Vessel Sealing Research Articles

Uncinate Dissection during Robotic Whipple

We present various techniques of uncinate dissection during robotic pancreaticoduodenectomy. A combination of monopolar scissors, bipolar vessel sealer, and locking plastic clips are used to ligate small branches the SMA or SMV. Occasionally, a suture is placed in the specimen side of the pancreas and used as a handle to facilitate identification and ligation of small vascular branches. We also show a technique of utilizing the robotic stapler to perform the uncinate dissection.

Incorporating the Laparoscopic Cusa into Robotic Hepatectomy

Introduction: Robotic technology has many advantages over laparoscopy including improved optics and instrument dexterity. However robotic hepatectomy has been slow to gain acceptance and one reason is the perceived inability to use the Cavitron Ultrasonic Surgical Aspirator (CUSA) during parenchymal transection. We provide a technical description for the successful incorporation of the laparoscopic CUSA during robotic hepatectomy.Methods: Surgical technique: Robotic ports are placed across the upper abdomen. The camera is placed in line with the liver hilum. An additional 12mm assist port is placed between the camera port and the most lateral right sided port for use of the CUSA during parenchymal transection. The liver is divided with the use of the laparoscopic CUSA. Intraparenchymal vascular and biliary structures are divided with a combination of the robotic vessel sealer and hem-o-lok clips. Larger hepatic veins are stapled with the robotic stapler. Results: Robotic hepatectomy was performed on 54 patients from September 2018 to December 2020 at our institution with the use of the laparoscopic CUSA. Major hepatectomy (>= 3 segments) was performed in 21 (39%) cases. Median EBL was 285mL (15-2200) and 5 (9%) of patients required blood transfusion. Major morbidity (grade III) occurred in 2 (4%) cases including 1 biloma and 1 pneumothorax. The median LOS was 2 days (1-9) and 30-day readmission was 7%. The 90-day mortality was 0%. Conclusions: Liver transection with the CUSA improves the visualization of intrahepatic vascular and biliary structures, reducing hemorrhage and biliary morbidity during robotic hepatectomy

Initial Experience of Robot-Assisted Adrenalectomy in Japan: What is the Optimal Selection of Robotic Forceps for Adrenalectomy?

Minimally invasive adrenalectomy is the preferred technique for managing adrenal tumors. Laparoscopic adrenalectomy is widely performed and covered by insurance in Japan, but robot-assisted adrenalectomy is not. To investigate the best forceps combinations for performing robot-assisted adrenalectomy safely, we performed robot-assisted adrenalectomy for two left and two right adrenal adenomas using different robotic forceps combinations (bipolar forceps, monopolar curved scissors, Vessel Sealer Extend, and SynchroSeal) for each case. Although we evaluated a small number of RAs, lower blood loss was observed in patients where the vessel sealing devices were used. The extent of dissection is small for adrenalectomy, and robotic bipolar vessel sealing tools may not be necessary, especially for the small adrenal tumors. However, considering the risk benefits, the combination of forceps with Vessel Sealer Extend (by the left arm) and monopolar curved scissors (by the right arm) will become one of the best forceps combinations for performing robot-assisted adrenalectomy safely.

Initial Experience of Robot-Assisted Laparoscopic Nephroureterectomy in Japan: A Useful Technique Using a Vessel Sealing Device for Securing a Good Surgical Field and Efficient Sealing.

Although robot-assisted nephroureterectomy (RANU) has been increasingly used worldwide, the history of RANU remains short, and the optimal surgical method for performing RANU has yet to be established. Here we introduce the ideal approach for RANU using the Vessel Sealer Extend (VSE). RANU was performed by using a da Vinci Xi surgical system with fenestrated bipolar forceps (by the left arm), and monopolar scissors or needle drivers (by the right arm), and the VSE (by the third arm). First, nephrectomy and lymphadenectomy were performed at the kidney direction stage, followed by the removal of the distal ureter and suturing of the bladder at the bladder direction stage. The key point of our technique is that the console surgeon can continue to obtain the optimal surgical field by traction using the third arm, and thus cut the tissue by smoothly switching between the right hand and the third arm without the need to exchange instruments, especially in the kidney direction stage. In this study we performed RANU in nine patients and lymphadenectomy in seven patients. The median console time was 195 (range: 165-265) min, the median blood loss was 55 (range: 5-179) ml. In eight cases of RANU using the VSE, no lymphatic leakage was observed and all procedures could be performed safely. The use of VSE provides sufficient coagulation and optimal surgical field development, thus allowing console surgeons to perform RANU more safely.

Robotic Vessel Sealer Device for Lymphocele Prevention After Pelvic Lymphadenectomy: Results of a Randomized Trial.

Introduction: Pelvic lymph node dissection (PLND) during robotic prostatectomy is associated with potential complications. The most common complication of PLND is lymphoceles, occurring in up to 50% of patients in studies with screening imaging but usually asymptomatic. We performed a prospective randomized trial to evaluate whether using advanced bipolar energy for PLND via the robotic vessel sealer can prevent lymphoceles. Methods: A total of 120 patients were enrolled in the trial with each patient serving as their own control. Robotic PLND was randomly performed using the vessel sealer on one side and standard PLND using clips on the other side. All patients underwent screening computed tomography scan 3 months postoperatively with radiologists blinded to the assigned technique. Significant lymphoceles were defined as fluid collections ≥3 cm in any plane. Results: Of those enrolled, 114 completed the study. The mean nodal yield was 6.5 nodes, with 3.1 versus 3.4 nodes for vessel sealer side versus standard technique (P = .35), respectively. The mean operative time for PLND was 11.3 versus 11.1 minutes (P = .62), respectively. Twenty-two lymphoceles were identified. Ten occurred on the vessel sealer side versus 12 on the standard side (8.8% versus 10.5%, P = .412). All lymphoceles were asymptomatic. Conclusions: While the robotic advanced bipolar device did not appear to prevent lymphoceles, the vessel sealer also did not increase the rate of lymphoceles compared with a standard technique using clips. Both techniques were equally efficacious, efficient, and safe for PLND such that surgeons who prefer to avoid clips can reasonably use the vessel sealer, although at increased cost. Clinical Trial Registration number: NCT02035475.

Total Vaginal Hysterectomy Using a Vessel Sealer Device Vs. Conventional Suture Ligation Technique: A Retrospective Cohort Analysis

<h3>Study Objective</h3> The aim of this study is to evaluate the duration of surgery, blood loss, and complications when performing a total vaginal hysterectomy (TVH) using a blood vessel sealer (BVS) device compared to standard technique. <h3>Design</h3> retrospective cohort analysis. <h3>Setting</h3> Tertiary care center serving a rural population. <h3>Patients or Participants</h3> 146 women undergoing TVH at the West Virginia University Hospitals system. The indications for the vaginal hysterectomy were recorded as either abnormal uterine bleeding (AUB), pelvic organ prolapse (POP), or other. Patient characteristics were recorded. The primary endpoint was the comparison of surgical times between the BVS and standard technique groups. Secondary endpoints were the amount of blood loss and complications after surgery between both groups. Complications were defined by blood loss >500 ml, conversion to laparotomy/laparoscopy, blood transfusion, urinary or bowel injury, readmission within 30 days, postoperative fever, and vaginal wall or labial burning. <h3>Interventions</h3> Use of a vessel sealer vs conventional technique. <h3>Measurements and Main Results</h3> Out of 142 surgeries, 102 patients had hysterectomies using standard technique and 40 used the BVS device. The two most common hysterectomy indications were AUB (32 with the vessel sealer and 45 with conventional technique) and POP repair (8 with the vessel sealer and 57 with conventional technique). Although the BVS group had faster surgical times than the standard technique group, the difference was not statistically significant (99.4 vs 112.1 minutes; p=0.0777). There was a significant difference in surgical blood loss in the vessel sealer group compared to the group of traditional surgery (240.5 vs 169.1 mL; p = 0.0343). There were no significant differences in complications following a TVH with a vessel sealer compared to the standard technique (OR=0.61; 95% CI 0.24 - 1.52). <h3>Conclusion</h3> The use of the vessel sealer device was not associated with decreased surgical times or complications and instead showed an increase in surgical blood loss.

Two-Port Robotic Laparoscopic Hysterectomy

<h3>Study Objective</h3> To demonstrate a surgical video wherein a technique for port-reducing robot-assisted laparoscopic hysterectomy was performed with the use of a gel-capped multi-trocar port that accommodates necessary instruments to safely complete the procedure. <h3>Design</h3> Case report, step-by-step video describing a port-reducing robot-assisted laparoscopic hysterectomy with the gel-capped multi-trocar port. Institutional Review Board (IRB) approval was not required. <h3>Setting</h3> Tertiary referral medical center in New Haven, Connecticut. A 40-year-old female with symptomatic uterine leiomyoma who underwent failed medical management. She has completed her childbearing. Her body mass index was 41 kg/m². A pelvic sonogram showed a 10-centimeter uterus with a 10-centimeter fibroid. On examination, her uterus was mobile. <h3>Patients or Participants</h3> Singular patient who consented for this demonstration video. <h3>Interventions</h3> The patient underwent an uncomplicated robotically assisted total laparoscopic hysterectomy and bilateral salpingectomy. This was accomplished using a two-port technique. A multi-channel port system and a second robotic trocar were used. <h3>Measurements and Main Results</h3> Effective dissection of the adnexal structures and ligaments of the uterus was accomplished. Isolation, coagulation, and transection of blood vessels was optimally done with the vessel sealer. Despite the size of the uterus and leiomyoma, the specimen was completely removed transvaginally, without morcellation. Vaginal cuff closure was done with delayed absorbable barbed suture with ease. The three-centimeter fascial incision was re-approximated. There were no intra-operative complications. Estimated blood loss was 150 ml. She was discharged home on the same day. Her final histopathology was benign. <h3>Conclusion</h3> The two-port robotic hysterectomy with the gel-capped multi-channel laparoscopic port afforded the use of additional necessary laparoscopic instruments to safely complete the procedure while avoiding the usual three to five port incisions most gynecological surgeons use. This approach utilized the advantages of robotic laparoscopy: superior operative visualization, improved instrument mechanics and stabilization, and upgraded ergonomics for the surgeon. Our robotic hysterectomy technique is a feasible alternative for the appropriately selected patients.

Differences in Surgical Outcome in Near Total Thyroidectomy for Benign Nodular Goiter: A Comparison of LigaSure Vessel Sealer versus Conventional Clamp Knot Tie Technique

Objective: To compare the efficacy of LigaSure Vessel Sealer in Near Total Thyroidectomy versus Conventional Clamp Knot Tie Technique in terms of bleeding, operative time and postoperative drainage.&#x0D; Methodology: This comparative cross sectional study was conducted at Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro. Study duration was one year from November 2019 to October 2020. All patients of any age with benign multinodular goiter and either of gender were included. The study subjects were grouped into two categories by randomization (odd / even). The odd numbers were given to patients operated for ligasure and even numbers were given to patients operated with conventional clamp knot tie technique. Outcomes were observed with respect to post-operative calcium level, intra-operative bleeding, operative time, post-operative pain &amp; post-operative hospital stay. All the data was recorded via study proforma. Data was analyzed by using SPSS version 20.&#x0D; Results: Total 55 patients were observed. Mean age was 33.25±10.60 years in clamp knot tie procedure group and 35.16±07.96 years in ligasure technique group; without significant difference (p-0.448). Pre and post-operative calcium levels were statistically insignificant among both groups (p-0.358 and 0.163), while loss of blood, hospital stay, post-operative pain and operative duration were significantly greater in clamp knot tie technique group in comparison to ligasure technique group (p-&lt;0.001).&#x0D; Conclusion: LigaSure Vessel Sealer is a feasible and reliable surgical technique and significantly more effective as compared to conventional clamp knot tie technique in terms of post-operative bleeding, operative time, post-operative pain and post-operative hospital stay. However, calcium level was statistically insignificant.

The Thermal Safety Profile of a New Bipolar Vessel Sealing Device for Thyroid Surgery

Introduction: Bipolar electrocautery devices used to achieve intraoperative hemostasis carry risk of imparting thermal energy to adjacent tissue, leading to postoperative morbidity. The aim of this study was to compare a new vessel sealing device, the CoolSeal™ Reveal (Bolder Surgical, Louisville, Colorado), with an established industry standard device, the LigaSure™ Exact Dissector (Valleylab, Boulder, Colorado), to assess their safety and the extent to which they impart thermal damage to tissue during thyroid surgery. Materials and Methods: Vascular bundles associated with the thyroid gland in anesthetized sheep were exposed and sealed with a single activation of each device and excised en bloc. Additionally, vascular structures of the sheep were also sealed 0, 1, or 2mm adjacent to the recurrent laryngeal nerve (RLN). Vascular and RLN samples were processed for histopathologic evaluation and assessed for extent of thermal injury, seal width, and coagulative changes. Results: The mean thermal injury extent across all sample sizes and vessel types was significantly lower for the CoolSeal™ Reveal device (547.2 ± 27.9μm) compared to the LigaSure™ device (802.7± 48.6μm) (p&lt;0.001). Seal widths were significantly smaller in samples sealed with the CoolSeal™ Reveal device (899.0 ± 14.9μm) than samples sealed with the LigaSure™ device (1645.3 ± 160.3μm) (p&lt;0.001). Conclusion: The CoolSeal™ Reveal device demonstrates significantly lower thermal spread in vivo compared to the LigaSure™ Exact Dissector. These results indicate that the CoolSeal™ Reveal is an effective tool for sealing blood vessels and minimizing thermal damage to adjacent structures during delicate surgeries or in narrow surgical fields associated with the thyroid gland.

Clinical benefits of vessel sealing system (LigaSure™) during surgery for soft tissue sarcoma: a propensity score matching analysis.

Soft tissue sarcomas arise in the deep sites of the buttocks and lower extremities. Since a tourniquet is not applied during surgery for soft tissue sarcomas at such sites, excessive intraoperative blood loss may occur. Various devices, including LigaSure™ (Medtronic, Dublin, Ireland), are used as electrothermal bipolar vessel sealers. However, its clinical relevance in soft tissue sarcomas surgery remains unclear. This study aimed to assess the effectiveness of LigaSure™ in soft tissue sarcomas surgery. This study included 168 patients who underwent surgeries for soft tissue sarcomas in the deep sites in the buttocks and lower extremities between January 2004 and March 2018. The primary outcome was intraoperative blood loss, and secondary outcomes were surgery duration, wound complications, perioperative haemoglobin concentrations and intraoperative blood transfusion. To reduce selection biases, propensity score matching was applied. We defined the matched cases wherein LigaSure™ was used as the 'using group' and the other matched cases as the 'non-using group'. Outcomes were compared between both groups. From each group, 35 cases were selected using propensity score matching. The intraoperative blood loss was significantly smaller statistically in the using group (181.5 ± 240.4 ml vs. 394.7 ± 547.3 ml, respectively; P = 0.041). The duration of operation was longer in the using group (189.9 ± 97.6 min vs. 140.6 ± 75.7 min, respectively; P = 0.007). There were no significant differences in other outcomes. By using LigaSure™ for soft tissue sarcomas occurring in the buttocks and lower extremities, we observed a trade-off between reduced intraoperative blood loss and longer operative time.

A rare cause of lower gastrointestinal bleeding treated with robotic colorectal surgery

BackgroundMetastatic melanoma to the colon is rarely diagnosed with an incidence of only 0.3% and more than 95% of cases identified post-mortem. Survival for patients with metastatic melanoma to the colon is poor, with 5-year survival rates of 26.5%. Nonetheless, surgical resection of the colonic metastatic melanoma lesions is recommended as it is associated with improved survival. Additionally, surgical resection is also indicated for palliative reasons, as symptom resolution is achieved in 90% of such patients. Use of the surgical robot has increased dramatically in the past decades, especially in the field of colorectal surgery. Furthermore, recent studies have demonstrated comparable outcomes between patients undergoing either laparoscopic or robotic-assisted colorectal surgery for cancer. Here, we describe the first case, to the authors knowledge, of a robot-assisted sigmoid colectomy for metastatic melanoma.Case presentationA 72-year-old male with a history of metastatic melanoma diagnosed in 2015 with a favorable response to immunotherapy presented to the emergency department with symptomatic lower gastrointestinal bleeding (LGIB). Endoscopy demonstrated a friable melanotic lesion of the sigmoid colon with biopsy demonstrating histopathologic evidence of metastatic melanoma. After further evaluation, the patient consented for an elective robot-assisted segmental colectomy for palliative intent. Diagnostic laparoscopy identified no evidence of further intra-abdominal metastatic disease. After identifying the metastatic lesion in the sigmoid colon, the mesentery of involved segment of sigmoid colon adjacent to the lesion was divided using the bipolar electrosurgical vessel sealer device. The colon was divided both proximal and distal to the lesion using a robotic stapler and a tension-free colo-colonic anastomosis was created intracorporeally. Postoperatively, the patient had an unremarkable course and was discharged home on post-operative day 3. On follow-up, the patient was doing well with resolution of preoperative LGIB.Conclusion This case highlights a rare presentation of metastatic melanoma to the colon in a patient presenting with LGIB. Furthermore, this case demonstrates the feasibility of the minimally invasive robotic-assisted approach for an uncommon pathology.

Swine Small Intestine Sealing Performed by Different Vessel Sealing Devices: Ex-Vivo Test.

This study aimed to evaluate the sealing quality of swine small intestine using different laparoscopic radiofrequency vessel sealing devices (two 5 mm: RFVS-1 and -2; one 10 mm: RFVS-3) and a harmonic scalpel (HS) compared to golden standard closure technique. The study was divided into two arms. In study arm 1: n = 50 swine intestinal loops (10 per group) were transected with each instrument and the loops in which the devices provided complete sealing, at the gross inspection, were tested for maximum burst pressure (BP) and histological evaluation and compared to an automatic linear stapler. After the BP tests, the devices that achieved significantly lower BP values were excluded from the second arm. The RFVS-1 and -3 provided statistically significant results and were used in study arm 2, to obtain full-thickness biopsies along the antimesenteric border of the loop and were compared with hand-sewn intestinal closure (n = 30; 10 per group). The biopsies were histologically evaluated for thermal injury and diagnostic features, and intestinal loops tested for BP. RFVS-3 achieved comparable results (69.78 ± 4.23 mmHg, interquartile range (IQR) 5.8) to stapler closing technique (71.09 ± 4.22 mmHg, IQR 4.38; p > 0.05), while the RFVS-1 resulted in significantly (p < 0.05) lower BP (45.28 ± 15.23 mmHg, IQR 24.95) but over the physiological range, conversely to RFVS-2 (20.16 ± 7.19 mmHg, IQR 12.02) and HS (not measurable). RFVS-3 resulted not significantly different (p > 0.05) (45.09 ± 8.75 mmHg, IQR 10.48) than Suture (35.71 ± 17.51 mmHg, IQR 23.77); RFVS-1 resulted significantly lower values (23.96 ± 10.63 mmHg, IQR 9.62; p < 0.05). All biopsies were judged diagnostic. Data confirmed that RFVS-1 and -3 devices provided suitable intestinal sealing, with BP pressures over the physiological range. Conversely, the HS and RFVS-2 should not be considered for intestinal sealing. RFVS devices could be employed to obtain small intestine stump closure or full-thickness biopsies. However, further studies should be performed in live animals to assess the role of the healing process.

Robotic reoperative pancreatectomy for recurrent disease after pancreaticoduodenectomy, with conversion of pancreaticojejunostomy to pancreaticogastrostomy: approach and outcomes

Presenter: Krishnaraj Mahendraraj MD | Cedars-Sinai Medical Center Background: We describe here the rare case of a reoperative pancreatectomy following pancreaticoduodenectomy with conversion of the pancreaticojejunostomy to a pancreaticogastrostomy. This is a 74yo woman who underwent a pancreaticoduodenectomy one year prior for pancreatic neuroendocrine tumor. On surveillance she was found to have a focal area of recurrence right at the pancreaticojejunostomy anastomosis, which progressed despite somatostatin analog therapy. Given that this was the sole site of recurrence and that she had 50-60% of native pancreas volume left, we opted for reoperative pancreatectomy. Methods: Case review Results: Four robotic ports were placed across the lower abdomen along with a suprapubic assist port. The pancreatic remnant was densely adherent to the underlying portal vein and superior mesenteric vein. Robotic exploration revealed a 3 cm mass of the proximal pancreatic remnant, right at the prior pancreaticojejunostomy. We traced the previous pancreaticobiliary limb to find a point between pancreas and the biliary anastomosis where this could be divided. We opened up the jejunum right at the pancreaticojejunostomy to allow full mobility. We used a linear stapler and divided the jejunum proximal to the biliary limb, preserving the hepaticojejunostomy. We were able to separate the pancreatic mass off the splenic artery as well as celiac artery and vein. Distally, fine branches were taken with clips and vessel sealer. We eventually got to the point where we were completely free of the underlying structures and the mass was completely mobilized. We used ultrasound to confirm our margin before dividing the pancreas down with cautery. The specimen was passed off the field in an Endobag and pathology confirmed negative margin at the point of transection. We now turned our attention to reconstruction. The stomach laid over the pancreatic remnant roughly at the body-tail junction of pancreas, which was well to the left of midline, placing it in an ideal location for tension-free anastomosis without the need for extensive mobilization. Her Whipple had been pylorus preserving, giving us a complete stomach to work with. We made a gastrotomy at the posterior gastric wall and the pancreatic anastomosis was performed by an invaginating technique. We used 4-0 Monocryl with interrupted horizontal mattress sutures to invaginate the gland into the back wall of the stomach. This anastomosis was tested with methylene blue into the stomach and we saw no leak. Her largest skin incision at the end of the operation was the 4 cm suprapubic assist post which was also used to deliver the specimen. The patient made an excellent recovery and was subsequently discharged on Postoperative Day 4 with normal vitals, ambulating, with good pain control, and tolerating food. She resumed somatostatin analog therapy and close surveillance is maintained due to her risk for recurrence. Pathology and subsequent imaging show her to be disease-free. Conclusion: The robotic approach allowed for precise navigation in narrow spaces, such as maneuvering the pancreatic remnant under the stomach. It allowed us to perform a complex oncologic resection through small incisions resulting in expedited recovery, as well as avoid her prior incision thereby reducing hernia risk.

Preclinical development of a novel coaptive vessel sealing device for liver resection

Presenter: Lucas Thornblade MD, MPH | City of Hope Cancer Center Background: The safety of liver resection has increased dramatically, in great part due to advances in devices for parenchymal transection. We identified five limitations to existing vessel sealer technology: bulky jaws, short seal-zones, propensity for tissue shearing, tissue-char fouling, and the cost of fully disposable units. We sought to develop an affordable sealing device platform that could safely reduce the time required for open liver resection. Methods: We partnered with engineers to develop a radiofrequency (RF) powered coaptive sealing device with five features unique among existing vessel sealers. First, the device achieves a 6.5cm long seal zone, allowing faster parenchymal transection (Figure panel A). Second, lower-profile jaws reduce tissue tearing upon insertion into liver parenchyma. Third a spring-loaded hinge provides parallel apposition and reduces tissue shear. Fourth, the device applies saline to the sealing surface which reduces fouling upon repeated firings. And lastly, the reusable handle and low-cost RF generator facilitates an affordable alternative to conventional vessel sealers. The device was tested on 12 partial hepatectomies in six live canine models in compliance with 510(k) processes in an accredited large animal lab. Necropsy was performed 7-9 days postoperatively by a veterinary pathologist. Results: All subjects tolerated liver resection with minimal blood loss ( < 20cc). Figure panel B demonstrates a completed partial hepatectomy of the canine liver. Transaminases peaked by postoperative day four (mean ALT 194 U/L). At necropsy, no hematoma or bile collections were found. Novel design elements were registered with the U.S. Patent Office. Conclusion: By careful study of the limitations of existing designs, surgeons have a unique opportunity to impact changes in future surgical technology. Further work includes design refinement, regulatory overview for testing in humans, and partnership with industry.

Robotic left hemihepatectomy with lymph node dissection for a large intrahepatic cholangiocarcinoma

Purpose: Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver tumor following HCC. The incidence of ICC is low in most parts of the world. However, incidence has been rising. The only curative treatment option involves surgical resection as part of a multidisciplinary treatment. The goal of surgery is to obtain negative section margins while leaving an adequate future liver remnant. The role of regional lymphadenectomy is still debated, as it might add to a higher postoperative morbidity. An expert consensus statement states that regional lymphadenectomy should be considered a standard part of surgical therapy for patients undergoing resection of ICC. Another question remains about the role of minimal invasive surgery for ICC. A laparoscopic approach may lead to lower morbidity without compromising oncological adequacy. However, some doubts remain about the extent of lymph node dissection in laparoscopic approach. This video aims to demonstrate the advantages of a robotic approach using the Da Vinci© XI for left hemihepatectomy with lymph node dissection for a large intrahepatic cholangiocarcinoma. Methods: After screening for hepatic of peritoneal metastases, an extensive lymph node dissection of lymph node groups one and two is performed. Hilar structures are divided selectively. Next, a left hemihepatectomy is performed using the robotic vessel sealer. Finally, the left hepatic vein is divided using a vascular stapler and resection is finished. Results: Operative time was 270 min and blood loss was 20ml. The postoperative course was uneventful and the patient was discharged on postoperative day 3. Pathologic investigation showed an intrahepatic cholangiocarcinoma of 5cm, with tumorfree margins of 17mm. 0/10 lymph nodes were positive. Conclusions: The robotic approach to major hepatectomy with lymph node dissection for intrahepatic cholangiocarcinoma is safe and feasible with an acceptable number of lymph nodes prelevated.

Efficacy and Safety of Electrothermal Bipolar Vessel Sealer vs ENSEAL in Total Laparoscopic Hysterectomy for Large Uterus: A Comparative Study in Mysuru, South India

Efficacy and Safety of Electrothermal Bipolar Vessel Sealer vs ENSEAL in Total Laparoscopic Hysterectomy for Large Uterus: A Comparative Study in Mysuru, South India

Robotic cholecystectomy and spleen preserving splenic cyst excision for inflamed splenic cyst and chronic cholecystitis

Presenter: Elizabeth Klein DO | The Jewish Hospital Background: Abdominal pain in bariatric patients after sleeve gastrectomy and significant weight loss is concerning for multiple differential diagnoses from food intolerance, concern for hiatal hernia, to biliary disease. We present a unique case of a 32-year-old female presenting with left upper quadrant abdominal pain, that began after losing 100 pounds weight loss after laparoscopic sleeve gastrectomy. She has a history of asymptomatic incidentally found splenic cyst on CT scan at the age of 26. Methods: Extensive workup with repeat CT scan of the abdomen and pelvis, right upper quadrant ultrasound, and esophagogastroduodenoscopy revealed chronic cholecystitis and a stable splenic cyst. Decision was made to proceed with robotic cholecystectomy and possible splenic cyst excision if no other clear etiology for LUQ pain was found. Results: Diagnostic laparoscopy showed clear inflammatory changes around the splenic cyst indicating that this cyst was the cause of pain. Intraoperatively, the splenic cyst was characterized via intraoperative ultrasound (Figure 1A) and its margins to the rest of the spleen with indocyanine green (ICG) firefly imaging (Figure 1B). Vessel sealer device was used for cyst excision. Firefly imaging was also used for cholecystectomy. This operation was successfully completed via single-docking robotic surgery. The patient was discharged home within 24 hours after surgery. Her abdominal pain resolved without further complications. Conclusion: Splenic cysts can cause symptoms even though they are asymptomatic most of the time. Splenic preserving surgery is feasible in appropriate patients and robotic approach can be helpful to accomplish it and may help expedite recovery time and minimize post-operative pain.

Impact of Electrothermal Bipolar Vessel Sealing System in Breast Surgery with Axillary Lymph Node Dissection and in Stage III Melanoma Patients: A Review of Current Evidence for its use in Surgical Practice

To consolidate the feasibility, safety and effectiveness in performing axillary lymph node dissection in breast surgery and in patients with stage III melanoma, using the electrothermal bipolar vessel sealing system, we revisit and analyze the main studies on the subject, in order to identify its use as the best in this surgical practice.

An intra-operative video comparison of laparoscopic versus robotic transabdominal lateral adrenalectomy.

The aim was to compare intraoperative conduct of adrenalectomy between laparoscopic and robotic approaches. Intraoperative video-recordings of patients who underwent robotic (n = 30) and laparoscopic adrenalectomy (n = 30) were analysed using Mann-Whitney U, chi-square and multivariate regression analyses. Demographics, indications and outcomes were similar between groups. For all tumour sizes, camera was more engaged to surgical task and exhibited less vision problems in robotic versus laparoscopic group. There was less instrument exchange and restriction of exposure with robotic approach. For dissection, robotic approach allowed for a wider range of instrument reach around adrenal. Robotically, there was an increased ability to do fine dissection, rather than en bloc division with rigid laparoscopic vessel sealers. Bleeding problems were less robotically. Despite similarities in post-operative morbidity and hospital stay, there was a superiority in quality of procedure performed with robotic versus laparoscopic adrenalectomy for both small and large adrenal tumours.

Safe and Efficient Removal of Massive Head and Neck Vascular Malformations Using Vessel Sealing Energy Devices

ABSTRACT Large vascular malformations (VMs) pose several difficult clinical challenges to the plastic surgeon. Traditionally surgical dissection was labor-intensive and required a significant amount of time and technique. The advent of more advanced vessel sealing devices has resulted in easier vascular and lymphatic control during resection surgery. The authors present 2 cases of large VMs resected using newer energy devices. First, an infant who was born with a large neck AVM that was acutely bleeding requiring immediate control. The authors utilized the Impact Ligasure device to perform a subtotal resection, stabilize the patient, and returned for definitive resection in the future. In the second case, an adult male with a large complex tongue/lip AVM, presented for elective resection. He underwent staged sclerotherapy, followed by resection using the Harmonic Scalpel. The use of vessel sealing devices allows for a safe and efficient resection for a previously difficult surgery.