Prospective, randomized trial of bipolar electrosurgery vs ultrasonic coagulation for division of short gastric vessels during laparoscopic Nissen fundoplication

Background: Division of the short gastric vessels (SGV) during laparoscopic Nissen fundoplication (LNF) may improve outcome. Several techniques are av ailable for SGV division. The aim of this study was to compare in a prospec tive randomized trial bipolar electrocautery with cutting blade versus ultr asonic coagulation of the SGV during LNF. Methods: In all, 86 consecutive patients undergoing LNF were prospectively randomized into two similar groups that underwent division of the SGV, resp ectively, using bipolar cutting forceps (BPCF) or harmonic coagulating shea rs (HCS). Operative time, bleeding episodes, complications, equipment probl ems, and surgeon's subjective scoring of satisfaction and ease of use were assessed. Results: Mean (+/-SD) time for fundic mobilization and division of the SGV was not significantly different between the two groups (BPCF = 20 +/- 12 mi n vs. HCS = 22 +/- 12 min). Bleeding events, estimated blood loss, surgeon satisfaction, and subjective ease of use were similar, and no transfusions were required. Complications in the BPCF group included a delayed gastric p erforation requiring reoperation and two gastric serosal burns repaired int raoperatively. There was one splenic capsular tear using the HCS and one sp lenic capsular tear using the BPCF, both of which were controlled intraoper atively. The number of functional equipment problems were few and statistic ally similar. In the authors' institution, the per case total costs with ca pital expenditures amortized over 100 cases indicate savings of approximate ly $202/case with use of the BPCF versus the HCS. Regression analysis demon strated a significant correlation between body mass index (BMI) and total c ase length and time for division of the SGVs. Conclusions: The BPCF and HCS appear to be equally efficacious for SGV divi sion during LNF. Judicious application of both energy forms and heightened vigilance for gastric serosal injury are required with use of both the BPCF and HCS in cases of tight gastrosplenic adhesions or short SGVs. The BPCF carries a potential cost advantage over the HCS in the authors' institution . The BMI directly correlates with time required to divide SGVs and total l ength of LNF.