Harold K L, Pollinger H, Matthews B D, Kercher K W, Sing R F, Heniford B T
Department of Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, MEB 601, Charlotte, NC 28203, USA.
Surg Endosc. 2003 Aug;17(8):1228-30. doi: 10.1007/s00464-002-8833-7. Epub 2003 Jun 13.
Advanced laparoscopic procedures have necessitated the development of new technology for vascular control. Suture ligation can be time-consuming and cumbersome during laparoscopic dissection. Titanium clips have been used for hemostasis, and recently plastic clips and energy sources such as ultrasonic coagulating shears and bipolar thermal energy devices have become popular. The purpose of this study was to compare the bursting pressure of arteries sealed with ultrasonic coagulating shears (UCS), electrothermal bipolar vessel sealer (EBVS), titanium laparoscopic clips (LCs), and plastic laparoscopic clips (PCs). In addition, the spread of thermal injury from the UCS and the EBVS was compared.
Arteries in three size groups (2-3, 4-5 and 6-7 mm) were harvested from freshly euthanized pigs. Each of the four devices was used to seal 16 specimens from each size group for burst testing. A 5-Fr catheter was placed into the open end of the specimen and secured with a purse-string suture. The catheter was connected to a pressure monitor and saline was infused until there was leakage from the sealed end. This defined the bursting pressure in mmHg. The ultrasonic shears and bipolar thermal device were used to seal an additional 8 vessels in each size group, which were sent for histologic examination. These were examined with hematoxylin and eosin stains, and the extent of thermal injury, defined by coagulation necrosis, was measured in millimeters. Analysis of variance was performed and, where appropriate, a Tukey's test was also performed.
The EBVS's mean burst pressure was statistically higher than that of the UCS at 4 or 5 mm (601 vs 205 mmHg) and 6 or 7 mm (442 vs 175 mmHg). EBVS had higher burst pressures for the 4 or 5-mm group (601 mmHg) and 6 or 7-mm group (442 mmHg) compared with its pressure at 2 or 3 mm (128 mmHg) ( p = 0.0001). The burst pressures of the UCS and EBVS at 2 or 3 mm were not significantly different. Both clips were statistically stronger than the thermal devices except at 4 or 5 mm, in which case the EBVS was as strong as the LC (601 vs 593 mmHg). The PC and LC were similar except at 4 or 5 mm, where the PC was superior (854 vs 593 mmHg). The PC burst pressure for 4 or 5 mm (854 mmHg) was statistically higher than that for vessels 2 or 3 mm (737 mmHg) but not different from the 6 or 7 mm pressure (767 mmHg). Thermal spread was not statistically different when comparing EBVS and UCS at any size (EBVS mean = 2.57 mm vs UCS mean = 2.18 mm).
Both the PC and LC secured all vessel sizes to well above physiologic levels. The EBVS can be used confidently in vessels up to 7 mm. There is no difference in the thermal spread of the LigaSure vessel sealer and the UCS.
先进的腹腔镜手术需要开发新的血管控制技术。在腹腔镜解剖过程中，缝合结扎可能耗时且繁琐。钛夹已用于止血，最近塑料夹以及诸如超声凝固剪和双极热能装置等能量源也变得流行起来。本研究的目的是比较用超声凝固剪（UCS）、电热双极血管闭合器（EBVS）、钛制腹腔镜夹（LC）和塑料腹腔镜夹（PC）封闭动脉的破裂压力。此外，还比较了UCS和EBVS热损伤的扩散情况。
从刚安乐死的猪身上获取三个尺寸组（2 - 3、4 - 5和6 - 7毫米）的动脉。使用四种器械中的每一种对每个尺寸组的16个标本进行封闭以进行破裂测试。将一根5F导管插入标本的开口端，并用荷包缝合固定。将导管连接到压力监测器，并注入生理盐水直至封闭端出现渗漏。这确定了以毫米汞柱为单位的破裂压力。超声剪和双极热能装置用于在每个尺寸组中额外封闭8条血管，将其送去进行组织学检查。用苏木精和伊红染色对这些血管进行检查，并以毫米为单位测量由凝固性坏死定义的热损伤范围。进行方差分析，并在适当情况下进行Tukey检验。
在4或5毫米（601对205毫米汞柱）以及6或7毫米（442对175毫米汞柱）时，EBVS的平均破裂压力在统计学上高于UCS。与2或3毫米时的压力（128毫米汞柱）相比，EBVS在4或5毫米组（601毫米汞柱）和6或7毫米组（442毫米汞柱）具有更高的破裂压力（p = 0.0001）。UCS和EBVS在2或3毫米时的破裂压力无显著差异。除了在4或5毫米时EBVS与LC一样坚固（601对593毫米汞柱）外，两种夹子在统计学上都比热能装置更坚固。PC和LC相似，除了在4或5毫米时PC更优（854对593毫米汞柱）。4或5毫米时PC的破裂压力（854毫米汞柱）在统计学上高于2或3毫米血管的破裂压力（737毫米汞柱），但与6或7毫米时的压力（767毫米汞柱）无差异。在比较任何尺寸的EBVS和UCS时，热扩散在统计学上无差异（EBVS平均值 = 2.57毫米对UCS平均值 = 2.18毫米）。
PC和LC都能将所有血管尺寸固定到远高于生理水平。EBVS可放心用于直径达7毫米的血管。LigaSure血管闭合器和UCS的热扩散没有差异。
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