Effectiveness of the ultrasonic coagulating shears, LigaSure vessel sealer, and surgical clip application in biliary surgery: A comparative analysis

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, W ith 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 structur es for possible use in liver or gallbladder surgery. After elective cholecy stectomy cystic ducts (n=45) were resealed ex vivo with surgical clips (n=1 4), ultrasonic coagulating shears (n=16), or electrothermal bipolar vessel sealer (n=15), and bursting pressures were measured. Nineteen additional hu man cystic ducts were randomized to seal by ultrasonic coagulating shears ( n=9) or electrothermal bipolar vessel sealer (n=10) and fixed in 10 per cen t buffered formalin for histologic evaluation of thermal spread (mm). After this nine adult pigs were randomized to laparoscopic ligation and transect ion of the common bile duct using surgical clips (n=3), ultrasonic coagulat ing shears (n=3), or electrothermal bipolar vessel sealer (n=3). The animal s underwent necropsy for assessment of seal integrity on the sixth postoper ative 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 ultra sonic coagulating shears was 278 mm Hg, which was statistically less than s urgical 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 unde rgoing ligation and transection of the common bile duct with ultrasonic coa gulating shears and electrothermal bipolar vessel sealer developed bile per itonitis by postoperative day 6 as a result of seal leak. All animals under going surgical clip ligation and transection of the common bile duct mainta ined 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 demo nstrated a significant difference in the cystic duct bursting pressure betw een surgical clips and ultrasonic coagulating shears and between electrothe rmal bipolar vessel sealer and ultrasonic coagulating shears. The ultrasoni c coagulating shears and electrothermal bipolar vessel sealer failed to mai ntain seal integrity in the in vivo animal study. Given the failure of the ultrasonic coagulating shears and electrothermal bipolar vessel sealer in t he animal model these energy sources should not be used for transection of the cystic duct or major hepatic ducts during hepatobiliary surgery.