Thermal Processes in Bile Ducts During Laparoscopic Cholecystectomy with Monopolar Instruments. Experimental Study Using Real-Time Intraluminal and Surface Thermography.

Introduction. A significant rate of complications during laparoscopic cholecystectomy (LC) occurs due to thermal injury caused by monopolar electrosurgery (MES) equipment. Most of them manifest weeks and months after surgery with the common bile duct (CBD) and large duodenal papilla strictures, some in the early postoperative period with bile leaks. Objective. To study thermal processes occurring in the lumen and on the surface of the bile ducts during monopolar coagulation in a porcine model of LC. Methods. The temperature of the bile ducts was measured using instrumentation consisted of biliary stent with temperature sensors, which was inserted in the porcine CBD, signal amplifier, and current sense transformer. Surface temperature was measured with a scientific grade thermal camera. Cholecystectomy was performed using a standard "critical view of safety" (CVS) approach with 5 mm monopolar laparoscopic instruments. Results. Application of MES caused significant tissue heating. Lateral thermal spread and the rate of tissue heating depended on the duration of energy application and the initial tissue temperature. In 5 out of 6 experiments, the intraluminal temperature rose up to the critical threshold, and the exposure time ranged from 54 to 560 seconds. A sensor positioned at the papilla site was heated in all the experiments but still below the cell damage inducing threshold. The analysis of thermographic charts revealed the presence of the "current channeling" effect and the pedicle effect. Conclusion. There is a possibility of a direct and delayed thermal injury to the bile ducts during LC.

Thermal effects of monopolar electrosurgery detected by real-time infrared thermography: an experimental appendectomy study.

BACKGROUND: Monopolar energy (ME) is routinely used in appendectomy. This study aimed to investigate the degree of lateral thermal spread generated by ME and to evaluate the thermal injury sustained by the close-lying tissues. METHODS: Appendectomy with a monopolar Maryland dissector was performed in 8 rabbits (at 30 and 60 W power settings). A high-resolution infrared camera was used to record tissue heating during the intervention. After autopsy macroscopic changes were evaluated and tissue samples were subjected to myeloperoxidase (MPO) assay and histological examination. RESULTS: No significant differences in the extent of thermal spread, MPO activity and histological signs of inflammation were observed between groups. Regardless of the power settings, the heat spread exceeded 2 cm laterally along the mesoappendix when application time exceeded 3 s. The spread of heat through tubular structures in both groups caused a significant temperature rise in the nearby intestinal loop, resulting in perforation (n = 3) and necrosis (n = 1). CONCLUSIONS: Application time is critical in thermal spread during appendectomy aided by ME. Tubular anatomic structures can enhance thermal injury on distant tissues. The observed effects of ME bear clinical relevance that need further investigation.

Effect of nanostructured thin film on minimally invasive surgery devices applications: characterization, cell cytotoxicity evaluation and an animal study in rat.

BACKGROUND: Minimally invasive surgery is performed using an endoscope and other instruments including the electrosurgical units. However, concerns including surgical smoke, tissue sticking and thermal injury are remaining in electrosurgery. AIMS: Accordingly, a newly developed electrosurgical electrode coating with hydrogenated Cu-incorporated diamond-like carbon (DLC-Cu) film is purposed to improve the instrument performance. METHODS: The morphologies of DLC-Cu surfaces were characterized using transmission electron microscopy, scanning electron microscopy and atomic force microscopy. In this study, lesions were made on the liver lobes of adult rats, using a monopolar electrosurgical unit equipped with untreated stainless steel electrodes or treated-electrodes. Animals were killed for evaluations at 0, 3, 7 and 28 days postoperatively. RESULTS: Treated-electrodes generate less sticking tissues and adhesive blood cells. Thermography revealed that the surgical temperature in liver tissue from the treated-electrode was significantly lower than the untreated-electrode. Total injury area of livers treated with treated-electrodes was significantly smaller than the untreated-electrodes treatment. Moreover, treated-electrodes caused a relatively smaller area of lateral thermal injury, a smaller area of fibrotic tissue and a faster process of remodeling than the untreated-electrodes. Western blot analysis showed that rats treated with treated-electrode expressed lower levels of NF-κB, caspase-3 and MMP-9 than untreated-electrode. Immunofluorescence staining for caspase-3 revealed that the untreated-electrode caused more serious injury. CONCLUSIONS: This study reveals that the plating of electrodes with hydrogenated Cu-incorporated diamond-like carbon film is an efficient method for improving the performance of electrosurgical units, and should benefit wound remodeling. However, more tests must be carried out to confirm these promising findings in human patients.

Monopolar Electrosurgery With Cochlear Implants.

OBJECTIVE: To evaluate safety of monopolar electrosurgery (MES) in patients with cochlear implants (CIs) by reporting outcomes of a series of patients who underwent MES after CI. STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: Patients with indwelling CI subsequently undergoing surgery with operative note specifically detailing MES use. MAIN OUTCOME MEASURES: Adverse outcomes in post-operative audiology/otolaryngology documentation; speech recognition scores. RESULTS: Thirty-five patients (10 with bilateral CI) experienced 63 unique MES exposure events, 85.7% below and 14.3% above the clavicle. No adverse events or decreased performance due to MES use were reported for any patient. Pre- and immediate postoperative speech recognition scores were not significantly different for patients using either consonant-nucleus-consonant (CNC; n = 23, 68%-66%, p = 0.80) or AzBio (n = 15, 82%-88%, p = 0.60). For individual CNC performance, 21 (91%) patients demonstrated stability, 1 improved >15%, and 1 declined >15%, although this patient had become a non-user due to magnet issues and, after resolution of these issues, exceeded baseline pre-operative score. For individual AzBio performance, 12 (80%) patients demonstrated stability, 3 improved >15%, and none declined >15%. CONCLUSIONS: No adverse events resulted from MES use in CI patients. Given the increased prevalence and expansion of indications for CIs, and widespread utility of MES, we suggest clarification and improved guidance from device manufacturers regarding safety and use of MES for patients with these devices. We hope that data regarding electrosurgery exposure events will better inform clinician decision-making with regards to relative benefits and risks for MES use for CI patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:933-937, 2023.

Contemporary use of ultrasonic versus standard electrosurgical dissection in laparoscopic nephrectomy: Safety, efficacy and cost.

OBJECTIVE: To assess the safety, efficacy and cost-effectiveness of ultrasonic dissection (USD) compared with standard monopolar electrosurgery (ES) in laparoscopic nephrectomy (LN). PATIENTS AND METHODS: Retrospective analysis of patients' records who underwent elective LN was performed. Patients were divided in to two groups: USD and ES groups depending on the energy source used during LN. The preoperative (demographics, indication for surgery), intraoperative (conversion to open surgery, operative time, estimated blood loss [EBL], complications), and postoperative (morbidity/mortality, volume of drainage, hospital stay, cost) data were collected and analysed. RESULTS: Between February 2004 and February 2008, 136 patients were included. The indications for nephrectomy were: inflammatory (51 patients), non-inflammatory (64), and tumours (21). The two groups were similar for preoperative data. The conversion rate to open surgery (12.5%) and mean operative time did not differ significantly between the groups. However, intraoperative mean EBL was significantly less with USD, at 140.8 mL vs 182.6 mL for ES. There were no differences in postoperative parameters and morbidity. USD was significantly more expensive than ES (59 000 vs 26 000 Indian Rupees). CONCLUSIONS: ES is a safe and feasible tool like USD in LN when used with caution. USD facilitates completion of difficult cases and reduces intraoperative blood loss. However, the majority of LNs can be completed safely with ES. ES is sturdy and cheap; therefore, selective use of USD appears to be the most cost-effective policy in the developing world.

Rare complication after totally extraperitoneal endoscopic inguinal hernia repair: Small bowel perforation without peritoneal disruption.

We report a rare case of visceral injury after totally extraperitoneal endoscopic inguinal hernia repair. A 48-year-old man underwent needlescopic totally extraperitoneal repair of a direct inguinal hernia. Bleeding from a branch of the inferior epigastric vessels occurred at the beginning of the extraperitoneal dissection with a monopolar electrosurgical device. Hemostasis was prolonged. However, herniorrhaphy and mesh repair were successfully performed, and no peritoneal disruption or pneumoperitoneum was visible. The patient was discharged home on the next day. However, 30 h after this operation, he underwent diagnostic and operative laparoscopy because of acute abdominal pain. Ileal perforation was found and repaired, and pathological examination indicated cautery artifact. Thus, thermal damage to the ileum during the initial operation may have caused the bowel perforation. To the best of our knowledge, no other cases of bowel perforation after totally extraperitoneal repair without peritoneal disruption have been reported.

Postoperative adhesion formation in a rabbit model: monopolar electrosurgery versus ultrasonic scalpel.

BACKGROUND AND OBJECTIVES: To determine if surgery using ultrasonic energy for dissection results in less adhesion formation than monopolar electrosurgical energy in the late (8 weeks) postoperative period. METHODS: Injuries were induced in rabbits by using ultrasonic energy on one uterine horn and the adjacent pelvic sidewall and using monopolar energy on the opposite side. Eight weeks postoperatively, the rabbits underwent autopsy and clinical and pathologic scoring of adhesions was performed by blinded investigators. RESULTS: There was no significant difference in clinical adhesion scores between the two modalities. The mean clinical score for monopolar cautery was 1.00 versus 0.88 for the Harmonic device (Ethicon Endo-Surgery, Cincinnati, Ohio) (P = .71). Furthermore, there was no significant difference found in the pathologic adhesion scores between the ultrasonic scalpel and monopolar energy. The mean pathologic score for monopolar electrosurgery was 4.35 versus 3.65 for the Harmonic scalpel (P = .30). CONCLUSION: Neither monopolar electrosurgery nor ultrasonic dissection is superior in the prevention of adhesion formation in the late postoperative period.

Electrosurgery in aesthetic and restorative dentistry: A literature review and case reports.

Electrosurgery has been used in dentistry for more than half a century. There is abundant literature on electrosurgery dating back more than a century. During the past three decades, a substantial increase in minimally invasive surgery and microvascular surgery prompted greater use of electrosurgery. Although this surge in utilization has resulted in new applications, equipment features, problems and solutions, the use of electrosurgery in the field of restorative dentistry has remained relatively unchanged. The presence of conflicting and sometimes confusing information on electrosurgical wound healing in the dental literature is the most likely reason. This article briefly explains the literature review of electrosurgery and clinical application of electrosurgery in aesthetic and restorative dentistry.