Matthews B D, Pratt B L, Backus C L, Kercher K W, Mostafa G, Lentzner A, Lipford E H, Sing R F, Heniford B T
Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina 28203, USA.
Am Surg. 2001 Sep;67(9):901-6.
Advancements in laparoscopic surgery are often dictated by the limitations of technical instrumentation. Energy sources other than electrosurgery have become popular with the promise of quick and effective vascular control. With their success surgeons have begun using these on structures other than blood vessels with little or no data establishing their efficacy or safety. This study evaluates alternative energy sources in sealing ductal structures for possible use in liver or gallbladder surgery. After elective cholecystectomy cystic ducts (n = 45) were resealed ex vivo with surgical clips (n = 14), ultrasonic coagulating shears (n = 16), or electrothermal bipolar vessel sealer (n = 15), and bursting pressures were measured. Nineteen additional human cystic ducts were randomized to seal by ultrasonic coagulating shears (n = 9) or electrothermal bipolar vessel sealer (n = 10) and fixed in 10 per cent buffered formalin for histologic evaluation of thermal spread (mm). After this nine adult pigs were randomized to laparoscopic ligation and transection of the common bile duct using surgical clips (n = 3), ultrasonic coagulating shears (n = 3), or electrothermal bipolar vessel sealer (n = 3). The animals underwent necropsy for assessment of seal integrity on the sixth postoperative day. In the ex vivo study the mean cystic duct bursting pressure was 621 mm Hg with surgical clips and 482 mm Hg with the electrothermal bipolar vessel sealer (P = 0.39). The mean cystic duct bursting pressure after ultrasonic coagulating shears was 278 mm Hg, which was statistically less than surgical clips (P = 0.007) and electrothermal bipolar vessel sealer (P = 0.02). The mean thermal spread was 3.5 mm for ultrasonic coagulating shears and 13.4 mm for electrothermal bipolar vessel sealer (P = 0.0002). All animals undergoing ligation and transection of the common bile duct with ultrasonic coagulating shears and electrothermal bipolar vessel sealer developed bile peritonitis by postoperative day 6 as a result of seal leak. All animals undergoing surgical clip ligation and transection of the common bile duct maintained seal integrity. The mean common bile duct pressure above the surgical clip was 12 mm Hg (range 10-14). In conclusion the acute ex vivo study demonstrated a significant difference in the cystic duct bursting pressure between surgical clips and ultrasonic coagulating shears and between electrothermal bipolar vessel sealer and ultrasonic coagulating shears. The ultrasonic coagulating shears and electrothermal bipolar vessel sealer failed to maintain seal integrity in the in vivo animal study. Given the failure of the ultrasonic coagulating shears and electrothermal bipolar vessel sealer in the animal model these energy sources should not be used for transection of the cystic duct or major hepatic ducts during hepatobiliary surgery.
腹腔镜手术的进展往往受制于技术器械的局限性。除电外科手术之外的能源因有望实现快速有效的血管控制而受到欢迎。随着这些能源的成功应用，外科医生已开始将其用于血管以外的结构，但几乎没有或根本没有数据来证实其有效性或安全性。本研究评估了用于封闭管道结构的替代能源在肝脏或胆囊手术中的潜在用途。在择期胆囊切除术后，将45条胆囊管用手术夹（14条）、超声凝固剪（16条）或电热双极血管封闭器（15条）在体外重新封闭，并测量破裂压力。另外19条人胆囊管被随机分配，分别用超声凝固剪（9条）或电热双极血管封闭器（10条）进行封闭，然后固定于10%中性福尔马林中，用于热扩散（毫米）的组织学评估。在此之后，将9只成年猪随机分配，分别使用手术夹（3只）、超声凝固剪（3只）或电热双极血管封闭器（3只）进行腹腔镜下胆总管结扎和横断。在术后第6天对这些动物进行尸检，以评估封闭的完整性。在体外研究中，使用手术夹时胆囊管的平均破裂压力为621毫米汞柱，使用电热双极血管封闭器时为482毫米汞柱（P = 0.39）。使用超声凝固剪后胆囊管的平均破裂压力为278毫米汞柱，在统计学上低于手术夹（P = 0.007）和电热双极血管封闭器（P = 0.02）。超声凝固剪的平均热扩散为3.5毫米，电热双极血管封闭器为13.4毫米（P = 0.0002）。所有使用超声凝固剪和电热双极血管封闭器进行胆总管结扎和横断的动物在术后第6天因封闭处渗漏而发生胆汁性腹膜炎。所有使用手术夹进行胆总管结扎和横断的动物均保持了封闭的完整性。手术夹上方胆总管的平均压力为12毫米汞柱（范围为10 - 14）。总之，急性体外研究表明，手术夹与超声凝固剪以及电热双极血管封闭器与超声凝固剪之间在胆囊管破裂压力方面存在显著差异。在体内动物研究中，超声凝固剪和电热双极血管封闭器未能保持封闭的完整性。鉴于超声凝固剪和电热双极血管封闭器在动物模型中的失败，在肝胆手术中不应将这些能源用于胆囊管或主要肝管的横断。
