Hemostasis and Energy SourcesHemostasis and Energy Sources

Thomas S. Lendvay, M.D.Assistant Professor

University of Washington

OverviewOverview

• Operative planningOperative planning• Laparoscopic hemostasis modalities

N• Non-energy• Energy

• Tips for maintaining dry field• Bowel injuryj y• Future perspectives

Operative PlanningOperative Planning• Pre-op imagingp g g• R/o bleeding diathesis/Rx• Adequate exposureq p• Instrument preparedness• Stay calm• Bleeding and charring steal light• For many bleeders, direct instrument pressure

• Raise pneumo (judiciously)• Add port, open

Non-energy TechniquesNon energy Techniques

• Suture ligatureSuture ligature• Pros

• Proven effective• Proven effective• Excellent training

• ConsCons• Time intensive• Technically challengingy g g

Non-energy TechniquesNon energy Techniques• Titanium clips • Vascular endo-staplers

• Pros• Withstand highest burst

pressures• No collateral damage

• Easy to use• Good for large vessels• But need big port 12 mm

Fi i lf ti• Cons• Dislodgement• May preclude stapler• Nidus for adhesions

• Firing malfunction• $$$

V l l• Plastic (locking)

• Pros• As above

• Vascular clamps• Bulldogs• Satinsky

• As above• Cons

• Application error• Multiple clips

L t• Leave stump• No data on adhesions

Lattouf

Entezari

Harold

Non-energy TechniquesNon energy Techniques

• Tissue sealantsTissue sealants• Gelatin matrix (FloSeal)

• Thrombin and gelatin from bovine sources• Collagen crosslinked to gluteraldehyde

• Fibrin glues (Tisseel)• Elements of clotting cascade• Elements of clotting cascade• Fibrinogen/thrombin/Factor VIII/ Ca++

• Extracted from human blood products

S i l• Surgicel• Fibrinogen and thrombin fleece

Lattouf

Entezari

Energy TechniquesEnergy Techniques

• MonopolarMonopolar• shears, hook, blade• > 85% laparoscopistsp p

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Vancaille

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Energy TechniquesEnergy Techniques

• Ultrasonic (55,000 Hz)Ultrasonic (55,000 Hz)• Pizoelectric transducer in hand piece• Denatures hydrogen bonds – coagulumDenatures hydrogen bonds coagulum• FDA approved for 3 mm vessels• Lower energy transducedgy

• May lead to smaller spread• Thermal spread

• continuous >> intermittent activation• Works as grasper well

Harold

Perko

Landman

Energy TechniquesEnergy Techniques

• Emam et al (2003)Emam et al. (2003)• After 15 sec of US

• 1 cm away 140 C• 1 cm away 140 C• Setting < than 4 less than 10 seconds

Thermal TechniquesThermal Techniques

• Bipolar Feedback (Ligasure)Bipolar Feedback (Ligasure)• FDA approved for vessels up to 7 mm• High current 4 A low voltage < 200V• High current 4 A, low voltage < 200V• Denatures collagen and elastin

Harold

Energy TechniquesEnergy Techniques• Argon beam coagulation (1989)g g ( )

• Monopolar current via electrode• Conduction of RF energy thru ionized beam of argon gas• Depth 2-5mm (solid organ)p ( g )

• Pros• Parenchymal surfaces, diffuse bleeding• Minimal smoke

L f• Large surface areas• Cons

• Not vessels• Gas embolization (vent abdomen)( )

• Lower flow, lower risk of embolism • < 4L/min for lap• Hand piece 1 cm from tissue (embolism)

Lattouf

Beckley

Energy TechniquesEnergy Techniques

• LASERLASER• Bloodless dissection with coagulation• Less tissue damage• Less tissue damage• Depth 2 mm

Head to Head StudiesHead to Head Studies• Harold et al. (2003)( )

• Ligated vessel burst pressure • Ultrasonic/Ligasure/Titanium clips/Plastic clips

• Ligasure > US burst pressure for 4-7 mm• Clips highest burst pressure• Ligasure as good as clips for 4-5 mm• Thermal spread energy sources ~2mm

Hruby et al (2007)• Hruby et al. (2007)• Harmonic Ace (up to 5mm), Ligasure (up to 7 mm)

• Consistent reproducible force • Proper coaptation of vessel which aids in coagulum• Too much, vessel cut too early• Too little, not coapted, not coagulated

• Harmonic ACE faster X 2Harmonic ACE faster X 2

Head to Head StudiesHead to Head Studies• Landman et al. (2003)• Pig vessel burst pressure tests

• Ligasure v. Harmonic scalpel v. Titanium clips v. EndostaplerLigasure• Ligasure

• Arteries up to 6 mm• Veins up to 12 mm• Ligasure not as good as clips

or staples• 2-6mm peripheral damage• $$ Ligasure and repeating clip

applier similar in cost butapplier similar in cost but generator $17K

• Staples most expensive• Harmonic faster

Head to Head StudiesHead to Head Studies• Tulikangas et al. (2001)g ( )• Pig bowel injury experiment• ME v. BE v. LASER v. US

• BE/ME at 40W US at 3 5• BE/ME at 40W, US at 3.5• Coagulative denaturation of

collagen bundles• ME>>>US bowel and bladder• ME>>>US bowel and bladder• CO2 LASER no deep tissue

injury• LASER most shallowLASER most shallow• BE injury 1.5 cm away in

ureter, 1 cm away in bladder• ME 2.3cm and 1cmME 2.3cm and 1cm

Head to Head StudiesHead to Head Studies• Diamantis et al. (2006)( )

• Monopolar vs. Bipolar v. Ligasure v. Ultrasonic• Divide short gastrics in 16 rabbits

• Studied coagulation sites and adjacent gastric wallg j g• LS/US complete hemostasis, no complications• LS least adjacent thermal injury, fastest healing• Failure rates – ME (25%), BE(30%), LS (0%), US (6%)• Adhesions in ME>BE>>LS/US• Adhesions in ME>BE>>LS/US• LS/US safer and more effective

Thermal InjuryThermal Injury• Underreported

R• Reasons• Insulation failure

• High voltage, cleaning wear, trocar passage

• Instrument coupling• Transmit current through adjacent

instrument (metal)• Capacitative coupling

• Parallel current running in tissue• Decreased field of view

• Hard to see other than tip• Fecal peritonitis mortality 25%• Fecal peritonitis mortality 25%• Possible signs of stray current

• Electrical interference on monitor• Reduced power at end-effector

Vancaille

Lattouf

Thermal InjuryThermal Injury• Bowel injury j y

• 2nd most common (Vascular #1)• 0.2-1.2% urologic lap procedures

• Over sew serosal injuries• Over sew serosal injuries• Late diagnosis > 50%• Free air after 24-48 hrFree air after 24 48 hr• Presentation (up to 2 weeks)

• Low grade feverL k i• Leukopenia

• Localized trocar site pain• Diarrhea

El-Banna

El-Hakim

Laparoscopic Immune ResponseLaparoscopic Immune Response• El Hakim et al. (2004), 40 bowel injured rabbits

• Lap/open/pneumoperitoneum/sham• Peritoneal fluid WBCs > in surgery grps, open > lap• Decrease in lymphocytes and monocytes in lap at 3 days• Systemic WBCS equal• Peritoneal IL-8 > in lap vs. pneumo but = open and lap• Granulation tissue open > lap• IL-8 elevated in pneumo over open sham• Lap did not sustain local inflammatory response

• Blunted peritoneal immune response• mask clinical signs /sx’s of peritonitis

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Laparoscopic Immune ResponseLaparoscopic Immune Response

• El-Hakim et al (2005) rabbitsEl Hakim et al. (2005), rabbits• Monocyte migration assessed• Monocyte apoptosis lap < open• Monocyte apoptosis lap < open• Migration Lap > open

Lap injuries• Lap injuries• Decreased priming of cellular immunity • Mask peritonitis• Mask peritonitis

Future PerspectivesFuture Perspectives

• RF anastomotic sealersRF anastomotic sealers• Bipolar fusion devices• Smulders et al• Smulders et al.

• Pigs bowel anastomoses• 7/8 intact POD#7• Normal re-epithelialization

Final WordsFinal Words

K ll t l i fi ld f i• Keep all metal in field of view

• Short bursts of activationShort bursts of activation

• Ligasure/Ultrasonic probably safestg p y

• Use lowest settings

• Respect the clinical signs

ReferencesReferences• Diamantis et al. Comparison of monopolar electrocoagulation, bipolar electrocoagulation, ultracsion, and ligasure. Surg Today (2006)

36:908.• Vancaille How to prevent unintentional thermal injury associated with monopolar electrosurgery at laparoscopy Surg Endo (1998)• Vancaille. How to prevent unintentional thermal injury associated with monopolar electrosurgery at laparoscopy, Surg Endo (1998)

12:1009.• Beckley et al. The use of argon beam coagulation to control hemorrhage: A case report and review of the technology, J Oral Maxillofac

Surg (2004) 62:615.• Harold et al. Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for hemostasis of small-, medium-, and large-

sized arteries, Surg Endo (2003) 17:1228.• Wu et al. Production and systemic absorption of toxic byproducts of tissue combustion during laparoscopic surgery, Surg Endo (1997)

11:107511:1075.• Tulikangas et al. Gross and histologic characteristics of laparoscopic injuries with four different energy sources, Fertil and Steril (2001)

75:806.• El-Hakim et al. Peritoneal and systemic inflammatory mediators of laparoscopic bowel injury in a rabbit model, J Urol (2004) 172:1515.\• Hruby et al. Evaluation of surgical energy devices for vessel sealing and peripheral energy spread in a porcine model, J Urol (2007)

178:2689.• Landman et al. Evaluation of a vessel sealing system, bipolar electrosurgery, harmonic scalpel, titanium clips, endoGIA, and sutures for

arterial and venous ligation in a porcine model (2002) J Urol 169:697arterial and venous ligation in a porcine model, (2002) J Urol 169:697.• Lattouf et al. Practical hints for hemostasis in laparoscopic surgery, Minimally inva Therapy (2007) 16:45.• Perko et al. Lateral thermal damage to rat abdominal wall after harmonic scalpel application, Surg Endo (2006) 20:322.• El-Banna et al. management of laparoscopic-related bowel injuries, Surg Endo (2000) 14:779.• Emam et al. How safe is high-power ultrasonic dissection? Annals of Surg (2003) 237:186.• Nduka et al. Does the ultrasonically activated scalpel release viable airborne cancer cells? Surg Endo (1998) 12:1031.• Smulders et al. Exploring new technologies to facilitate laparoscopic surgery, Surg Endo (2007) 21:2105.• El-Hakim et al. Laparoscopic bowel injury in an animal model, Surg Endo (2005) 19:484.• Entezari et al. A review of the currently available sealing systems, Minim Invas Therapy (2007) 16:52.