Alternative sources of cautery may improve post-operative hematoma rates but increase operative time in thyroid surgery.

A retrospective risk-adjusted analysis was completed using data from the National Surgical Quality Improvement Program (NSQIP) to (1) compare the risks of post-operative hematoma for thyroid surgery using conventional cautery compared alternative energy devices (defined as LigaSure and Harmonic Scalpel), and (2) compare operative times for the same. The primary outcome variable was post-operative hematoma occurrence. The secondary outcome variable was operative time. The exposure variable was use of conventional or alternative sources of cautery. All adult patients who underwent a total thyroidectomy, subtotal thyroidectomy or completion thyroidectomy between 2016 and 2018 were included. Multivariable linear and logistic regression analyses were performed to control for potentially confounding variables. A total of 13,330 cases were analyzed; 4342 used conventional cautery, and 8988 used alternative sources. There was a statistically significant decrease in post-operative hematoma risk using alternative sources of cautery compared to conventional cautery (OR 0.75; 95% CI 0.58-0.98) (p = 0.04). Use of alternative sources of cautery added 4.95 min onto operative time (95% CI 2.45-7.45) which was statistically significant (p < 0.0001). After controlling for confounding variables, there was a statistically significant lower rate of post-operative hematoma in thyroidectomies performed using alternative sources of cautery compared to those performed with traditional hemostatic methods. Alternative sources of cautery increased operative time by 4.95 min.

Precision silver nitrate cautery of the posterior nasal cavity.

BACKGROUND: This technical note describes a novel method of cauterising the posterior nasal cavity through the use of a plastic straw and silver nitrate. OBJECTIVE: This technique aims to prevent unwanted damage to surrounding nasal mucosa. METHODS: Once the nasal cavity has been prepared for cauterisation, the silver nitrate stick is navigated to the bleeding point covered by the plastic straw. The silver nitrate stick is then advanced onto the bleeding point allowing precise cauterisation of the nasal mucosa, without effecting surrounding healthy mucosa.

Thermal Conductance Through the Skull Base From Endoscopic Surgery Cauterization Instruments: Cadaver and Goat Model.

OBJECTIVE: Cauterization prevents hemorrhage and optimizes the surgical field during endoscopic sinus surgery but may cause injury to nearby structures. The objective of this study is to examine thermal conductance from cauterization equipment across the skull base. STUDY DESIGN: Cadaver and animal model. SETTING: Surgical skills laboratory of an academic tertiary medical institution. METHODS: A pilot study was conducted with a deidentified cadaver head and expanded to a goat head animal model. Endoscopic dissection was performed to expose the lamina papyracea, ethmoid roof, sphenoid roof, and frontal sinus. Cautery was applied to the frontal sinus of goat heads, and temperatures were measured via thermocouple sensors placed along the intracranial skull base. Surgical instruments studied included monopolar, bipolar, and endoscopic bipolar devices at various power settings. RESULTS: Temperature increase, as averaged across all cautery powers and measurement positions, was highest for the monopolar cautery (17.55 °C) when compared with the bipolar and endoscopic bipolar devices (<2 °C for bipolar, Endo-Pen, Stammberger, and Wormald; P < .001). Monopolar cautery reached 30.86 °C at high power when averaged over all positions (P < .001) as compared with <3 °C for the other instruments. Temperatures rose as power of cautery was increased from low to medium and high. Temperatures decreased as the distance of the thermocouple sensor probe from the cautery origin increased. CONCLUSION: Thermal conductance across the skull base varies depending on equipment and power of cautery, with monopolar resulting in the largest temperature increase. Choice and implementation of cauterization instruments have implications on inadvertent transmission of thermal energy during endoscopic sinus surgery.

Giant Choroid Plexus Papilloma Resection Utilizing a Transcollation System.

BACKGROUND: Large vascular brain tumors pose an exceptional challenge in young children. Choroid plexus papilloma (CPP) is an example of a rare, often large and especially vascular neuroepithelial tumor that most commonly arises in children under 5 yr old. Although patients may be cured by total resection, this tumor poses significant surgical risks and challenges related to intraoperative hemostasis. OBJECTIVE: To describe our experience using a transcollation system during brain tumor surgery in a child to achieve hemostasis and minimize blood loss while preserving normal brain tissue. METHODS: A 3-yr-old girl presented following a fall and was found to have a giant CPP growing from the right lateral ventricle. Given the vascularity of the tumor and the low intravascular reserve in a small child, a transcollation device was used to reduce blood loss intraoperatively. RESULTS: Gross total resection was achieved with approximately 300 mL of blood loss without complications. The patient did well postoperatively. Imaging performed at 3 mo after resection revealed return of normal brain architecture. CONCLUSION: Transcollation devices appear to be an effective and safe addition to the armamentarium of neurosurgical hemostatic options in intracranial tumor resection in which there is a high risk of intraoperative hemorrhage.

Oxidative and histopathological effects of the application of electrosurgical devices to the penile tissue of rats.

INTRODUCTION: This study was performed to evaluate the oxidative and histopathological changes that occur following the application of electrosurgical devices (monopolar or bipolar cautery) to penile tissue. MATERIAL AND METHODS: Eighteen Wistar albino male rats were randomly distributed into three groups. In the control group (CG, n = 6), all penile tissues were sampled without any additional process following the administration of anesthesia. In the monopolar cautery group (MPG, n = 6), a 15-W cauterization process lasting 5 s was performed on an approximately 2 mm2 area of the ventral side of the penile shaft, 0.5 cm proximal to the edge of the glans in the midline. Bipolar cautery was practiced in the third group (BPG, n = 6) using the same techniques outlined in the previous statement. Penile tissues consisted of the cautery application area, the edge of the glans, and dorsal side of the penis and were sampled after 90 min; then, histopathological evaluation and biochemical examination involving malondialdehyde (MDA), nitric oxide (NO), and superoxide dismutase (SOD) measurements were performed. RESULTS AND DISCUSSION: Histopathologically, the MPG and BPG demonstrated increased inflammation, fibrosis, and epithelial loss in the urethra in the areas to which cautery was applied as compared to the CG (P < 0.05). The vascular structures of the corpus cavernosa were significantly decreased in the cautery application area of both the MPG and the BPG as compared to the CG (P < 0.05). In the Masson's trichrome stained samples, significant collagen deposition was observed in the cautery application area both in the MPG and the BPG as compared to the CG (P < 0.05). However, S-100 staining was decreased in these groups as compared to the CG (P < 0.05). S-100 staining was also decreased in the MPG as compared to the BPG on the edge of the glans (P < 0.05). Biochemically, MDA values were significantly increased in the MPG as compared to the CG and the BPG (P < 0.05). CONCLUSION: Monopolar and bipolar cautery both did cause oxidative changes and triggered inflammatory, vascular, and peripheral nerve alterations in the cautery application area while bipolar cautery did not cause any distant effects.

Iron and laterality effects on healing of cautery disbudding wounds in dairy calves.

Hot-iron disbudding, the process of cauterizing the horn buds of calves or goat kids at an early age to prevent horn growth, is routinely practiced in dairy production. The wounds take weeks to heal and are painful to touch throughout this time. Possible strategies to hasten the healing of disbudding wounds are not well understood, but the type of iron used may be an important factor to consider. When evaluating strategies to hasten healing, a within-subjects design may be preferable, but laterality effects might act as a potential source of variation and confounding in this type of experiment. Our objectives were to compare healing after disbudding with 2 commercially available irons, and to determine whether wounds healed differently on the left versus the right side of the head. Ten Holstein calves 4 to 10 d of age were disbudded using the Rhinehart X50A electric disbudder (Rhinehart Development Corp., Spencerville, IN) on one horn bud and the Portasol gas disbudder (Portasol USA, Elmira, OR) on the other; side (left vs. right) was balanced between treatments. We scored wounds daily for the presence of 6 tissue types: attached necrotic tissue, detached necrotic tissue, exudate, granulation, crust, and epithelium. Surface temperature and size of the wound were measured twice-weekly using thermal and digital photographs, respectively. The type of iron used did not affect latency to re-epithelialize, which took on average (mean ± standard deviation) 53 ± 3 d and 55 ± 3 d for Portasol and Rhinehart wounds, respectively (range: 40-70 d). However, compared with Portasol wounds, those from the Rhinehart had fewer days of granulation tissue and tended to have more days of detached necrotic tissue. The Portasol tip had a smaller total surface area than the Rhinehart, which may have resulted in a less severe burn, causing the necrotic tissue to fall off sooner. The left side tended to re-epithelialize faster than the right side (mean ± standard error: left 51 ± 3 d; right 57 ± 3 d) and have fewer days of crust. Left-sided wounds were also cooler and tended to be smaller than those on the right. To assess the external validity of these laterality effects in our primary experiment (experiment A), we analyzed wound healing data from 2 other disbudding studies, one on calves (experiment B) and one on goat kids (experiment C). We observed laterality effects in the opposite direction in Experiment B, but negligible effects in experiment C, indicating that the differences in laterality had low external validity; the biological meaning of this asymmetry is unclear. Nonetheless, if using a within-subjects design, asymmetries in wound healing should be considered to avoid confounding effects. In conclusion, wounds from both irons took 7 to 8 wk to heal, on average; other strategies to accelerate healing should be explored.

Thermal cautery-assisted circumcision and principles of its use to decrease complication rates.

INTRODUCTION: Circumcision is one of the most frequently applied surgical procedures all over the world and a number of techniques and devices have been described concerning its method. Especially in developing countries where circumcision has been performed intensively under local anaesthesia, the thermocautery device developed to perform circumcisions in a short time and safely has found a widespread application. OBJECTIVE: We aim to share our experiences concerning application principles of the thermocautery device so as to be able to achieve better cosmetic results with lower complication rates. MATERIALS AND METHODS: Between the years 2009 and 2016, a total of 12,355 children between the ages of 40 days and 16 years (mean: 5.1 ± 2.0 years) were circumcised at our hospital. All circumcisions were performed by urologists under local anaesthesia using a thermocautery device (Thermo-Med TM 802B device; Thermo Medikal, Adana, Turkey). RESULTS: Bleeding that required surgical intervention did not occur in any patient. Compressive dressing was applied to 62 patients who had moderate degrees of bleeding, for haemostasis purposes. Twelve syncopes and four epileptic seizures developed secondary to local anaesthesia were managed in consultation with the Department of Children Health and Diseases. The most serious complication, trapped penis, was seen in 48 patients. All these complications were resolved using surgical interventions. Infection developed in 15 patients, and it was relieved with the administration of oral antibiotherapy. Penile adhesions were relieved in 25 cases, and anti-inflammatory treatment was organised. Meatal stenosis occurred in three cases, and two cases of inclusion cysts were treated with surgical intervention. DISCUSSION: In countries where circumcision is routinely applied, developing swift and safer methods are of the utmost importance. To this end, we prefer thermocautery, which can satisfy patient demands swiftly and safely. CONCLUSION: To reduce the complications after circumcision using thermocautery, we think that it is appropriate to pay attention to the following issues during circumcision: The cautery should be turned in a serial manner and both sides of the blade should be used for cutting, and temperature of the thermocauter should be adjusted according to the skin thickness. The cutting process should be achieved in two steps, and another method should be preferred for buried penis. If these rules are followed, we think that the thermocautery-supported method can be a very safe and fast circumcision method.

A study of laparoscopic instrument use during colorectal surgery.

The aim of this study was to quantify laparoscopic instrument use and actions of both limbs during a sample of common colorectal surgical procedures. A method was devised using Observer XT software to code video recordings. Anonymised HD video recordings of nine laparoscopic colorectal procedures performed by a single surgeon were analysed. We determined the percentage and frequency of instrument use and limb actions throughout the total laparoscopic surgical duration, as well as the duration of instrument inactivity. Seven instruments and seven actions were studied across nine surgical procedures. Manoeuvring, blunt dissection, and tenting up tissues accounted for the longest amount of total surgical time (non-dominant hand (NDH) 29%, dominant hand (DH) 39%), followed by grasping (NDH 33%, DH 9%), and cauterising (NDH <0.2%, DH 8%). Least time was spent performing other actions such as suction/irrigation (NDH 0.01%, DH 3%) and stapling colorectal tissue (NDH 0.03%, DH 0.5%). The total duration of instrument use and hand actions by the dominant and non-dominant hands were similar overall. However, the frequency of actions performed was lower for the non-dominant hand. This indicates that the non-dominant hand spent more time holding actions than switching between actions, supporting the actions of the dominant hand. These findings highlight the lengthy durations of laparoscopic surgical procedures involved in navigating to anatomical planes and moving tissues. Further, the results detail the extent of secondary functions performed with the surgical instruments.

Cautery selection for oculofacial plastic surgery in patients with implantable electronic devices.

PURPOSE: To discover oculofacial plastic surgeon practice patterns for cautery selection in the setting of implantable electronic devices and present guidelines based on a review of current literature. METHODS: A 10-Question web-based survey was sent to the email list serve of the American Society of Ophthalmic Plastic and Reconstructive Surgery to determine surgeon cautery preference in the setting of various implantable electronic devices and comfort level with the guidelines for cautery selection in their practice or institution. The relationship between survey questions was assessed for statistical significance using Pearson's Chi-square tests. RESULTS: Two hundred ninety-three (41% response rate) surveys were completed and included for analysis. Greater than half of respondents either had no policy (36%) or were unaware of a policy (19%) in their practice or institution regarding cautery selection in patients with a cardiac implantable electronic device. Bipolar cautery was favored for use in patients with a cardiac implantable electronic device (79%-80%) and this number dropped in patients with implantable neurostimulators (30%). Overall, one-third of respondents did not feel comfortable with their practice/institution policy. CONCLUSION: Choices and comfort level among oculofacial plastic surgeons for cautery selection in patients with implantable electronic devices vary considerably, and some choices may increase the risk for interference-related complications. Practice patterns vary significantly in the setting of a neurostimulator or cochlear implant, where interference can cause thermal injury to the brain and implant damage, respectively. Guidelines are proposed for cautery selection in patients with implantable electronic devices undergoing oculofacial plastic surgery.

Pain sensitivity and injury associated with three methods of disbudding goat kids: Cautery, cryosurgical and caustic paste.

Pain sensitivity and skull/brain injury associated with cautery, cryosurgical and caustic paste disbudding were evaluated in goat kids. Kids (reared for meat; n=280) were randomly assigned to one of four treatments (n=70 per treatment): (1) sham-handling (SHAM) or (2) cautery (CAUT), (3) cryosurgical (CRYO) or (4) caustic paste (CASP) disbudding. A pain sensitivity test was carried out 15min pre-treatment and 1h post-treatment. Skull/brain injury was assessed at post-mortem examination. Kids with evidence of injury to the skull/brain, as well as a random sample of kids (n=15 per treatment) without evidence of skull/brain injury, were selected for histological examination of brain tissue. Average daily gains (ADG) were calculated from body weight measurements taken 10min pre-treatment and then at 2, 7 and 14days post-treatment as a measure of the potential effects of pain or injury on growth. CASP and CRYO kids displayed higher pain sensitivity post-treatment than CAUT or SHAM kids, suggesting that they experienced more acute pain 1h post-treatment. One of 70 CAUT kids had a perforated skull, but there was no histological evidence of brain injury in this animal; a further nine CAUT kids exhibited hyperaemia of the skull. The other treatments did not result in injury to the skull/brain. There was no evidence of a difference in ADG across treatments. Caustic paste and cryosurgical disbudding resulted in greater acute pain sensitivity than cautery disbudding; however, cautery disbudding has the potential to cause skull injury if performed incorrectly.

Vagal Nerve Stimulator Lead Revision Using Needle-Tip Cautery: Case Series, Literature Review, and Technical Note.

BACKGROUND: Vagal nerve stimulators (VNs) have been in use in the United States since the 1990s as a palliative treatment option for drug-resistant epilepsy. Over time, the electrode coils wrapped around the vagus nerve become encapsulated by extensive scar tissue, making complete electrode removal challenging. We present a case series of lead revision surgeries with a unique way to remove the scar tissue around the vagus nerve, demonstrating a technique for complete electrode removal. METHODS: This was a case series of 9 consecutive patients who underwent complete removal of an existing VNs electrode using needle tip monopolar electrocautery. RESULTS: Complete removal of the entire VNs electrode array was achieved in all patients with no permanent complications seen at postoperative follow-up at 3 months. CONCLUSIONS: Complete VNs electrode array removal can be safely achieved by using needle tip monopolar electrocautery.

Experience and dissection device are more relevant than patient-related factors for operation time in laparoscopic sigmoid resection-a retrospective 8-year observational study.

PURPOSE: Surgical outcome is influenced by multiple patient-specific factors and operative expertise of the surgeon. Clinical relevance of medical technical innovations often remains unclear even though laparoscopic surgical procedures are characterized by continual advancement of various devices. Lately, in dissection and sealing technology, fast-cutting ultrasonic scissors are combined with simultaneous bipolar coagulation (bimodal dissection device (BDD)). We investigated how this new technology, operative expertise, and patient-specific factors (body mass index, age) influence operation time in laparoscopic-assisted sigmoid resection. METHODS: Between 2008 and 2016, 161 laparoscopic sigmoid resections (52% conventional dissection device (CDD); 48% BDD) performed in a single center were retrospectively evaluated. Biometric patient data, complication rates, and surgery duration, reflecting the learning curve, were analyzed. Operations were performed by experienced surgeons (n = 3) and trainees (n = 4). RESULTS: Minor postoperative complications (e.g., impaired wound healing, non-revisional secondary bleeding) occurred in 11 cases (6.8%). Major complications (e.g., bleeding requiring revision, anastomotic leakage) were observed in 3.7%. No heat-related coagulation damage was observed. BDD reduced operation time for both experienced (CDD 150 min, BDD 125 min; p < 0.001) and trainee surgeons (CDD 169 min, BDD 135 min; p = 0.036). Reduction of operation time (indicative of a learning curve in progress) was observed for all surgeons. The curve was steeper using BDD. CONCLUSIONS: Patient-specific factors did not have a significant effect on operation time. Even taking the learning curve into account, a combination of ultrasonic dissection and simultaneous bipolar coagulation reduces operation time of laparoscopic-assisted sigmoid resection, regardless of surgeon's expertise.

Comparative effectiveness of flexible versus rigid neuroendoscopy for endoscopic third ventriculostomy and choroid plexus cauterization: a propensity score-matched cohort and survival analysis.

OBJECTIVE Endoscopic third ventriculostomy (ETV)/choroid plexus cauterization (CPC) has become an increasingly common technique for the treatment of infant hydrocephalus. Both flexible and rigid neuroendoscopy can be used, with little empirical evidence directly comparing the two. Therefore, the authors used a propensity score-matched cohort and survival analysis to assess the comparative efficacy of flexible and rigid neuroendoscopy. METHODS Individual data were collected through retrospective review of infants younger than 2 years of age, treated at 1 of 2 hospitals: 1) Boston Children's Hospital, exclusively utilizing flexible neuroendoscopy, and 2) Nicklaus Children's Hospital-Jackson Memorial Hospital, exclusively utilizing rigid neuroendoscopy. Patient characteristics and postoperative outcomes were assessed. A propensity score model was developed to balance patient characteristics in the case mix. RESULTS A propensity score model for neuroendoscope type was developed with 5 independent variables: chronological age, sex, hydrocephalus etiology, prior CSF diversion, and prepontine scarring. Propensity score decile-adjusted and 1-to-1 nearest-neighbor matching analysis revealed that compared with flexible neuroendoscopy, rigid neuroendoscopy had an ETV/CPC failure odds ratio (OR) of 1.43 (p = 0.31) and 1.31 (p = 0.47), respectively, compared with an unadjusted OR of 2.40 (p = 0.034). Furthermore, in a Cox regression analysis controlled by propensity score, rigid neuroendoscopy had a hazard ratio (HR) of 1.10 (p = 0.70), compared with an unadjusted HR of 1.61 (p = 0.031). CONCLUSIONS Although unadjusted analysis suggested worse ETV/CPC outcomes for infants treated by rigid neuroendoscopy, much of the difference could be attributed to the case mix and other predictors of outcome. A larger sample observational study or randomized controlled trials are required to provide evidence-based guidelines on ETV/CPC technique.