Director of getwell media, R. Preece: None Declared, A. Speller: None Declared, O. Golf: None Declared, R. Goldin: None Declared, A. Darzi: None Declared, Z. Takats: None Declared. Reference Balog J, Sasi-Szabo L, Kinross J, et al . Intraoperative tissue identification using rapid evaporative ionization mass spectrometry. Sci Transl Med. 2013; 5 (194):194ra93

Randomized Study Comparing Use of THUNDERBEAT Technology vs Standard Electrosurgery during Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy for Gynecologic Cancer

Study ObjectiveTo compare operative time with use of THUNDERBEAT (TB) vs standard electrosurgery (SES) during laparoscopic radical hysterectomy and pelvic lymphadenectomy to treat gynecologic tumors. DesignEvidence obtained from a properly designed, randomized, controlled trial (Canadian Task Force classification I). SettingGynecologic Oncology Unit of the Catholic University of the Sacred Heart in Rome, Italy. PatientsFifty patients with early cervical cancer (FIGO stages IA2, IB1, IIA <2 cm) or locally advanced cervical cancer (FIGO stages IB2, IIA >2cm, IIB) who received neoadjuvant treatment (chemotherapy or radiochemotherapy) and demonstrated a complete or partial clinical response and early stage endometrioid endometrial cancer (FIGO stages IB, II) were randomly assigned to undergo TB (arm A) or SES (arm B). InterventionLaparoscopic radical hysterectomy with bilateral pelvic lymphadenectomy, using an easily reproducible technique was performed. Measurements and Main ResultsFifty patients were available for analysis, with 25 women randomly assigned to TB (arm A) and 25 to SES (arm B). The median operative time was 85 minutes for TB vs 115 minutes for SES (p = .001). At multivariate analysis, endometrial cancer (p = .001) and TB (p = .001) were independently associated with shorter operating time. No differences in perioperative outcomes and postoperative complications were observed between the 2 arms. Patients who underwent TB reported less postoperative pain, both at rest (p = .005) and after the Valsalva maneuver (p = .008), with less additional analgesic therapy other than standard therapy required in patients who underwent SES (p = .02). ConclusionTB is associated with shorter operative time and less postoperative pain than is the standard technique (SES) in patients with uterine cancer.

Radiofrequency treatment of tonsillar hypertrophy.

To describe radiofrequency electrosurgery and the devices and techniques available for using this technology to treat tonsillar hypertrophy. Review. Electrosurgical devices, which include the Bovie, Elmed, somnoplasty, and coblation systems and argon plasma coagulators, use energy transfer by means of electromagnetic radiation to generate heat within tissue for cutting and coagulation. With these devices, tonsillar tissue can be removed completely, partly ablated, or decreased in volume. Tissue ablation with radiofrequency that preserves the outer portion of the tonsillar capsule may reduce postoperative pain and allow earlier return to normal diet and activity. Removal of the entire tonsil using the coblation method may produce less damage in adjacent tissue than standard electrosurgery, thereby decreasing postoperative pain and healing time. Tissue reduction procedures may have a reduced risk of bleeding and produce less patient discomfort than other methods and can be performed in the office setting in some patients. Use of radiofrequency technology may decrease the morbidity associated with treatment of tonsillar hypertrophy. Preliminary trials of radiofrequency procedures have yielded promising results, but larger studies evaluating costs and benefits are needed.

Ultrasonically Activated Shears in Gastrectomy for Large Gastric Cancers

High-frequency ultrasound energy was introduced in gastrointestinal surgery to improve dissection and coagulation. We assessed the safety and efficacy of ultrasonic dissection compared with standard electrosurgery in gastrectomy for large gastric cancers, which is associated with high morbidity. The subjects of this retrospective study were 52 patients who underwent gastrectomy for gastric cancers, > or =7 cm in diameter. Gastrectomy was performed with ultrasonically activated shears (UAS) between January 2005 and June 2006 (UAS group, n = 26) and with standard electrosurgery between July 2003 and December 2004 (control group, n = 26). We compared morbidity, operating time, and intraoperative blood loss between the two groups. The mean operating time and intraoperative blood loss were significantly lower in the UAS group than in the control group. Morbidity in the UAS group was also lower, but the difference was not significant. Our findings showed that UAS gastrectomy was safe, with significantly shorter operating times and less intraoperative blood loss than standard electrosurgery.

Ultrasonic Versus Standard Electric Dissection in Laparoscopic Colorectal Surgery

To assess the safety and efficacy of the ultrasonic dissection (UC) compared with standard electrosurgery (ES) in laparoscopic colorectal surgery. High-frequency ultrasound energy was introduced in laparoscopic surgery to improve dissection and coagulation. Very limited data have been published on its use in laparoscopic colorectal surgery. Patients eligible for elective laparoscopic right or left hemicolectomy (RH and LH), sigmoidectomy (SG), or low anterior resection (LAR) were randomized to either UC or ES. The following data were collected and analyzed: preoperative data (individual patient data, indication for surgery), intraoperative data (conversion to open surgery, conversion ES to UC, operative time, blood loss, complication rate), and postoperative data (morbidity and mortality, volume of drainage, hospital stay). Between January 2002 and December 2003, 171 patients underwent elective laparoscopic colorectal resection. Twenty-5 patients did not satisfy the inclusion criteria and were excluded. The diagnosis of the remaining 146 patients was diverticulitis (44), colonic adenoma (31), adenocarcinoma (70), or epidermoid carcinoma (1). These patients underwent laparoscopic RH (28), LH (31), SG (47), or LAR (40). There were no differences in preoperative data. The overall conversion rate to open surgery was 11.6%, with no differences between the two groups; 20.8% undergoing ES were converted to UC, more frequently during right hemicolectomy or low anterior resection. Operative time, the primary endpoint of this study, did not differ between the two groups: UC 93 minutes versus ES 102.6 minutes (P = 0.46). Intraoperative blood loss was significantly less in UC 140.8 mL versus ES 182.6 mL (P = 0.032). No differences were observed in postoperative morbidity or other preoperative or postoperative parameters. UC is a useful device in laparoscopic colorectal surgery that facilitates completion of difficult cases and reduces intraoperative blood loss. Nevertheless, the majority of laparoscopic procedures can be completed with ES. Therefore, selective use of UC appears to be the most cost-effective policy.

Fibreoptic bronchoscopic electrosurgery under local anaesthesia for rapid palliation in patients with central airway malignancies: a preliminary report.

Obstruction of a major airway by tumour causes serious morbidity. There is still scope for a widely applicable, simple and effective treatment to provide rapid palliation. A fibreoptic bronchoscope prototype with an insulated inner sheath was used under local anaesthesia in 17 patients with locally advanced tracheobronchial malignancies. An insulated flexible electro-surgery probe was used to coagulate intraluminal tumour mass using standard electrosurgery equipment. Immediate reopening of the airway was obtained in 15 of the 17 patients. Two appeared to have extraluminal disease. Eleven patients had an obvious bronchoscopic response in whom a > 75% reopening of the normal airway diameter was achieved. Eight patients had subjective improvement of their dyspnoea, but only in four cases was there an objective improvement in physiological parameters. Haemoptysis resolved in four. There were no deaths resulting from treatment. Minor bleeding occurred in one patient and an aspiration pneumonia occurred in one. Three patients received additional treatment. Fibreoptic bronchoscopic electrosurgery is a simple technique for rapid palliation and immediate tumour debulking in patients with central tracheobronchial tumours. Further work is needed to compare its efficacy with other techniques.

Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy has been reported to be a safe and effective way to remove a diseased gallbladder with essentially no morbidity or mortality (1,2). This procedure was first introduced in Europe using electrosurgery, and later introduced in the United States using the laser (1). No clinical trial compares the laser to the standard electrosurgery method. In a review, as well as an ongoing study, morbidity, mortality, intraoperative procedures, indications, and cost effectiveness are considered in these two groups. Three hundred cases were reviewed with 150 patients in each group. There were no deaths or significant complications in either group. In the laser group, bleeding seemed slightly more excessive during removal of the gallbladder from the liver bed and required more time to control. The electrosurgery group required slightly less operative time and was less costly. The postoperative recovery time was the same in each group.