Interact CardioVasc Thorac Surg 2009;9:11-14. doi:10.1510/icvts.2008.199307
© 2009 European Association of Cardio-Thoracic Surgery
Institutional report - Thoracic non-oncologic |
Comparing bipolar electrothermal device and endostapler in endoscopic lung wedge resection
Ottó Kovácsa,
Zoltán Szántóa,*,
Géza Krasznaib and
György Herra
a Department of Thoracic-Vascular and General Surgery, County Hospital Szolnok, Hungary
b Department of Pathology, County Hospital Szolnok, Hungary
Received 29 November 2008;
received in revised form 26 February 2009;
accepted 27 February 2009
*Corresponding author. Department of Surgery, Hetényi County Hospital, Tószegi u. 21, Szolnok 5000, Hungary. Tel.: +3656503603; fax: +3656422412.
E-mail address: surgic{at}freemail.hu (Z. Szántó).
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Abstract
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Video-assisted thoracoscopy (VATS) is gaining on thoracic surgery, having newly developed devices next to endostaplers for haemostatic and airtight sealing of lung parenchyma. Though the bipolar electrothermal Ligasure has good results for pulmonary wedge resection, its literature is small in numbers. Authors compared Ligasure and endostapler for pulmonary wedge resection of solitary pulmonary nodules (SPN). Authors performed a retrospective analysis of 44 consecutive patients. The indication of operation was non-verified SPN in all cases. They carried out pulmonary wedge resection for 22 patients with Ligasure–Atlas and 22 patients with ETS Flex endostapler via VATS. Authors examined the gender, average age (62 vs. 49 years), mean hospital stay (6.6 vs. 6.8 days), average operation time (55 vs. 50 min), number of complications (2 vs. 1), average drainage time (2.8 vs. 2.7 days), average fluid loss (190 vs. 160 ml), and instrumental costs ( 367 vs. 756) of both groups. They accomplished the histological analysis of the coagulated lung parenchyma as well. According to the results, the Ligasure–Atlas is eligible for pulmonary wedge resection. The method is safe, easy to use, having minimal rate of complications. It can moderate costs of operation, compared to endostaplers.
Key Words: Video-assisted thoracoscopy; Solitary pulmonary nodules; Wedge resection; Ligasure; Low costs
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1. Introduction
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The new age requires minimal invasivity in thoracic surgery, having the well-known advantages. These advantages, and the day-by-day evolving armamentarium, facilitate the spreading of video-assisted thoracoscopy (VATS) technique. This procedure results in growing costs of the surgical departments.
Presenting endostaplers opened the way for safe resection of lung parenchyma via VATS. Therefore, the wedge resection of lung parenchyma was attainable by staplers alone [1, 2]. This made the largest costs of a short hospital stay, short operating time VATS procedure. Efforts were made in the last decade for safe lung parenchyma cutting. There were publications of using ultracision [3–5], saline enhanced thermal sealing [6, 7], Argon beam coagulator and Nd:YAG laser [8] for pulmonary wedge resection aside from staplers.
Using diathermy is common in all branches of surgery for decades, and with proper indication makes satisfactory tissue sealing and haemostasis [9].
The Ligasure endoscopic electrothermal bipolar device (Valleylab, a division of Tyco Healthcare Group LP, 5920 Longbow Dr, Boulder, CO, USA) is used as a daily routine in abdominal surgery, and has minimal literature in thoracic surgical applying. Few examined this device for VATS wedge resection of lung parenchyma [10–12]. Based on the wide spread of Ligasure in laparoscopy, considering the method's cheapness, good control of haemostasis, and not leaving foreign body on the surface treated, we intended to prove its usefulness in wedge resection of solitary pulmonary nodules (SPN). Though having good results for pulmonary wedge resection, its literature is small in numbers.
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2. Objectives
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We examined the applicability of electrothermal bipolar Ligasure–Atlas for pulmonary wedge resection, and compared results with the same way as used by endostaplers, during VATS. The indication of operation was non-verified, peripherial SPN (maximum diameter of 3 cm, on HR CT) in all cases, or rather former primer malignant tumor's metastasis by clinical data.
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3. Materials and methods
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We compared data of 44 consecutive patients retrospectively, between 10 March 2004 and 20 December 2007. All 44 patients had VATS pulmonary wedge resection of SPN, of unknown dignity, using Ligasure–Atlas (Fig. 1) or endostapler (ETS Flex 45 mm ETHICON, Route 22 West Somerwille, NJ, USA). We excluded patients who had malignant intraoperative frozen histological results. These patients had anatomical resection via thoracotomy. We examined the average age, gender, mean hospital stay, average operation time, number of complications, average drainage time, average fluid loss, and the costs of the two instruments used for resection. We also accomplished the histological analysis of the in-vivo coagulated lung parenchyma.
The primary intention was to prove the usefulness of Ligasure–Atlas for sutureless pulmonary wedge resection of SPNs via VATS. Ligasure–Atlas generates thermal energy, which causes the fusion of collagen and elastin in the blood vessel wall, and in the parenchyma, creating an air- and watertight remodelled tissue zone, according to the literature and our data. We always made palpation by fingers through the wounds of VATS ports, when the localization of nodule was questionable.
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4. Results
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Twenty-two patients had wedge resection with Ligasure–Atlas. The mean age was 62 years (35–76) of the 7 men and 15 women. After an average 55 min (30–92) of operation, they spent 6.6 days (4–9) in hospital. Persistent air leak (continuous air leak, going on for >48 h after the operation) occurred in two cases, one of them required re-drainage. There were no other complications. Average drainage time was 2.8 days (range 2.5–5 days), while the mean fluid loss was 190 ml (110–240). The histology showed 13 malignant metastases, nine benign tumors. The Ligasure–Atlas, used for the study, cost 367 per operation (one instrument is suitable during the entire operation).
Twenty-two patients had wedge resection using endostapler. The mean age of the 15 men and 7 women was 49 years (18–70). They spent an average 6.8 days (4–8) in hospital, and 50 min (range 30–85 min) in the operating room. One patient had persistent air leak, not requiring re-drainage. No other complications occurred. Average drainage time was 2.7 days (range 2.4–5 days), while the mean fluid loss was 160 ml (100–210). The histology showed 12 malignant metastases, 10 benign tumors (Tables 1 and 2).
The ETS Flex 45 mm, used for the study, cost 400 per operation, plus an average of 2.136 (range 2–4) cartridges which cost 356 per operation. The total cost of endostapler ETS Flex 45 mm was 756 per operation.
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5. Histology
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The presented photos are of a resected inferior lobe of a patient who did not participate in our study. Before the lobectomy, we made wedge resection of the SPN, using Ligasure–Atlas (because of intraoperative verification of NSCLC), therefore, the histological signs are showing in vivo, Ligasure caused vital reactions.
There is condensation and coagulation without nuclear coloration in the zone of Ligasure intervention. In the very next subpleural segment, there is intact basic tissue structure, with coagulation in the wall of the blood vessels (Figs. 2–4 ). The wall of the septal vessels is homogenous, structureless. The walls of the bronchioli and the blood vessels are intact in the following segment. All of the 44 wedge resections had complete resection margins.
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Fig. 4. Proper condensation in the wall of the small muscular artery. Flaked intimal cells in the lumen.
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6. Discussion
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The endoscopic wedge resection of lung parenchyma is performed by endostaplers, most often, according to literature, and guidelines. It means excellent tissue sealing and hemostasis [1, 2]. Its disadvantages are the foreign bodies, left in the suture, and the high costs. Because of the endostapler's head size and length, it can be difficult to use in certain operative situations.
There are reports of ultracision for pulmonary wedge resection [3–5, 13] (animal experimental models). The official indication is for 5–7 mm vessel diameter. Its advantage is the minimal tissue damage. Harold and colleagues did not find difference between the depth of thermal damage caused by Ultracision or Ligasure [13]. Molnár and colleagues compared with endostapler, experienced significantly shorter period of operative time [3]. But despite of above, Ultracision had not spread widely.
Cooper, Perelman and Yim used thermal sealing in the same indication. Two devices, the floating ball and the sealing forceps, both based on the method of saline-enhanced thermal sealing. Their clinical application issued in good results without major complications [6, 7].
Argon beam coagulator and Nd:YAG laser caused in vitro thermal damage of resected lung lobes, has been examined also. The study was particularly for volumen reduction, and they found the Argon beam coagulators caused less thermal damage of the lung parenchyma in vitro [8].
The bipolar Ligasure generates thermal energy that causes the fusion of collagen and elastin in the wall of blood vessels. This causes definitive sealing. It is easy to use, and has lower costs than endostaplers. Santini and colleagues used Ligasure for pulmonary wedge resection, bullectomies and fissure dissection in both open and video-assisted surgery. They had good experimental and clinical results [10, 12]. Shigmeura and colleagues combined Ligasure with Ultracision, also having fair results in 12 human patients [11].
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7. Conclusions
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In the summarization of our first consecutive experiences with the Ligasure–Atlas for wedge resection of SPN via VATS, we made sure about usability. It is appropriate for pulmonary wedge resection with correct indication, and can be an alternative for endostaplers and Ultracision. We found it safe, easy-to-use, and having minimal rates of complications. It can be used for open surgery, but its undeniable advantages are in VATS. Its head is smaller than the endostapler's head, therefore, can facilitate approaching difficultly situated areas. It does not leave any foreign body in the cut surface, and produces safety tissue sealing and hemostasis, without deep tissue damage. We considered the general expenses of hospital care the same, in both groups. For this very reason, the difference in the expenses of the two groups of patients seemed the instrument's (endostapler or Ligasure) price alone. This showed the use of Ligasure more favorable in a financial aspect. Its disadvantage is the sticking of the device's head, but it can be handled with regular mechanical cleaning during the operation. This does not enhance considerably the duration of surgery. Ligasure–Atlas is eligible for pulmonary wedge resection, and mobilization of tumors, which cannot be accessed by staplers, and suitable for combining the two procedures. Our initial results are promising, therefore, we encourage the further application of this method.
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References
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Abstract
1. Introduction
