Available at www.obgmanagement.com S U pp L ement to This supplement is supported by a grant from Ethicon Endo-Surgery, Inc., and has been peer reviewed by the editors of OBG Management. November 2009 Advanced energy systems for laparoscopic gynecology procedures Multifunctional technology yields reliable outcomes, enhances patient safety, and increases procedure efficiency Chair Dr Brill: Probably no surgical instrument defines the gynecolo- gist more than the Kleppinger forceps, the first bipolar device Andrew I. Brill, MD Director of Minimally Invasive used for tubal ligation. It remains an important part of our ar- Gynecology mamentarium despite thermal spread, smoke, char, tissue stick- California Pacific Medical Center ing, and inconsistent hemostasis,1-5 shortcomings that have led San Francisco, California to the development of newer bipolar electrosurgical devices— the LigaSure™ Vessel Sealing System, PlasmaKinetic (PK) plat- Faculty form, and ENSEAL®. These energy-based surgical devices offer John D. Bertrand, MD Director added functionality—coagulation and cutting in a single instru- Minimally Invasive Surgery ment—as well as increased efficiency. These instruments offer Texas Health Dallas specific features that appeal to gynecologic surgeons who have Walnut Hill OB/GYN Associates Dallas, Texas different needs and preferences. Ultrasonic energy technology has also advanced significantly, with instruments such as the Steven D. McCarus, MD Harmonic ACE®, which both cuts and coagulates at the point Chief, Division of Gynecologic Surgery of impact for use in soft-tissue incisions and transections. Director, The Center for Despite our collective surgical experience, the comparative Pelvic Health Florida Hospital Cenebration strengths and weaknesses of these devices have yet to be clearly Orlando, Florida established in an unbiased and reproducible fashion. Ex vivo studies have attempted to quantify the comparative effective- Disclosures ness of these devices with wide variances in results, primarily Dr Bertrand reports that he serves as a consultant to Ethicon Endo-Surgery & Women’s Health and American based on the use of non-standardized protocols. We must await Medical Systems. He serves on the speakers bureaus of the results of well-designed in vivo studies that compare effi- Johnson & Johnson, Ethicon Endo-Surgery & Women’s Health, American Medical Systems, and Olympus. He ciency, sealing time, lateral thermal spread, smoke product, and also has a financial relationship with Warner Chilcott. burst pressures to define their relative use for ligating and cut- Dr Brill reports that he serves as a consultant to and is on the speakers bureaus for Ethicon, Karl Storz, and ting vascular tissue. Conceptus. Dr McCarus serves as a consultant to Ethicon New technologies expand range of procedures Endo-Surgery, Inc. Dr Brill: As teachers, do you meet physicians who see little rea- son to use newer devices, given that they have had no problems with conventional bipolar devices? Dr McCarus: Yes. If a clinician says, “I haven’t had any problems Copyright © 2009 Dowden Health Media Supplement to OBG Management / November 2009 S1 ADVANCED ENERGY SYSTEMS FOR LAPAROSCOPIC GYNECOLOGY PROCEDURES FIGURE 1 FIGURE 2 Sealing by proximal thrombus Sealing with electrosurgery The Kleppinger forceps create hemostasis by This seal, created by ENSEAL®, is produced through low contraction of the vessel walls. temperature, high pressure, and pulsed energy. with the equipment I use,” I ask what advance. I evaluate its ergonomics and type of surgery he performs. The scope its cost and, most importantly, whether of electrosurgery extends beyond tubal it is safer than other devices. Patient safety ligation; new tools enable us to perform Dr McCarus: Another consideration is, has fueled many procedures and manage anatomic does the instrument provide dependable advances in difficulties with increased patient safety. and predictable vessel hemostasis? In- instrumentation. Dr Bertrand: The Kleppinger forceps, a traoperative bleeding is our number one wonderful device, has safety issues: lat- practical concern. Given operating room eral spread and heat generation.6 Phy- scheduling issues and costs, I look for sicians who reject change probably do versatile and multifunctional equipment not work on involved cases that bring that will shorten procedure times. us close to the ureter, bowel, or bladder. Dr Brill: I am very concerned about the Newer devices allow us to perform pro- multifunctionality of a new device for cedures in proximity to these vital struc- tissue dissection. I assess any new en- tures and organs in a safer fashion. ergy-based device not just for thermal Dr Brill: True: Based on fundamental bio- characteristics, but for ease of use, abil- physics of electrosurgery in living tissue, ity to lift, grasp, and dissect tissue, and voltage is the primary cause of thermal its performance in heterogeneous desic- damage. Importantly, newer bipolar li- cated, fatty, or vascular tissue. gating devices deliver low-voltage elec- Dr Bertrand: We should not forget the tricity to lessen thermal damage and cavitational effect of Harmonic® instru- result in more predictable spread. New mentation, in which steam accomplish- devices also “communicate” with the es the natural plane dissection by quick tissue—based on changes in tissue resis- and localized action, minimizing lateral tance called impedance—to deliver pre- thermal energy. cisely the amount of energy necessary to Dr Brill: When a surgeon understands the accomplish the task.7 fundamental principles of energy-based surgery—and the relative strengths and Considerations in adopting weaknesses of any device in this con- new technology text—it is possible to take the device to Dr Brill: How do you decide if a new de- a higher level of performance, achieving vice fits into your armamentarium? otherwise impossible tissue effects. Some Dr Bertrand: First I determine whether devices, designed simply to perform liga- the instrument marks a true scientific tions, can be modified to desiccate and S2 November 2009 / Supplement to OBG Management Instrumentation to expand surgical options here are 3 bipolar platforms that utilize low constant voltage, pulsed current, and Timpedance feedback, along with a paired ligating-cutting device. By historic sequence, the LigaSure Vessel Sealing Device (Covidien, Boulder, CO) applies a high coaptive pressure during the generation of tissue temperatures under 100ºC; hydrogen cross-links are first ruptured and then re-natured, resulting in a vascular seal that has high tensile strength. The second instrument, the PlasmaKinetic Cutting Forceps (Gyrus/ACMI/Olympus, Minneapolis, MN), lacks the compressive pressure needed to create a true vessel seal but provides efficient coagulation with visibly pulsed energy that is moderated by impedance feedback. The third device, the EnSeal Laparoscopic Vessel Fusion System (EES, Cincinnati, OH) utilizes temperature-sensitive polymeric material (PTC) embedded with nanometer- sized spheres of carbon that automatically controls a locally regulated current, regulating temperatures at about 100º C. Desiccation with this device is facilitated by advancing an innovative “I-Blade” that provides extremely high pressure along the length of the jaw to both cut and squeeze the tissue bundle, eliminating tissue water and steam. Using the dynamic tissue effects of mechanical energy, ultrasonic blades, and shears, tissue effects from ultrasonic energy using the Harmonic Scalpel (EES, Cincinnati, OH) are actuated by a titanium blade of variable excursion that vibrates nearly 55,500 Hz/second from Durable an in-line piezoelectric crystal housed in the hand piece of the device. The high frequency vessel seals vibration in tissue causes a low temperature protein denaturation by rupturing the hydrogen can be obtained bonds of tissue proteins. Tissue cutting from cavitational fragmentation naturally evolves from the mechanical vibration and percussive effects of steam that emanates through the tissue without parenchyma. Differing from the volumetric thermal tissue effects during electrosurgery, lateral significant thermal damage with ultrasonic energy is limited by the linear nature of energy propagation through the tip of the blade. thermal change to tissue. Brill AI. Energy systems for operative laparoscopy. Am J Assoc Gynecol Laparosc. 1998;5:333-349. Brill AI. Bipolar electrosurgery: convention and innovation. Clin Obstet Gynecol. 2008;51:153-158. vaporize tissue. Do you agree? each device, with its unique combination Dr McCarus: Most gynecologic surgeons of software-driven energy delivery mod- don’t understand the principles of energy erated by the changing resistance of tis- and current flow through the path of sue as it is progressively desiccated. The least resistance. You’ve championed the Gyrus is the closest cousin to the Klep- term “the cognitive surgeon” to describe pinger and therefore the most intuitive individuals who understand and control of these new devices for the gynecologic energy’s effect on tissue and thereby reg- surgeon to use. LigaSure™ provides an ulate the procedure. Our residents and automated click and play solution for li- fellows must learn not just to activate gating vascular tissue. More recently, the an energy source to desiccate or char ENSEAL® also provides true vessel seal- tissue. They need to understand the ef- ing and transection with a uniquely so- fects on the tissue and be cognizant of phisticated combination