Prevention of Seroma Formation and Its Sequelae After Axillary Lymph Node Dissection: An Up-to-Date Systematic Review and Guideline for Surgeons.

INTRODUCTION: Seroma formation after axillary lymph node dissection (ALND) remains a troublesome complication with significant morbidity. Numerous studies have tried to identify techniques to prevent seroma formation. The aim of this systematic review and network meta-analysis is to use available literature to identify the best intervention for prevention of seroma after standalone ALND. METHODS: A literature search was performed for all comparative articles regarding seroma formation in patients undergoing a standalone ALND or ALND with breast-conserving surgery in the last 25 years. Data regarding seroma formation, clinically significant seroma (CSS), surgical site infections (SSI), and hematomas were collected. The network meta-analysis was performed using a random effects model and the level of inconsistency was evaluated using the Bucher method. RESULTS: A total of 19 articles with 1962 patients were included. Ten different techniques to prevent seroma formation were described. When combining direct and indirect comparisons, axillary drainage until output is less than 50 ml per 24 h for two consecutive days results in significantly less CSS. The use of energy sealing devices, padding, tissue glue, or patches did not significantly reduce the incidence of CSS. When comparing the different techniques with regard to SSIs, no statistically significant differences were seen. CONCLUSIONS: To prevent CSS after ALND, axillary drainage is the most valuable and scientifically proven measure. On the basis of the results of this systematic review with network meta-analysis, removing the drain when output is < 50 ml per 24 h for two consecutive days irrespective of duration seems best. Since drainage policies vary widely, an evidence-based guideline is needed.

Clinical and biological effects of different energetic surgical devices currently used for mini-invasive anatomical lung resections for the treatment of NSCLC: a prospective interventional study.

BACKGROUND: This study aims to compare three commonly used energy devices for dissection during Video-Assisted Thoracoscopic Surgery (VATS) lobectomy: monopolar hook, advanced bipolar, and ultrasonic device, in terms of duration of the surgical procedure and clinical intra- and post-operative outcomes. MATERIALS AND METHODS: In this prospective single-center study, 75 patients undergoing VATS lobectomy for non-small cell lung cancer between January 2022 and May 2023 were enrolled and divided into 3 groups based on the device used during the surgical procedure (Group 1: Ultrasonic Device, Group 2: Advanced Bipolar, Group 3: Monopolar Hook). The duration of the surgical procedure, daily pleural fluid production, post-operative pain, length of hospital stay, and occurrence of post-operative complications were compared for each group. In a subgroup of 20 patients (10 from Group 1 and 10 from Group 3), concentrations of inflammatory cytokines in pleural fluid at 3 h and 48 h post-surgery were analyzed. RESULTS: Pleural fluid production on the first and second post-operative days was significantly lower in patients treated with the Ultrasonic device compared to the other two groups (p < 0.001). The duration of the surgical procedure was significantly shorter when using the Ultrasonic device (p < 0.001). There were no significant differences in length of hospital stay (p = 0.975), pain on the first and second post-operative days (p = 0.147 and p = 0.755, respectively), and blood hemoglobin levels on the first post-operative day (p = 0.709) and at discharge (p = 0.795). No differences were observed in terms of post-operative complications, although the incidence of post-operative cardiac arrhythmias was borderline significant (p = 0.096), with no cases of arrhythmias recorded in Group 1. IL-10 levels in pleural fluid of patients in Group 3 peaked at 3 h post-surgery, with a significant reduction at 48 h (p = 0.459). DISCUSSION: The use of the ultrasonic device during VATS lobectomy may reduce pleural fluid production and shorten the duration of the surgical procedure compared to using a monopolar hook or advanced bipolar device. The choice of energy device may influence the local inflammatory response, although further studies are needed to confirm these results.

Recent advances in two-dimensional nanomaterials for sustainable wearable electronic devices.

The widespread adoption of smart terminals has significantly boosted the market potential for wearable electronic devices. Two-dimensional (2D) nanomaterials show great promise for flexible, wearable electronics of next-generation electronic materials and have potential in energy, optoelectronics, and electronics. First, this review focuses on the importance of functionalization/defects in 2D nanomaterials, a discussion of different kinds of 2D materials for wearable devices, and the overall structure-property relationship of 2D materials. Then, in this comprehensive review, we delve into the burgeoning realm of emerging applications for 2D nanomaterial-based flexible wearable electronics, spanning diverse domains such as energy, medical health, and displays. A meticulous exploration is presented, elucidating the intricate processes involved in tailoring material properties for specific applications. Each research direction is dissected, offering insightful perspectives and dialectical evaluations that illuminate future trajectories and inspire fruitful investigations in this rapidly evolving field.

Outcomes of conventional and advanced energy devices in laparoscopic surgery: a systematic review.

INTRODUCTION: Hemostasis is an important step in all surgical procedures. Mechanical methods of hemostasis have been gradually abandoned in favor of electrosurgery. The aim of this systematic review was to evaluate the effectiveness of electrosurgical instruments utilized in minimally invasive gynecological procedures. MATERIAL AND METHODS: We performed a systematic review, including randomized controlled trials, prospective and retrospective studies, comparing the outcomes of different energy devices (EDs) used in laparoscopic gynecologic surgeries. We extracted data about blood loss (BL), mean operative time, post-operative pain, hospital stay and complications associated with each electrosurgical device. RESULTS: We included 30 studies reporting comparative outcomes concerning conventional (bipolar and monopolar) and innovative EDs (Harmonic scalpel, LigaSure, Plasma kinetic gyrus, Thunderbeat, EnSeal, Marseal, Caiman and ALAN). New EDs were found to be more efficient in complex surgeries due to less intraoperative BL and shorter operative time. No significant decrease in hospital stay, post-operative pain or complications was found with the use of new energy instruments. CONCLUSIONS: Although new electrosurgical devices seem an appealing and safer option, there is still insufficient evidence for one vessel-sealing technology to be considered superior to another. Therefore, monopolar and conventional bipolar (CB) are still widely used in laparoscopic gynecology.

Micro/Nano-Fabrication of Flexible Poly(3,4-Ethylenedioxythiophene)-Based Conductive Films for High-Performance Microdevices.

With the increasing demands for novel flexible organic electronic devices, conductive polymers are now becoming the rising star for reaching such targets, which has witnessed significant breakthroughs in the fields of thermoelectric devices, solar cells, sensors, and hydrogels during the past decade due to their outstanding conductivity, solution-processing ability, as well as tailorability. However, the commercialization of those devices still lags markedly behind the corresponding research advances, arising from the not high enough performance and limited manufacturing techniques. The conductivity and micro/nano-structure of conductive polymer films are two critical factors for achieving high-performance microdevices. In this review, the state-of-the-art technologies for developing organic devices by using conductive polymers are comprehensively summarized, which will begin with a description of the commonly used synthesis methods and mechanisms for conductive polymers. Next, the current techniques for the fabrication of conductive polymer films will be proffered and discussed. Subsequently, approaches for tailoring the nanostructures and microstructures of conductive polymer films are summarized and discussed. Then, the applications of micro/nano-fabricated conductive films-based devices in various fields are given and the role of the micro/nano-structures on the device performances is highlighted. Finally, the perspectives on future directions in this exciting field are presented.

Comparison of perioperative outcomes between bipolar sealing, ultrasonic shears and a hybrid device during laparoscopic gastrectomy for early gastric cancer: a prospective, multicenter, randomized study.

BACKGROUND: Although EBDs are essential for minimally invasive surgery, well-established prospective randomized studies comparing EBDs are scarce. This study aimed to compare the intraoperative inflammatory response and short-term surgical outcomes among different energy-based devices (EBDs) in laparoscopic distal gastrectomy (LDG). METHODS: Patients with clinical stage I gastric cancer scheduled for LDG at two different medical centers were prospectively randomized into three groups: ultrasonic shears (US), advanced bipolar (BP) and ultrasonic-bipolar hybrid (HB). The C-reactive protein (CRP) level, operation time, intraoperative blood loss (IBL), laboratory tests, cytokines (interleukin (IL)-6 and IL-10), hospital stay, and complication rate were analyzed. A novel semiquantitative measurement method using indocyanine green (ICG) and a near-infrared camera measured the amount of lymphatic leakage. RESULTS: The primary endpoint, the CRP level, was significantly lower in the BP (n = 60) group than in the US (n = 57) or HB (n = 57) group [9.03 ± 5.55 vs. 11.12 ± 5.02 vs. 12.67 ± 6.14, p = 0.001, on postoperative day (POD) 2 and 7.48 vs. 9.62 vs. 9.48, p = 0.026, on POD 4]. IBL was significantly lower in BP than in US or HB (26.3 ± 25.3 vs. 43.7 ± 42.0 vs. 34.9 ± 37.0, p = 0.032). Jackson-Pratt drainage triglycerides were significantly lower in BP than in US (53.6 ± 33.7 vs. 84.2 ± 59.0, p = 0.11; HB: 71.3 ± 51.4). ICG fluorescence intensity, operation time, laboratory results, cytokines, hospital stay, and complication rate were not significantly different among the 3 groups. CONCLUSION: BP showed a lower postoperative CRP level and less IBL than US and HB, suggesting less collateral thermal damage and better sealing function. Surgeons may consider this when selecting EBDs for laparoscopic surgery.

Use of High Energy Devices (HEDs) versus electrocautery for laparoscopic cholecystectomy: a systematic review and meta-analysis of randomised controlled trials.

INTRODUCTION: According to the literature, there is no clear definition of a High Energy Devices (HEDs), and their proper indications for use are also unclear. Nevertheless, the flourishing market of HEDs could make their choice in daily clinical practice arduous, possibly increasing the risk of improper use for a lack of specific training. At the same time, the diffusion of HEDs impacts the economic asset of the healthcare systems. This study aims to assess the efficacy and safety of HEDs compared to electrocautery devices while performing laparoscopic cholecystectomy (LC). MATERIALS AND METHODS: On behalf of the Italian Society of Endoscopic Surgery and New Technologies, experts performed a systematic review and meta-analysis and synthesised the evidence assessing the efficacy and safety of HEDs compared to electrocautery devices while performing laparoscopic cholecystectomy (LC). Only randomised controlled trials (RCTs) and comparative observational studies were included. Outcomes were: operating time, bleeding, intra-operative and post-operative complications, length of hospital stay, costs, and exposition to surgical smoke. The review was registered on PROSPERO (CRD42021250447). RESULTS: Twenty-six studies were included: 21 RCTs, one prospective parallel arm comparative non-RCT, and one retrospective cohort study, while three were prospective comparative studies. Most of the studies included laparoscopic cholecystectomy performed in an elective setting. All the studies but three analysed the outcomes deriving from the utilisation of US sources of energy compared to electrocautery. Operative time was significantly shorter in the HED group compared to the electrocautery group (15 studies, 1938 patients; SMD - 1.33; 95% CI - 1.89 to 0.78; I2 = 97%, Random-effect). No other statistically significant differences were found in the other examined variables. CONCLUSIONS: HEDs seem to have a superiority over Electrocautery while performing LC in terms of operative time, while no difference was observed in terms of length of hospitalisation and blood loss. No concerns about safety were raised.

Response predictor for pigment reduction after one session of photo-based therapy using convolutional neural network: A proof of concept study.

BACKGROUND: Identifying treatment responders after a single session of photo-based procedure for hyperpigmentary disorders may be difficult. OBJECTIVES: We aim to train a convolutional neural network (CNN) to test the hypothesis that there exist discernible features in pretreatment photographs for identifying favorable responses after photo-based treatments for facial hyperpigmentation and develop a clinically applicable algorithm to predict treatment outcome. METHODS: Two hundred and sixty-four sets of pretreatment photographs of subjects receiving photo-based treatment for esthetic enhancement were obtained using the VISIA® skin analysis system. Preprocessing was done by masking the facial features of the photographs. Each set of photographs consists of five types of images. Five independently trained CNNs based on the Resnet50 backbone were developed based on these images and the results of these CNNs were combined to obtain the final result. RESULTS: The developed CNN algorithm has a prediction accuracy approaching 78.5% with area under the receiver operating characteristic curve being 0.839. CONCLUSION: The treatment efficacy of photo-based therapies on facial skin pigmentation can be predicted based on pretreatment images.

Recent Advances in Synthesis and Applications of Single-Atom Catalysts for Rechargeable Batteries.

The rapid development of flexible and wearable optoelectronic devices, demanding the superior, reliable, and ultra-long cycling energy storage systems. But poor performances of electrode materials used in energy devices are main obstacles. Recently, single-atom catalysts (SACs) are considered as emerging and potential candidates as electrode materials for battery devices. Herein, we have discussed the recent methods for the fabrication of SACs for rechargeable metal-air batteries, metal-CO2 batteries, metal-sulfur batteries, and other batteries, following the recent advances in assembling and performance of these batteries by using SACs as electrode materials. The role of SACs to solve the bottle-neck problems of these energy storage devices and future perspectives are also discussed.

A pilot randomized controlled trial comparing THUNDERBEAT to the Maryland LigaSure energy device in laparoscopic left colon surgery.

BACKGROUND: The THUNDERBEAT is a multi-functional energy device which delivers both ultrasonic and bipolar energy, but there are no randomized trials which can provide more rigorous evaluation of the clinical performance of THUNDERBEAT compared to other energy-based devices in colorectal surgery. The aim of this study was to compare the clinical performance of THUNDERBEAT energy device to Maryland LigaSure in patients undergoing left laparoscopic colectomy. METHODS: Prospective randomized trial with two groups: Group 1 THUNDERBEAT and Group 2 LigaSure in a single university hospital. 60 Subjects, male and female, of age 18 years and above undergoing left colectomy for cancer or diverticulitis were included. The primary outcome was dissection time to specimen removal (DTSR) measured in minutes from the start of colon mobilization to specimen removal from the abdominal cavity. Versatility (composite of five variables) was measured by a score system from 1 to 5 (1 being worst and 5 the best), and adjusted/weighted by coefficient of importance with distribution of the importance as follow: hemostasis 0.275, sealing 0.275, cutting 0.2, dissection 0.15, and tissue manipulation 0.1. Other variables were: dryness of surgical field, intraoperative and postoperative complications, and mortality. Follow-up time was 30 days. RESULTS: 60 Patients completed surgery, 31 in Group 1 and 29 in Group 2. There was no difference in the DTSR between the groups, 91 min vs. 77 min (p = 0.214). THUNDERBEAT showed significantly higher score in dissecting and tissue manipulation in segment 3 (omental dissection), and in overall versatility score (p = 0.007) as well as versatility score in Segment 2 (retroperitoneal dissection p = 0.040) and Segment 3 (p = 0.040). No other differences were noted between the groups. CONCLUSIONS: Both energy devices can be employed effectively and safely in dividing soft tissue and sealing mesenteric blood vessels during laparoscopic left colon surgery, with THUNDERBEAT demonstrating some advantages over LigaSure during omental dissection and tissue manipulation. CLINICALTRIAL: gov # NCT02628093.

A systematic review and network meta-analysis comparing energy devices used in colorectal surgery.

BACKGROUND: The aim of this study was to compare energy devices used for intraoperative hemostasis during colorectal surgery. METHODS: A systematic literature review and Bayesian network meta-analysis performed. MEDLINE, EMBASE, Science Citation Index Expanded, and Cochrane were searched from inception to August 11th 2021. Intraoperative outcomes were operative blood loss, operative time, conversion to open, conversion to another energy source. Postoperative outcomes were mortality, overall complications, minor complications and major complications, wound complications, postoperative ileus, anastomotic leak, time to first defecation, day 1 and 3 drainage volume, duration of hospital stay. RESULTS: Seven randomized controlled trials (RCTs) were included, reporting on 680 participants, comparing conventional hemostasis, LigaSure™, Thunderbeat® and Harmonic®. Harmonic® had fewer overall complications compared to conventional hemostasis. Operative blood loss was less with LigaSure™ (mean difference [MD] = 24.1 ml; 95% confidence interval [CI] - 46.54 to - 1.58 ml) or Harmonic® (MD = 24.6 ml; 95% CI - 42.4 to - 6.7 ml) compared to conventional techniques. Conventional hemostasis ranked worst for operative blood loss with high probability (p = 0.98). LigaSure™, Harmonic® or Thunderbeat® resulted in a significantly shorter mean operative time by 42.8 min (95% CI - 53.9 to - 31.5 min), 28.3 min (95% CI - 33.6 to - 22.6 min) and 26.1 min (95% CI - 46 to - 6 min), respectively compared to conventional electrosurgery. LigaSure™ resulted in a significantly shorter mean operative time than Harmonic® by 14.5 min (95% CI 1.9-27 min) and ranked first for operative time with high probability (p = 0.97). LigaSure™ and Harmonic® resulted in a significantly shorter mean duration of hospital stay compared to conventional electrosurgery of 1.3 days (95% CI - 2.2 to - 0.4) and 0.5 days (95% CI - 1 to - 0.1), respectively. LigaSure™ ranked as best for hospital stay with high probability (p = 0.97). Conventional hemostasis was associated with more wound complications than Harmonic® (odds ratio [OR] = 0.27; CI 0.08-0.92). Harmonic® ranked best with highest probability (p = 0.99) for wound complications. No significant differences between energy devices were identified for the remaining outcomes. CONCLUSIONS: LigaSure™, Thunderbeat® and Harmonic® may be advantageous for reducing operative blood loss, operative time, overall complications, wound complications, and duration of hospital stay compared to conventional techniques. The energy devices result in comparable perioperative outcomes and no device is superior overall. However, included RCTs were limited in number and size, and data were not available to compare all energy devices for all outcomes of interest.

Dual Network Sponge for Compressible Lithium-Ion Batteries.

Compressible energy devices have received increasing attention with the rapid development of flexible electronics and wearable devices due to their size adaptability and functional stability. However, it is hard to simultaneously achieve satisfactory energy density and mechanical stability for electrodes. Here an open-porous dual network sponge (DNS) with two networks of highly conductive carbon nanotubes and Li+ -intercalating TiO2 -B nanowires is synthesized and employed as compressible lithium ion battery electrodes. All 1D components inside the DNS mutually penetrate with each other to form two physically distinct but functionally coupling networks, endowing DNS excellent compressibility and stability. A prototype compressible lithium-ion battery (C-LIB) is also demonstrated, in which the DNS exhibits a specific capacity of >238 mAh g-1 under static 50% strain, and further in situ measurements show that under 1000 times of cyclic strains, DNS can charge and discharge normally maintaining a high capacity of 240 mAh g-1 and exhibits robustness to fast strain rates up to 500% min-1 . The dual network structure can be extended to design high-performance compliant electrodes that are promising to serve in future compressible and deformable electronics and energy systems.

Predictors and Consequences of Hematoma After Thyroidectomy: An American College of Surgeons National Surgical Quality Improvement Program Database Analysis.

BACKGROUND: Hematoma after thyroid surgery is a serious complication. The purpose of this study was to determine the predictors and consequences of hematoma after thyroid surgery. MATERIALS AND METHODS: A retrospective analysis of 11,552 open thyroidectomies was conducted using the American College of Surgeons National Surgical Quality Improvement Program 2016-2017 main and thyroidectomy-targeted procedure databases. Predictors of hematoma and the effect of hematoma on outcomes were analyzed by multivariate logistic regression, resulting in risk-adjusted odds ratios of hematoma and morbidity/mortality, respectively. Statistical analysis was performed using R version 3.5.1. RESULTS: We found that male gender (odds ratio 1.71, 95% confidence interval 1.25-2.32; P value 0.0007), Black race (1.89, 1.27-2.77; 0.0014), other race (1.76, 1.23-2.50; 0.0017), hypertension (1.68, 1.20-2.35; 0.0026), diabetes (1.45, 1.00-2.06; 0.0460), and bleeding disorders (3.63, 1.61-7.28; 0.0007) were independent risk factors for postoperative hematoma. The use of an energy device for hemostasis (0.63, 0.46-0.87; 0.0041) was independently associated with decreased hematoma rate. Postoperative hematoma was an independent risk factor for overall morbidity (3.04, 2.21-4.15; <0.0001), hypocalcemia (1.73, 1.08-2.66, 0.0162), recurrent laryngeal nerve injury (2.42, 1.57-3.60, <0.0001), pulmonary morbidity (18.91, 10.13-34.16, <0.0001), wound morbidity (10.61, 5.54-19.02, <0.0001), readmission (5.23, 3.34-7.92, <0.0001), return to operating room (90.73, 62.62-131.97; <0.0001), and length of stay greater than the median (5.10, 3.62-7.15, <0.0001). CONCLUSIONS: Identified by this study are the predictors of postthyroidectomy hematoma and the consequences thereof. Notably, the use of energy devices for hemostasis was shown to be protective of postoperative hematoma. The results of this study may guide pre- and intra-operative decision-making for thyroidectomy to reduce rates of postoperative hematoma.

Current status on the adoption of high energy devices in Italy: An Italian Society for Endoscopic Surgery and New Technologies (SICE) national survey.

BACKGROUND: In the past three decades, different High Energy Devices (HED) have been introduced in surgical practice to improve the efficiency of surgical procedures. HED allow vessel sealing, coagulation and transection as well as an efficient tissue dissection. This survey was designed to verify the current status on the adoption of HED in Italy. METHODS: A survey was conducted across Italian general surgery units. The questionnaire was composed of three sections (general information, elective surgery, emergency surgery) including 44 questions. Only one member per each surgery unit was allowed to complete the questionnaire. For elective procedures, the survey included questions on thyroid surgery, lower and upper GI surgery, proctologic surgery, adrenal gland surgery, pancreatic and hepatobiliary surgery, cholecystectomy, abdominal wall surgery and breast surgery. Appendectomy, cholecystectomy for acute cholecystitis and bowel obstruction due to adhesions were considered for emergency surgery. The list of alternatives for every single question included a percentage category as follows: " < 25%, 25-50%, 51-75% or > 75%", both for open and minimally-invasive surgery. RESULTS: A total of 113 surgical units completed the questionnaire. The reported use of HED was high both in open and minimally-invasive upper and lower GI surgery. Similarly, HED were widely used in minimally-invasive pancreatic and adrenal surgery. The use of HED was wider in minimally-invasive hepatic and biliary tree surgery compared to open surgery, whereas the majority of the respondents reported the use of any type of HED in less than 25% of elective cholecystectomies. HED were only rarely employed also in the majority of emergency open and laparoscopic procedures, including cholecystectomy, appendectomy, and adhesiolysis. Similarly, very few respondents declared to use HED in abdominal wall surgery and proctology. The distribution of the most used type of HED varied among the different surgical interventions. US HED were mostly used in thyroid, upper GI, and adrenal surgery. A relevant use of H-US/RF devices was reported in lower GI, pancreatic, hepatobiliary and breast surgery. RF HED were the preferred choice in proctology. CONCLUSION: HED are extensively used in minimally-invasive elective surgery involving the upper and lower GI tract, liver, pancreas and adrenal gland. Nowadays, reasons for choosing a specific HED in clinical practice rely on several aspects, including surgeon's preference, economic features, and specific drawbacks of the energy employed.

A Novel, Low Computational Complexity, Parallel Swarm Algorithm for Application in Low-Energy Devices.

In this work, we propose a novel metaheuristic algorithm that evolved from a conventional particle swarm optimization (PSO) algorithm for application in miniaturized devices and systems that require low energy consumption. The modifications allowed us to substantially reduce the computational complexity of the PSO algorithm, translating to reduced energy consumption in hardware implementation. This is a paramount feature in the devices used, for example, in wireless sensor networks (WSNs) or wireless body area sensors (WBANs), in which particular devices have limited access to a power source. Various swarm algorithms are widely used in solving problems that require searching for an optimal solution, with simultaneous occurrence of a different number of sub-optimal solutions. This makes the hardware implementation worthy of consideration. However, hardware implementation of the conventional PSO algorithm is challenging task. One of the issues is an efficient implementation of the randomization function. In this work, we propose novel methods to work around this problem. In the proposed approach, we replaced the block responsible for generating random values using deterministic methods, which differentiate the trajectories of particular particles in the swarm. Comprehensive investigations in the software model of the modified algorithm have shown that its performance is comparable with or even surpasses the conventional PSO algorithm in a multitude of scenarios. The proposed algorithm was tested with numerous fitness functions to verify its flexibility and adaptiveness to different problems. The paper also presents the hardware implementation of the selected blocks that modify the algorithm. In particular, we focused on reducing the hardware complexity, achieving high-speed operation, while reducing energy consumption.

The safe use of surgical energy devices by surgeons may be overestimated.

BACKGROUND: Surgical energy injuries are an underappreciated phenomenon. Improper use of surgical energy or poor attention to patient safety can result in operating room fires, tissue injuries, and interferences with other electronic devices, while rare complications can be devastatingly severe. Despite this, there is no current standard requirement for educating surgeons on the safe use of energy-based devices or evaluation of electrosurgery (ES) education in residency training, credentialing, or practice. The study aimed to assess the current baseline knowledge of surgeons and surgical trainees with regards to ES across varying experiences at a tertiary level care center. METHODS: Surgeons and surgical trainees from seven surgical specialties (General Surgery, Cardiothoracic Surgery, Vascular Surgery, Obstetrics/Gynecology, Orthopedic Surgery, Urology, and Otorhinolaryngology) at a tertiary level care hospital were tested. Testing included an evaluation regarding their background training and experiences with ES-related adverse events and a 15 multiple-choice-question exam testing critical knowledge of ES. RESULTS: A total of 134 surveys were sent out with 72 responses (53.7%). The mean quiz score was 51.5 ± 15.5% (passing score was 80%). Of staff surgeons, 33/65 (50.8%) completed the survey with mean and median scores of 54.9 and 53.3%, respectively (range 33.3-86.7%). Of surgical trainees, 39/69 (56.5%) completed the survey with mean and median scores of 48.6 and 46.7%, respectively (range 13.3-80.0%). There were no statistically significant differences based on training status (p = 0.08), previous training (p = 0.24), number of cases (p = 0.06), or specialty (p = 0.689). CONCLUSION: Surgeons and surgical trainees both have a significant knowledge gap in the safe and effective use of surgical energy devices, regardless of surgical specialty and despite what they feel was adequate training. The knowledge gap is not improved with experience. A formal surgical energy education program should be a requirement for residency training or credentialing.

Comparison of Industry-Leading Energy Devices for Use in Gynecologic Laparoscopy: Articulating ENSEAL versus LigaSure Energy Devices.

STUDY OBJECTIVE: To compare 2 laparoscopic bipolar electrosurgical devices used in total laparoscopic hysterectomy (TLH). An articulating advanced bipolar device (ENSEAL G2; Ethicon Endo-Surgery, Cincinnati, OH) and an electrothermal bipolar vessel sealer (LigaSure; Medtronic, Minneapolis, MN) were analyzed for differences in surgeon perception of ease of instrument use and workload using the NASA Raw Task Load Index (RTLX) scale. A second objective was to examine differences in operative time, estimated blood loss (EBL), and perioperative complication rates between the 2 devices. DESIGN: Single-institution, single-blinded, randomized controlled trial (Canadian Task Force classification I). SETTING: Division of Minimally Invasive Gynecologic Surgery in a university hospital. PATIENTS: Eligibility required planned TLH, over age 18 years, and able to give informed consent; exclusions were stage III or IV endometriosis, known gynecologic malignancy, and early decision for conversion to laparotomy. One hundred seventy-eight patients screened, 142 enrolled, 2 withdrew, and 140 completed the study. Patients were followed 1 month postoperatively. INTERVENTIONS: Preoperative randomization to articulating advanced bipolar device or electrothermal bipolar vessel sealer to be used during TLH. MEASUREMENTS AND MAIN RESULTS: At the end of each hysterectomy the primary surgeon completed an ergonomic assessment tool, the RTLX. Results were analyzed to detect differences in workload between the 2 devices. For each case the time to ligation of the bilateral uterine arteries, EBL, and complications (including device failure, blood transfusion, or other injury) were recorded. Statistical analysis was performed using the t test for normally distributed data, χ2 test for categorical data, and Mann-Whitney U-test for nonparametric data. There were no differences in age, body mass index, parity, prior surgery, uterine weight, race, indication, pathology, and comorbidities between the 2 groups. A statistically significant increase in RTLX scores (p < .0001), device failures (p = .0031), and time to ligation of bilateral uterine arteries (p = .0281) was noted in the articulating device group. No significant differences in EBL or complication rates were noted between the groups. CONCLUSIONS: The articulating advanced bipolar device was shown to have a statistically significant increase in surgeon-perceived workload and rate of device failure when used in TLH; however, clinical and surgical outcomes were equivalent.

Energy Device Applications of Synthesized 1D Polymer Nanomaterials.

1D polymer nanomaterials as emerging materials, such as nanowires, nanotubes, and nanopillars, have attracted extensive attention in academia and industry. The distinctive, various, and tunable structures in the nanoscale of 1D polymer nanomaterials present nanointerfaces, high surface-to-volume ratio, and large surface area, which can improve the performance of energy devices. In this review, representative fabrication techniques of 1D polymer nanomaterials are summarized, including electrospinning, template-assisted, template-free, and inductively coupled plasma methods. The recent advancements of 1D polymer nanomaterials in energy device applications are demonstrated. Lastly, existing challenges and prospects of 1D polymer nanomaterials for energy device applications are presented.

Ultrasonic, bipolar, and integrated energy devices: comparing heat spread in collateral tissues.

BACKGROUND: Integrated devices incorporating ultrasonic and bipolar technology have been used in laparoscopic surgery, however, are not yet incorporated into open operations. Here, we compare thermal spread and recurrent laryngeal nerve (RLN) functional data of the integrated THUNDERBEAT Open Fine Jaw device, the bipolar Ligasure Small Jaw, and the ultrasonic Harmonic Focus for open thyroidectomy. MATERIALS AND METHODS: The three energy devices were compared in a live porcine model using three tissue types including liver, muscle, and thyroid. The devices were fired three times on each energy setting, and the thermal spread was measured by thermocouples that were inserted in surrounding tissues at 1-mm intervals. To determine RLN injury, devices were fired at successive 1-mm increments from the RLN until the monitor signal was lost. RESULTS: When comparing heat generated across these devices at 1 mm, the peak temperature (Celsius) reached in liver tissue was observed with the ultrasonic device (115.4 ± 86.7), in muscle tissue with the integrated device (104.2 ± 82.1), and in thyroid with the bipolar device (81.4 ± 41.3). Temperatures generated at individual settings on each device were similar (P = 0.11-0.81). RLN injury occurred after firing on manually approximated tissue 1-mm away from the RLN for all devices; however, there was no signal loss at ≥2 mm. CONCLUSIONS: Heat transfer was similar among all devices with the exception of the ultrasonic device when used in the liver, which showed higher temperatures. Liver tissue showed the most consistent results. RLN injury did not occur if the devices were fired on manually approximated tissue ≥2 mm from the nerve.

Comparison of skin-sparing mastectomy using LigaSure™ Small Jaw and electrocautery.

BACKGROUND: Skin-sparing mastectomy (SSM) is increasingly used in patients with breast cancer. We compared the differences between use of electrocautery and LigaSure™ Small Jaw in patients with breast cancer who underwent SSM. METHODS: Between January 2012 and December 2015, 81 patients with breast cancer who underwent SSM were selected and were divided into the electrocautery group and the LigaSure™ Small Jaw group based on the devices that were used. Clinicopathological characteristics, body mass index, operative time, and weight of removed breast were obtained from medical records. Total amount and days of drain use, until removal, and postoperative skin necrosis, requiring debridement, were also analyzed. RESULTS: The study population consisted of 50 patients in the electrocautery group and 31 in the LigaSure™ Small Jaw group. The latter group has significantly shorter operative time (117.5 ± 16.9 vs. 104.0 ± 23.6 min, P = 0.004). The mean total volume of drainage was less (805 ± 278 vs. 694 ± 131 mL, P = 0.017) and mean duration of drainage was also significantly shorter in the LigaSure™ Small Jaw group (11.3 ± 2.5 vs. 10.1 ± 2.0 days, P = 0.029). CONCLUSIONS: The use of LigaSure™ Small Jaw during skin-sparing mastectomy shortened the operative time and duration of drainage and reduced the total volume of drainage.