Comparison of the harmonic scalpel with scissors in women who experience obturator nerve injury during lymph node dissection for gynaecological malignancies.

OBJECTIVES: Lymphadenectomy is crucial for accurate staging in most gynecological malignancies. Serious complications can occur during the surgery. The present study aimed to present the early and late findings associated with obturator nerve injury, which is rarely observed during lymphadenectomy but can result in serious sequela if not noticed. MATERIAL AND METHODS: The files of the patients who underwent lymphadenectomy at our clinic between 2012 and 2018 were examined. Patients with obturator nerve incisions were identified retrospectively. RESULTS: In total, 287 women patients underwent lymphadenectomy at our clinic between 2012 and 2018. Examination of surgical notes revealed that nine patients underwent obturator nerve incisions using a scissor or a harmonic scalpel (energy- activated ultrasonic scissors). With respect to management of obturator nerve damage, no significant difference was found between the use of a harmonic scalpel and scissors (p < 1.000) and the trendelenburg and lithotomy positions (p < 0.167). In addition, no significant difference was found between laparoscopy and laparotomy in terms of surgical type (p < 0.167). At 6 months post-operatively, sensory-motor examinations and EMG findings of the patients were completely normal. CONCLUSIONS: Surgeries performed for gynaecological malignancies have high mortality and morbidity rates. Moreover, in the event of a complication such as nerve damage during laparoscopy, successful management of the complication before the patient undergoes laparotomy allows the patient to continue benefitting from the advantages of the laparoscopy. The results of our study show that these high-risk surgeries should be performed in advanced and well-equipped medical centres by teams experienced in gynaecological oncology.

Risk factors of calculi in upper urinary tract after radical cystectomy with urinary diversion. / Factores de riesgo de formación cálculos en el tracto urinario superior tras cistectomía radical con derivación urinaria.

INTRODUCTION AND OBJECTIVES: The study was conducted to identify the risk factors of upper tract stone formation in patients with diversions after radical cystectomy (RC). MATERIALS AND METHODS: All patients with diversion after RC were collected in our center from January 2005 to December 2013. Three different common diversions were included: Orthotopic neobladder (ON: 168 patients), Ileal Conduit (IC: 93 patients) or Ureterocutaneostomy (UC: 104 patients). Univariable and multivariable logistic regression analysis were conducted to identify the independent predictors of stone formation in the upper tract. RESULTS: A total of 365 consecutive patients (316 males, 49 females) were included. At a median follow-up of 48 months (range 12-65 months), 36 patients (9.9%) developed upper tract stone. Among them, 26 (72.2%), 5 (13.9%) and 5 (13.9%) patients underwent ON, IC and UC, respectively. 25 patients had renal stone and 11 ureter stone. Minimally invasive operations (endoscopic laser lithotripsy via the anterograde or retrograde approach in 24 cases, percutaneous nephrolithotomy in 9 cases and shock wave lithotripsy in 3 cases) were carried out successfully in all stone cases. On univariable and multivariable logistic regression analysis, diabetes mellitus, hypertension, urinary tract infection (UTI), anastomotic stenosis and types of diversions (P<.05) were positively associated with upper tract stone formation. CONCLUSIONS: The variable predictors of upper tract stone may contain diabetes mellitus, hypertension, UTI, anastomotic stenosis and types of diversion.

Ultrasonic bone scalpel: utility in cervical corpectomy. A technical note.

PURPOSE: Anterior cervical corpectomy and fusion (ACCF) is a technically challenging surgery. Use of conventional instruments like high-speed burr and kerrison rongeurs is associated with high complication rates such as increased blood loss and incidental durotomy. Use of ultrasonic bone scalpel (UBS) in cervical corpectomy helps to minimize such adverse events. METHODS: We performed a retrospective study based on the data of 101 consecutive patients who underwent cervical corpectomies with UBS for different cervical spine pathologies from December 2014 to December 2016. Total duration of surgery, time taken for corpectomy, estimated blood loss, and incidental durotomies were noted. RESULTS: Total surgical time was 30-80 min (59.36 ± 13.21 min) for single-level ACCF and 60-120 min (92.74 ± 21.04 min) for double-level ACCF. Time taken for single-level corpectomy was 2 min 11  ± 10 s and 3 min 41  ± 20 s for double-level corpectomy. Estimated blood loss ranged from 20-150 ml (52.07 ± 29.86 ml) in single level and 40-200 ml (73.22 ± 41.64 ml) in double level. Four (3.96%) inadvertent dural tears were noted, two during single-level corpectomy and other two during double-level corpectomy. CONCLUSIONS: Use of UBS is likely to provide a safe, rapid, and effective surgery when compared to conventional rongeurs and high-speed burr. The advantages such as lower blood loss and lower intra-operative incidental dural tears were noted with the use of UBS.

Does ultrasonic advanced energy reduce lymphocele incidence in laparoscopic para-aortic lymphadenectomy?

OBJECTIVE: To evaluate the use of ultrasonic advanced energy in reducing the occurrence of symptomatic lymphocele and its related complications in laparoscopic extra-peritoneal para-aortic lymphadenectomy in patients with gynecological cancer. STUDY DESIGN: A retrospective cohort study of consecutive patients in a tertiary referral center identified 2 groups of patients, undergoing laparoscopic extra-peritoneal para-aortic lymphadenectomy with or without the use of ultrasonic advanced energy. Surgery time, hospital stay, number of retrieved nodes and lymphocele requiring treatment were studied. Results were also compared between trained and trainee surgeons. RESULTS: 163 patients were scheduled for laparoscopic extra-peritoneal para-aortic lymphadenectomy: 81 treated using bipolar energy (control group: group 1) between August 1999 and January 2005, and 82 treated using ultrasonic advanced energy (study group: group 2) between July 2010 and March 2014. The main indication (90% in group 1, 61% in group 2) was advanced cervical carcinoma (stage IB2 and above). Ultrasonic advanced energy significantly decreased operative time (p=0.001) and intra-operative bleeding (p=0.01) and increased the number of para-aortic nodes retrieved (p=0.02). There was no significant difference in hospital stay or lymphocele requiring treatment (8.6% in group 1, 8.5% in group 2: p=0.98). For senior than for junior surgeons, surgery time was shorter but not significantly (p=0.80) and postoperative lymphocele rates were identical. CONCLUSION: Ultrasonic advanced energy may provide benefit in laparoscopic para-aortic lymphadenectomy, facilitating surgical ergonomics, but did not decrease post-surgery lymphocele.

Axillary lymph node dissection for breast cancer utilizing Harmonic Focus®.

BACKGROUND: For patients with axillary lymph node metastases from breast cancer, performance of a complete axillary lymph node dissection (ALND) is the standard approach. Due to the rich lymphatic network in the axilla, it is necessary to carefully dissect and identify all lymphatic channels. Traditionally, these lymphatics are sealed with titanium clips or individually sutured. Recently, the Harmonic Focus®, a hand-held ultrasonic dissector, allows lymphatics to be sealed without the utilization of clips or ties. We hypothesize that ALND performed with the Harmonic Focus® will decrease operative time and reduce post-operative complications. METHODS: Retrospective review identified all patients who underwent ALND at a teaching hospital between January of 2005 and December of 2009. Patient demographics, presenting pathology, treatment course, operative time, days to drain removal, and surgical complications were recorded. Comparisons were made to a selected control group of patients who underwent similar surgical procedures along with an ALND performed utilizing hemostatic clips and electrocautery. A total of 41 patients were included in this study. RESULTS: Operative time was not improved with the use of ultrasonic dissection, however, there was a decrease in the total number of days that closed suction drainage was required, although this was not statistically significant. Complication rates were similar between the two groups. CONCLUSION: In this case-matched retrospective review, there were fewer required days of closed suction drainage when ALND was performed with ultrasonic dissection versus clips and electrocautery.

Implementing the general use of dissection devices in thyroid surgery from prospective randomized trial to daily use.

Routine use of vascular sealing and dissecting devices was implemented in our Tertiary Center of Endocrine Surgery with a high volume of thyroid operations. Beginning with a prospective randomized trial on 82 patients that compared thyroid surgery with assistance of a new, high-frequency-powered electrothermal device (Precise™, Covidien, Boulder, Colorado) to conventional thyroid surgery, approximately 30% of operation time was saved in the group using the device. Surgeons were then free to decide whether to use LigaSure (Precise™), an ultrasonic device (Focus™, Ethicon Endo Surgery, Cincinnati, Ohio), or the classic tie-and-knotting procedure. This change of procedure resulted in an increase of surgery with devices, when compared to classic procedures from 20.2% to 98.4%, during a period of 5 years with 2,591 patients. The equal results of device-supported thyroid surgery were demonstrated when 100 consecutive patients with Precise™ and Focus™ were compared, by measuring time of surgery (-36% or 43 min) and postoperative morbidity. The authors advocate the use of vascular sealing and dissecting devices for thyroid operations and, especially, for surgical units with high operative frequency.