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Ann Thorac Surg 2004;77:1415-1418
© 2004 The Society of Thoracic Surgeons
a Division of General Thoracic Surgery, Takarazuka Municipal Hospital, Hyogo, Japan
b Department of Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
Accepted for publication April 28, 2003.
* Address reprint requests to Dr Shigemura, Department of Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
e-mail: n-shige{at}blue.ocn.ne.jp
Abstract
PURPOSE: We present our initial evaluation of a new surgical technique of lung tissue sealing for nonanatomical pulmonary resection composed of sutureless and stapleless thoracoscopic surgery.
DESCRIPTION: Twelve patients who required therapeutic thoracoscopic pulmonary resection from April 2001 to April 2002 were recruited for this study. Resection of lung parenchyma was performed with an ultrasound-driven scalpel, and the cut end was sealed using LigaSure, a new bipolar system. Measurement of the cut surface after resection during the surgery and assessment of LigaSure sealing strength was performed.
EVALUATION: There were no deaths or major intraoperative complications. The mean operation time was 65 minutes, and mean hemorrhage volume was 46 mL. Average chest drain duration was 3 days, and average hospital stay was 6 days. One patient with a giant bulla and cut surface diameter of 50 mm experienced persistent air leak for 1 week. Late complications did not occur over the 8-month follow-up period.
CONCLUSIONS: Video-assisted thoracoscopic surgery pulmonary resection using LigaSure instead of staplers appears technically feasible and easy, and produces satisfactory preliminary results. Although further studies are required to confirm the sealing strength and reliability of LigaSure, this technique should be considered for use in nonanatomical pulmonary resections.
Video-assisted thoracoscopic surgery (VATS) using finely tuned automatic suture-stapling devices has been in clinical use for more than a decade [1]. However, when using the technique in patients with giant bullae or multiple pulmonary cysts, the large amount of resected and sacrificed functional lung tissue leads to a loss of postoperative pulmonary function, and the need for repeated stapling and use of numerous reloadable cartridges contributes to the high consumable costs [2]. To avoid these problems, we employed a novel surgical technique for pulmonary resection/bullectomy that uses an ultrasound-driven scalpel and a newly developed LigaSure Vessel Sealing System (LVSS; Tyco Healthcare, Vallylab, Boulder, CO) [3]. We describe our experiences and preliminary results with this method and discuss technical problems along with potential solutions.
Technique and clinical experience
The present study includes our experience with 3 patients with giant bullae, 4 patients with pulmonary cysts, and 5 patients with metastatic lung tumors (peripheral tumor) who underwent pulmonary wedge resection from April 2001 to April 2002. Patient demographics and clinical data are summarized in Table 1. Full informed consent was obtained from all patients before treatment.
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In the present patients, the size of the cut surface area was determined after resection and before sealing. The size of the operated lung with an applied pressure of 15 cm H2O was determined as: the maximum diameter (mm) x minimum diameter (mm) (Fig 2-B). Various values, including operating time, amount of intraoperative hemorrhage, duration of thoracic drainage, and length of postoperative hospitalization, were reviewed and described.
Evaluation
Patient demographics, clinical characteristics, and cut surface sizes are summarized in Table 1. Lung inflation was favorable, with application of a pressure of 15 cm H20, and cut surface measurements were performed in the inflated lung in all cases. After cut surface measurement, the cut end was sealed by LVSS, and expansion of the remnant lung was confirmed. The longest major and minor axes were in a patient with a giant bulla (case 6), and major air leak was not present during the surgery after sealing in this patient. The mean operating time was 65 ± 19 minutes (range, 45 to 90 minutes) (Table 2) . Intraoperative hemorrhage volume was 46 ± 28 mL (range, 15 to 90 mL). The duration of thoracic drainage was less than 4 days in all cases except for 1 patient (case 6) with removal of a giant bulla. This patient had a persistent air leak for 1 week that resolved on its own. Postoperative temperature of more than 38°C was seen in three cases. Although we have not understood the reasons behind the fever, no further complication, including postoperative wound infection and pneumonia, was found in these patients, and the fever improved spontaneously. Postoperative hospitalization duration was 6 ± 3 days (range, 4 to 10 days), and no late complications were observed over an average follow-up period of 8 months. In Figure 3, we show a set of pre- and postoperative chest radiographs of case 1 with a giant bulla as an example.
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The conventional technique for pulmonary resection was previously electrocautery followed by manual suturing. The procedure was modified by Drs Perelman and Cooper to achieve precise, nonanatomical pulmonary resection with favorable results [4]. However, the success of such modified techniques, which are not suitable for a VATS approach, is dependent on the individual skill and experience of the surgeon. The advent of mechanical staplers provided a method to perform clamping, severance, and closure simultaneously, and the technique is now widely used. Asamura and associates reported no fatal accidents, with a misfire rate of only 0.1% with use of the stapler for pulmonary resection [5].
Certain situations require that the stapler is used quite heavily, such as during pulmonary resection for a giant bulla or multiple pulmonary cysts. In these cases, loss of postoperative respiratory function may occur secondary to increased area of resected and sacrificed functional lung tissue, and the cost of the procedure increases dramatically secondary to the use of multiple reloadable cartridges [2, 3]. Further, surgical fields with a long major axis make manipulation of the stapler difficult because a larger diameter porthole limits the insertion angle. Also, complete pulmonary resection is sometimes difficult near the hilum or near great vessels because the movable range of larger or longer staplers is limited within the thoracic cavity [2].
To avoid these limitations, we employed an ultrasound-driven scalpel with LVSS for sealing. The scalpel was applied through a 5-mm port and was easy to handle, as was also used by Kaseda and associates [6] Tissue severance was adequate and produced less local damage than occurred with electrocautery, which minimized the amount of normal lung tissue resected.
LVSS utilizes a new bipolar technology for vascular sealing with a higher current and lower voltage (180 V) than conventional electrocautery. LVSS has the ability to regulate output based on the particular kind of tissue and stop automatically in order to minimize the effect on surrounding tissue [7, 8]. Forceps are inserted through a porthole 5 mm in diameter. The instruments are also easy to handle and, once the operator is accustomed to their handling, sealing is easily obtained because they automatically stop the work at an adequate level by the equipped ability of computer feedback system. Transmission of heat to the surrounding tissue occurs within a distance of 1.0 to 1.5 mm, similar to the heat transmission obtained with the ultrasound-driven scalpel. We previously documented complete sealing with minimal tissue degeneration by histopathological techniques [3]. The use of LVSS has been authorized by the FDA in the US, and it has been previously applied in general, urological, and gynecological surgeries 8, 9, but not in thoracic surgeries.
Other groups have reported techniques for pulmonary resection that do not rely on the use of a stapler. Yim and associates reported favorable results with nonanatomical pulmonary resection using thermal sealing [10]. We agree with their conclusion and consider that our new sealing technique is not a replacement for the speedy, reliable, and convenient gold standard of staplers, but rather as coexisting to provide new choices for pulmonary resection. Preliminary results suggest that this novel technique produced satisfactory intra- and perioperative values that were similar to those for conventional methods (operating time, 65 minutes; hemorrhage, 46 mL; postoperative drainage, 3 days; hospitalization, 6 days). In the present study, sealing strength was demonstrated by absence of air leakage with application of a pressure of 15 cm H2O. Results were favorable in all cases except for 1 patient (case 6), with a 50-mm cut surface axis that had a persistent air leak for 1 week. Thus, this technique may not be optimal for bullae with a broad base. Otherwise, studies to assess the effect of this technique in terms of heat injury on pulmonary tissue are ongoing.
We believe this technique is well suited for sutureless and stapleless thoracoscopic surgery. Advantages of this novel technique include (1) better hemostasis with good handling devices, adapted for the VATS approach; (2) effective seal of the cut surface with minimal effects on surrounding functional lung tissue; and (3) repeated use of the instrument is possible, making the procedure more economical, minimizing consumable costs.
Disclosures and freedom of investigation
The generator and tips of the LVSS were purchased by Takarazuka Municipal Hospital. The authors have had full control of the design of the study, methods used, outcome values, analysis of data, and production of the written report.
Footnotes
The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.
References
This article has been cited by other articles:
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  S. Barakzai, S. E. Taylor, and J. Keen Use of a tissue sealing device for thoracoscopically guided lung biopsy in a pony Vet Rec., November 22, 2008; 163(21): 634 - 635. [Full Text] [PDF]
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 M. Santini, G. Vicidomini, A. Fiorello, P. Laperuta, and L. Busiello Electrothermal bipolar tissue sealing systems in lung surgery MMCTS, September 15, 2008; 2008(0915): 3111. [Abstract] [Full Text] [PDF]
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 T. Sakuragi, Y. Okazaki, M. Mitsuoka, F. Yamasaki, M. Masuda, D. Mori, T. Satoh, and T. Itoh The utility of a reusable bipolar sealing instrument, BiClamp(R), for pulmonary resection Eur. J. Cardiothorac. Surg., September 1, 2008; 34(3): 505 - 509. [Abstract] [Full Text] [PDF]
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T. Lacin, H. F. Batirel, K. Ozer, A. Demirutku, R. Ahiskali, and M. Yuksel Safety of a thermal vessel sealer on main pulmonary vessels Eur. J. Cardiothorac. Surg., March 1, 2007; 31(3): 482 - 485. [Abstract] [Full Text] [PDF]
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M. Santini, G. Vicidomini, A. Baldi, G. Gallo, P. Laperuta, L. Busiello, M. P. Di Marino, and V. Pastore Use of an electrothermal bipolar tissue sealing system in lung surgery Eur. J. Cardiothorac. Surg., February 1, 2006; 29(2): 226 - 230. [Abstract] [Full Text] [PDF]
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