Clipless internal mammary artery harvesting for minimally invasive coronary artery bypass grafting using the shear-tip harmonic scalpel.

Background: The internal mammary artery (IMA) is the most commonly used graft in coronary artery bypass grafting (CABG) because of its superior long-term patency rate. However, its small diameter poses challenges in handling, and any vascular damage that may occur during harvesting can significantly affect surgical outcomes. The primary focus during IMA harvesting is to ensure safe and effective hemostasis without direct vascular injury, while ensuring secure and reliable ligation of the vascular branches. Various methods using multiple surgical instruments have been used for this purpose. Unlike traditional instruments, the shear-tip Harmonic scalpel offers more precise vessel branching control, while minimizing damage to surrounding tissues. In this study, we assessed the utility of the shear-tip Harmonic scalpel in patients undergoing minimally invasive coronary artery bypass grafting (MICABG). Methods: From April 2019 to May 2023, a total of 40 patients underwent MICABG. The IMA was harvested using the shear-tip Harmonic scalpel with a clipless skeletonized technique. In this cohort, 5 patients underwent complete endoscopic harvesting, while 34 patients underwent direct visualization harvesting through minimal thoracotomy. Graft patency was assessed by measuring a Doppler flowmeter in the bypass conduit. Results: Successful graft patency was achieved in all patients. The mean duration of IMA harvesting was 87 min. In total, 38 of the 40 patients underwent MICABG without the need for cardiopulmonary bypass, ensuring a stable procedure. There were no graft-related events or complications observed in any of the patients, and all were discharged without any issues. During a median follow-up period of 15.2 months, only one patient experienced graft occlusion necessitating intervention. Conclusions: The utilization of shear-tip Harmonic scalpel for IMA harvesting in MICABG is feasible and yields stable early results.

Comparison of Intraoperative and Postoperative Outcomes With Skin Flaps Raised Using Either Harmonic Scalpels or Electrocautery During Modified Radical Mastectomy.

BACKGROUND: Breast cancer is one of the most common malignancies in women. Hence, its treatment has become our utmost priority in developing countries like India. Modified radical mastectomy (MRM) has traditionally been used as the standard of care for early-stage invasive breast carcinoma and still is the most commonly used surgical treatment for carcinoma breast. AIM: The study compared the incidence of intraoperative and postoperative outcomes with skin flaps raised using a harmonic scalpel versus those raised using electrocautery. METHODS: Sixty women with biopsy-proven breast cancer who had to undergo MRM were randomly assigned to undergo skin flap raising during mastectomy by using electrocautery or harmonic scalpel. Thirty patients had surgery with electrocautery (Group 1) and 30 with a harmonic scalpel (Group 2) by the same surgical team. RESULTS: The mean operative time was significantly longer with harmonic scalpel when compared to that with electrocautery (140.67 ± 28.55 vs. 122.00 ± 19.16 mins, P =0.004). The amount of intraoperative blood loss (178.33 ± 21.06 vs 138.50 ± 28.53 mL P = 0.001) was less in the group operated with the harmonic scalpel, which was statistically significant. There was no significant difference between the groups regarding total drainage content (310.83 ± 88.93 vs 298.20 ± 127.87 mL, P = 0.659), drain duration (6.83 ± 0.75 vs 7.43 ± 2.27 days, p=0.174), seroma (3.3% vs. 0%) wound infection (3.3% vs 0%), flap necrosis (16.7% vs. 3.3%, P = 0.195), duration of hospital stays (8.57 ± 0.77 vs 8.43 ± 1.61 days, p=0.684). CONCLUSION: Harmonic scalpels have a few advantages over electrocautery, but are not cost-effective.

Utilization of harmonic scalpel for the bloodless surgical management of a vascular lesion of the tongue and review of the literature.

A constant search for methods to limit blood loss, especially the vascular lesions of the tongue, has led to the acceptance of ultrasonic harmonic scalpels.The harmonic scalpel's reliability exists in its ability for lasting hemostasis with minimal heat dispersion to the surrounding structures.Surgical removal of the vascular pathology in a restricted area of the oral cavity and oropharynx dictates a bloodless surgical field, further allowing increased visibility of the lesion and the surrounding anatomical structures, subsequently narrowing the surgical time frame.We report a rare case of haemangioma of the lateral border of the tongue managed with complete resection of the tumor achieved using the harmonic scalpel with reduced intraoperative blood loss, increased visibility, evidently reduced post-operative necrosis and highly preserved tissue for the histopathological examination.

Effect of tobacco use on Zenker's diverticulotomy outcomes.

OBJECTIVE: To compare clinical outcomes in patients with and without history of tobacco use who underwent Zenker's diverticulotomy (ZD). STUDY DESIGN: Single institution retrospective review. SETTING: Tertiary care academic hospital. METHODS: A retrospective review of patients who underwent ZD via an open stapler, rigid endoscopic CO2 laser, stapler or harmonic scalpel, and flexible endoscopic technique from January 2006 to December 2020 was performed. Data were abstracted for patient demographics, diverticular features, and rates of adverse events and symptomatic recurrence. RESULTS: Out of 424 patients, 146 (34.4 %) had a history of tobacco use: 126 (29.7 %) were former smokers, and 20 (4.7 %) were active smokers. In univariable cross-sectional analyses, the likelihood of postoperative bleeding, perforation, emergency department visits, unplanned readmission, or recurrence did not demonstrate an association with tobacco use history even after adjustment for age, sex, and surgical approach. Similarly, in Cox Proportional Hazards regression, tobacco use was not associated with an increased risk of recurrence, even after correcting for age, sex, and type of surgery. The median time to recurrence observed in our cohort was 11.5 years amongst non-smokers, 8.7 years amongst former smokers, and 1.2 years amongst active smokers (p = 0.94). CONCLUSIONS: There were no significant differences in post-operative adverse events or frequency of recurrence of ZD between active, former, and non-smokers. Although underpowered and not statistically significant, median time to recurrence appears to be shorter in smokers when compared with former and non-smokers following surgery.

Comparison of the effect of ultrasounic-harmonic scalpel and electrocautery in the treatment of axillary lymph nodes during radical surgery for breast cancer.

OBJECTIVE: To compare the efficacy of ultrasounic-harmonic scalpel and electrocautery in the treatment of axillary lymph nodes during radical surgery for breast cancer. METHODS: A prospective study was conducted in the Department of Breast Surgery, Zhongda Hospital Affiliated to Southeast University. A total of 128 patients with pathologically confirmed breast cancer who were treated by the same surgeon from July 2023 to November 2023 were included in the analysis. All breast operations were performed using electrocautery, and surgical instruments for axillary lymph nodes were divided into ultrasounic-harmonic scalpel group and electrocautery group using a random number table. According to the extent of lymph node surgery, it was divided into four groups: sentinel lymph node biopsy, lymph node at station I, lymph node at station I and II, and lymph node dissection at station I, II and III. Under the premise of controlling variables such as BMI, age and neoadjuvant chemotherapy, the effects of ultrasounic-harmonic scalpel and electrocautery in axillary surgery were compared. RESULTS: Compared with the electrosurgical group, there were no significant differences in lymph node operation time, intraoperative blood loss, postoperative axillary drainage volume, axillary drainage tube indwelling time, postoperative pain score on the day after surgery, and the incidence of postoperative complications (p>0.05). CONCLUSION: There is no significant difference between ultrasounic-harmonic scalpel and electrocautery in axillary lymph node treatment for breast cancer patients, which can provide a basis for the selection of surgical energy instruments.

Is Using the Harmonic Scalpel Better than Conventional Hemostasis in Neck Dissection? A Meta-Analysis.

Study Design: Systematic review and meta-analysis. Objective: The clinical decision to pursue harmonic scalpel (HS) method vs conventional hemostasis to treat head and neck cancers has been arguably predicated on the clinical outcomes observed. This study aims to evaluate the surgical outcomes of neck dissection between both techniques and perform an updated meta-analysis using the available literature. Methods: We searched PubMed, Scopus, and Cochrane Library through 31st December 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcome metrics included operative time and intraoperative blood loss. Secondary outcomes consisted of length of hospital stay, length of drain stay, total drain output, and postoperative complications. A meta-analysis was conducted using Review Manager Version 5.3 (RevMan) software employing the Random Effects Model. Results: We identified 114 articles, out of which 10 randomized control trials (RCTs) analyzing a combined total of 558 patients met the inclusion criteria after title and full-text screening. Meta-analysis shows the group treated with HS had a significantly shorter operative time. [MD = -23.21, 95% CI (-34.30, -12.12) P value <.0001 I2 = 92%] but an insignificant lesser intraoperative blood loss [MD = -61.53, 95% CI (-88.61, -34.45) P < .00001 I2 = 79%]. Conclusions: This study confirms that that HS use in neck dissection yields a reduced operative time and intra operative blood loss relative to conventional hemostasis. Furthermore, our paper shows no superiority of HS method over conventional hemostasis where length of hospital stays, length of drain stays, and postoperative complications are concerned. Future RCTs with high-level evidence may further elucidate the relative effectiveness of HS method over conventional hemostasis in treating head and neck cancers.

Chemical constituents, viable micro-organism and malignant cell content in ultrasonic scalpel plume: A literature review.

PURPOSE: To identify all published data on the chemical, micro-organism and malignant cell contents of ultrasonic scalpel plume, if any, and on any clinical implications of the contents on patients and operating staff. METHODS: Searches were conducted aiming to identify all published evidence on the chemical constituents, presence/absence of viable micro-organisms and malignant cells in ultrasonic scalpel plume. Attempts were made to source unpublished industry data. RESULTS: There is evidence from human and in vitro studies of the presence of a range of harmful, and some human carcinogenic, chemicals within ultrasonic plume, mostly at very low concentrations. Any clinical relevance of this has not been studied. There is evidence from experimental studies of the presence of hepatitis virus, human coronavirus and human papillomavirus material within ultrasonic plume. Any clinical effect of this has not been studied. There is conflicting evidence from combined in vitro and mouse model studies of the presence of viable malignant cells within ultrasonic plume. Any clinical relevance of this has also not been studied. CONCLUSION: Overall, relatively little research into the plume has been published, and further study is required to more clearly delineate any potential risk to patients, surgeons and other theatre staff. Current safety recommendations are discussed.

Jaboulay's versus harmonic scalpel hydrocelectomy: prospective randomized controlled study.

OBJECTIVES: Surgical procedures for vaginal hydroceles have been varied with the aims of preventing recurrence, hematoma and edema formation and providing a better cosmetic outcome. The Jaboulay's procedure remains a preferred procedure owing to its simplicity and good long term outcome. However, sac eversion during the procedure leads to scrotal edema and mass sensation due to remnant sac in cases of large or secondary hydrocele sacs. Sac excision in these cases may provide better outcomes by removing the excess tissue. We aimed to compare the postoperative outcome after Jaboulay's procedure and harmonic scalpel excision of the sac in terms of scrotal edema, hematoma formation and the final cosmetic appearance. PATIENTS AND METHODS: 72 adult patients with vaginal hydrocele were randomized into two groups, who underwent harmonic scalpel sac excision and Jaboulay's procedure respectively, performed by a single surgeon. Preoperatively, patient demographics were noted. Postoperatively, data was recorded on the 1st day, 3rd day & 10th day about postoperative complications, and outcomes. Satisfaction on final cosmetic outcome was compared between the groups at the 3rd month. RESULTS: Post operative edema and sensation of mass in the scrotum were more (but not significant) in the Jaboulay's procedure group. Seroma and wound infection rates were similar in both groups. Patient satisfaction on cosmesis was better in the sac excision group. CONCLUSION: Hydrocelectomy with excision of the sac using a harmonic scalpel results in a lower incidence of postoperative oedema and better patient satisfaction in terms of cosmetic outcome compared to Jaboulay's procedure in the treatment of adult hydroceles.

Harmonic Scalpel Tonsillectomy Versus Coblation Tonsillectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Aim: This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to comprehensively evaluate the efficacy of coblation versus harmonic scalpel methods among patients undergoing tonsillectomy. Methods: PubMed, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and Google Scholar databases were systematically screened from inception until October 2022. The outcomes were summarized as risk ratio (RR) or mean difference/standardized mean difference (MD/SMD) with 95% confidence interval (CI) in a random-effects model. Results: Six RCTs were analyzed, encompassing a sum of 461 patients (harmonic scalpel = 233 patients and coblation = 228 patients). The overall quality assessment was low risk of bias in two RCTs, some concerns of bias in three RCTs, and high risk of bias in one RCT. There was no significant difference between harmonic scalpel and coblation groups regarding the mean operative time (n = 6 RCTs, MD=-7.45 min, 95% CI [-15.26, 0.01], p = 0.06) mean intraoperative blood loss (n = 5 RCTs, MD=-36.03 ml, 95% CI [-77.46, 5.41], p = 0.09), and rate of postoperative hemorrhage (n = 5 RCTs, RR = 0.59, 95% CI [0.25, 1.39], p = 0.23). The overall postoperative pain score was significantly reduced in favor of the coblation group compared with the harmonic scalpel group (n = 5 RCTs, MD = 0.40, 95% CI [0.10, 0.69], p = 0.009)". Conclusions: The harmonic scalpel and coblation techniques share equal efficacy among patients undergoing tonsillectomy. The reduction in postoperative pain score provided by the coblation method is not clinically meaningful in clinical practice. Additional RCTs are needed to consolidate the power and quality of the presented evidence. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04022-7.

A Comparison of Harmonic Scalpel and Conventional Techniques for Thyroidectomy.

Thyroidectomy is one of the most frequently performed surgeries. Conventional techniques using electrocautery carry the risk of tissue injury. Recently, there has been increased use of harmonic scalpels in thyroid surgery. The harmonic scalpel utilizes ultrasonic shears for cutting and coagulation, thus minimizing thermal injury. The objective of our study was to determine differences in operative duration, hypocalcemia, and RLN palsy. This single-center retrospective comparative study included consecutive patients undergoing hemithyroidectomies using the harmonic scalpel and conventional technique in the past one year (n = 64, harmonic group = 28 and conventional group = 36). The mean operative duration for the harmonic scalpel group was 70.4 min, vs. 81.31 min for the conventional technique group, and the difference in mean duration was found to be 10.84 min (p = 0.027). There was no statistically significant difference in the rates of hypocalcemia (p = 0.751) or RLN palsy (p = 0.121). None of the patients in either group developed permanent hypocalcemia or RLN palsy. The use of a harmonic scalpel during thyroidectomy is safe. The overall surgical duration was reduced when the harmonic scalpel was used, and the complication rates were comparable to those of the conventional technique, making it a non-inferior technique for surgical intervention in thyroidectomy and warranting harmonic scalpel consideration as a valuable addition to the armamentarium of thyroid surgeons.

Myotomy for myocardial bridge utilizing harmonic scalpel.

INTRODUCTION: Myocardial bridge is defined as epicardial coronary arteries that course through the myocardium. While frequently asymptomatic, it can present on a spectrum from stable to life threatening angina. Medical management is often successful, but failure requires stenting or bypass, both of which are inferior to myotomy in appropriate surgical candidates, the former due to morbidity and the later theoretically due to competitive flow. PRESENTATION OF CASE: We present an otherwise healthy 50 year old gentleman with myocardial bridge refractory to medical management who was effectively managed via myotomy performed with the harmonic scalpel, enjoying complete relief of previous exertional chest pain. DISCUSSION: Historically, myotomy has been described sharply and with electrocautery. Compared to the harmonic scalpel, these techniques risk poor hemostasis and damage to the underlying left anterior descending artery, not to mention their inefficiency in terms of operative speed. CONCLUSION: In appropriately diagnosed patients, who are also suitable surgical candidates, myotomy, specifically with the harmonic scalpel, has short-term, intra-operative benefits of better hemostasis, protection of underlying left anterior descending artery and heart cavity, and improved operative efficiency. Given the lack of long-term symptomatic data on different myotomy techniques it is difficult to make comparisons of this nature.

Modelo animal para la evaluación del sellado de colaterales venosas con dispositivos liberadores de energía en cirugía de revascularización / Animal model to assess collateral vein sealing with energy-based devices in revascularization surgery

Introducción: los dispositivos liberadores de energía permiten la hemostasia de los vasos mediante generación de calor y la coagulación de las proteínas de la pared. Sin embargo, se desconoce su comportamiento a medio plazo en la cirugía arterial con injertos venosos. Objetivos: desarrollar un modelo animal que permita evaluar la eficacia y seguridad del sellado a medio plazo tras el proceso de cicatrización. Comparar y evaluar qué modelo in vivo presenta menor morbilidad y mayor supervivencia a las 4 semanas. Material y métodos: estudio experimental animal de 16 conejos New Zealand a los que se interpuso un fragmento de vena safena humana (VS) con una colateral. Se desarrollaron dos modelos arteriales: bypass termino-terminal de VS en aorta infrarrenal (n = 5) y plastia de aorta con parche de VS (n = 11). La colateral venosa fue sellada, previa aleatorización, con electrocoagulación bipolar controlada por temperatura (EB) o bisturí armónico (BA). Todos los animales recibieron inmunosupresión y profilaxis antitrombótica. Se registró la tasa de paraplejia, de infección, de hemorragia y de supervivencia. Resultados: la supervivencia a los 7 días fue del 50 % (2/4) en el modelo de injerto de interposición. Sin embargo, ningún animal sobrevivió a las 4 semanas de seguimiento en este modelo. En el grupo de plastia de aorta, la supervivencia a los 7 días fue del 55,56 % (5/9) y del 44,44 % (4/9) a las 4 semanas (p = 0,5). La tasa de paraplejia en el grupo de interposición fue del 100 % e inferior en el modelo de plastia de aorta (25 %) (p = 0,03). El tiempo medio de isquemia en el modelo de plastia de aorta (37,11 ± 8,1 min) fue inferior al del grupo del bypass (42 ± 10,61 min) (p = 0,414). En ningún caso se objetivó hemorragia intraabdominal ni reacción adversa a la inmunosupresión. Conclusiones: el modelo arterial de plastia de aorta con parche de VS presentó menor tasa de paraplejia, así como menor mortalidad posoperatoria a los 7 días...(AU)

Introduction: energy sealing devices achieve hemostasis of the vessels through the heat generated and coagula-tion of the vascular wall proteins. However, the mid-term efficacy profile for venous graft sealing in arterial bypasssurgery remains unknown.Objectives: to create an animal model to compare the mid-term efficacy and safety profile at the sealing areaafter the healing process. To compare and assess which in vivo arterial models show lower morbidity and highersurvival rates after 4 weeks.Material and methods: this was an in vivo experimental study of 16 New Zealand rabbits. In each rabbit a humansaphenous vein (SV) with, at least, 1 venous collateral was implanted. Two arterial models were developed: infrarre-nal aorta bypass with SV (n = 5) and aortoplasty with SV patch (n = 11). In both models the collateral was randomizedand sealed with either 1 these 2 energy sealing devices: electrothermal bipolar vessel sealing (EBVS) or Harmonicscalpel (HS). Every animal was treated with antithrombotic prophylaxis and immunosuppressive medication. Therates of intraoperative mortality, paraplegia, infection, bleeding, and survival were all studied.Results: two animals (50 %) survive 7 days after surgery in the bypass model. However, no animal survived 4 daysafter surgery in this model. In the aortoplasty group, the 7-day survival rate was 55.56 % (5/9) while the 4-weeksurvival rate was 44.44 % (4/9) (p = 0.05). The rate of paraplegia was 100 % for the bypass model and much lowerfor the patch group (25 %) (p = 0.03). The mean ischemic time was lower for the aortoplasty model (37.11 ± 8.1 min)compared to the bypass group (42 ± 10.61 min) (p = 0.414). No animal showed intrabdominal hemorrhages oradverse drug reactions associated with the immunosuppressive medication.Conclusion: aortoplasty with the SV patch model showed lower rates of paraplegia and 7-day mortality in theanimal model...(AU)

Comparison of the effect of the harmonic scalpel and monopolar cautery in transaxillary endoscopic dual-plane breast augmentation.

BACKGROUND: Transaxillary endoscopic dual-plane breast augmentation is becoming increasingly mature. The intraoperative separation of the implant into the space is often performed using monopolar cautery. The use of the harmonic scalpel has proved more beneficial in several surgeries. However, no study has ever addressed the effects of harmonic scalpel usage compared to monopolar cautery in transaxillary endoscopic dual-plane breast augmentation. METHODS: In this randomized controlled study, we enrolled patients (n = 78) who underwent breast augmentation in our hospital from January to October 2022. Participants were randomized with an intentional unequal allocation ratio (2:1 in the harmonic scalpel group: monopolar cautery group). Outcome measures included: total postoperative drainage volume, postoperative drainage volume for the first 24 h, number of postoperative drainage days, daily pain scored through the visual analog scale, operative time, and reoperation rate. RESULTS: A total of 51 patients in the harmonic scalpel group and 24 patients in the monopolar cautery group were analyzed. Overall, in comparison to the monopolar cautery group, the harmonic scalpel group showed improved total postoperative drainage volume, postoperative drainage volume for the first 24 h, number of postoperative drainage days, and postoperative pain scores. No differences were found regarding operative time and reoperation rate. CONCLUSION: Compared with monopolar cautery, harmonic scalpel usage in transaxillary endoscopic breast augmentation has evident advantages regarding postoperative drainage and patients' pain scores, making it an instrument worth of recommendation.

Ultrasonic scalpel versus electrocautery for internal mammary artery harvesting: a meta-analysis.

OBJECTIVE: Although an ultrasonic harmonic scalpel (HS) has been used to harvest the internal mammary artery (IMA) for coronary artery bypass grafting, the benefits and risks compared to conventional electrocautery (EC) are not clear. We aimed to compare the outcomes of HS versus EC for IMA harvesting. METHODS: An electronic search was performed to identify all relevant studies. Baseline characteristics, perioperative variables, and clinical outcomes were extracted and pooled for meta-analysis. RESULTS: This meta-analysis included 12 studies. Pooled analyses demonstrated that both groups had comparable preoperative baseline characteristics including age, gender, and left ventricular ejection fraction. HS included more diabetic patients [33% (95% CI 30, 35) vs. 27% (23, 31), p = 0.01]. Harvest time for unilateral IMA was significantly longer with HS than EC [39 (31, 47) minutes vs. 25 (17, 33) minutes, p < 0.01]. However, the rate of pedicled unilateral IMA was significantly higher for EC compared with HS [20% (17, 24) vs. 8% (7, 9), p < 0.01]. The rate of intact endothelium was significantly higher with HS than EC [95% (88, 98) vs. 81% (68, 89), p < 0.01). There was no significant difference in postoperative outcomes including bleeding [3% (2, 4)], sternal infection [3% (2, 4)], and operative/30-day mortality [3% (2, 4)]. CONCLUSIONS: HS required longer IMA harvest times which could be partially attributed to a higher skeletonization rate in this category. HS may cause less endothelial injury than EC; however, no significant differences in postoperative outcomes were seen between the groups.

Comparing Open Versus Rigid Endoscopic and Flexible Endoscopic Techniques for the Treatment of Zenker's Diverticulum.

OBJECTIVE: To describe the outcomes of patients undergoing open stapler versus transoral rigid and flexible endoscopic therapies for symptomatic Zenker's diverticulum. STUDY DESIGN: Single institution retrospective review. SETTING: Tertiary care academic hospital. METHODS: We retrospectively evaluated the outcomes of 424 consecutive patients who underwent Zenker's diverticulotomy via an open stapler, rigid endoscopic CO2 laser, rigid endoscopic stapler, rigid endoscopic harmonic scalpel, or flexible endoscopic technique from January 2006 to December 2020. RESULTS: A total of 424 patients (173 females, mean age 73.1 ± 11.2 years) from a single institution were included. A total of 142 patients (33%) underwent endoscopic laser treatment, 33 (8%) underwent endoscopic harmonic scalpel, 92 (22%) underwent endoscopic stapler, 70 (17%) underwent flexible endoscopic, and 87 (20%) underwent open stapler. All open and rigid endoscopic procedures and most of the flexible endoscopic procedures (65%) were performed under general anesthesia. The flexible endoscopic group had a higher percentage of procedure-related perforation, defined as subcutaneous emphysema or contrast leak on imaging (14.3%). The recurrence rates were higher in the harmonic stapler, flexible endoscopic, and endoscopic stapler groups at 18.2%, 17.1%, and 17.4%, respectively, and lower in the open group (1.1%). Length of hospital stay and return to oral intake were similar among groups. CONCLUSION: The flexible endoscopic technique was associated with the highest rate of procedure-related perforation, while the endoscopic stapler had the lowest number of procedural complications. Recurrence rates were higher among the harmonic stapler, flexible endoscopic, and endoscopic stapler groups and lower in the endoscopic laser and open groups. Prospective comparative studies with long-term follow-up are needed.

Use of a Harmonic scalpel for laparoscopic adrenalectomy in two cats.

Case series summary: Adrenal tumors are rare in cats and reports of laparoscopic adrenalectomy in cats are limited. This case series describes two cats that underwent laparoscopic adrenalectomy using a Harmonic scalpel for dissection and coagulation. Both surgeries were successful, with minimal hemorrhage, smoke production and lateral thermal damage. Vessels were appropriately sealed and surgical times were appropriate. Both cats recovered without complications postoperatively. Relevance and novel information: To our knowledge, this is the first veterinary report to describe the use of the Harmonic scalpel for laparoscopic adrenalectomy as the sole device in cats. Owing to the absence of hemorrhage, there was no indication for irrigation, suction or hemostatics. The Harmonic scalpel is an ultrasonic vessel-sealing device with benefits over conventional electrosurgery, including less lateral thermal damage, less smoke production and improved safety due to the lack of an electrical current. This case report aims to highlight the usefulness of ultrasonic vessel-sealing devices for laparoscopic adrenalectomy in cats.

Endoscopic, endoscopic-assisted and open approaches in the treatment of juvenile angiofibroma: what has been new in the past decade (and 1586 cases)?

PURPOSE: Juvenile angiofibroma (JA) is a benign, but locally invasive tumor of the nasopharynx. Surgical resection of JA is performed through endoscopic (EA), endoscopic-assisted (EAA), or open approaches (OA). The management of these tumors is constantly evolving. We aimed to compare the surgical efficiency and morbidity of EA, EAA, and OA in JA treatment by conducting a systematic review of the literature published over the last 10 years. METHODS: A systematic review of the English literature on surgical cases of JA published between 2012 and 2022 was performed. Eligible articles were analyzed for individual patient data (IPD) and aggregate patient data (APD). The primary predictor variable was the surgical approach. The primary outcome variable was recurrence rate. RESULTS: The search retrieved 75 articles reporting 1586 JA surgical cases; 129 in IPD, and 1457 in APD data sets. Within the IPD data set, recurrence rates were significantly lower in cases completed by EA than that by OA (p < 0.05). There was no significant difference in recurrence rates between the EA and EAA groups (p > 0.05). EAA had a lower recurrence rate than that of OA (p < 0.05). For the APD data set, the recurrence rate following EA was significantly lower than that following OA (p < 0.05). There was no significant difference in recurrence between the EA and EAA groups (p > 0.05), and between the EAA and OA groups (p > 0.05). CONCLUSIONS: EA represents the method of choice for mild and moderately advanced JA. EAA and OA still play important roles in the treatment of advanced-stage JA.

Harmonic Scalpel Versus Clips for Ligation of Cystic Duct in Laparoscopic Cholecystectomy: A Systematic Review.

The gold standard treatment for benign gallbladder disease is laparoscopic cholecystectomy (LC). LC is commonly performed using monopolar diathermy with ligation of the cystic duct and artery with clips. The aim of the current systematic review was to compare harmonic scalpel (HS) with clips in LC. Eligible studies were identified from PubMed, Cochrane library, Embase and Medline and meta-analysis was conducted using Review Manager 5.4. The primary outcome evaluated was bile leak while secondary outcomes evaluated were overall postoperative complications, operative time, conversion to open surgery and gall bladder perforation. Eight randomized control trials met the eligibility criteria which included a total of 1,205 patients. There was no statistically significant difference between the two groups in terms of bile leak (p = 0.56, I2=0%). With respect to the operative time (p = 0.004, I2=97%), conversion to open surgery (p = 0.02, I2=0%) and gall bladder perforation (p = 0.0001, I2=26%) HS was superior to clips. HS is an acceptable alternative to the use of clips when ligating the cystic duct.

Evaluation of the safety of using harmonic scalpel during laparoscopic cholecystectomy in children: A preliminary report.

Background and objective: In spite of being one of the most common surgical procedures performed in adults, laparoscopic cholecystectomy (LC) is relatively uncommon in the pediatric age group. Most surgeons prefer to dissect the cystic duct using a monopolar electrosurgical hook and occlude it with simple metal clips. Although the safety of using the ultrasonically-activated shears, e.g., harmonic scalpel for dissection of the gallbladder is confirmed in many studies, its efficacy in the closure of the cystic artery and duct in adults is still debatable. Furthermore, very few reports studied its safety in children during LC. The aim of our work is to study the safety and efficacy of ultrasonic shears in controlling the cystic duct and artery during LC in children. Materials and methods: A prospective study was conducted from May 2017 to April 2020, where all children having symptomatic gallbladder stone disease were included in the study. HS was used as a sole instrument in gallbladder dissection as well as in controlling cystic duct and artery. No metal clips or sutures were used throughout the procedure. Results: A total of forty-two children having symptomatic gallstone disease were included in the study. The main indication for LC was hemolytic anemia. Their age ranged from 3 to 13 years with a mean of 8.4 ± 3.25 years. All operations were completed laparoscopically, i.e., no conversion to open surgery was needed. The mean operative time was 40 ± 10.42 min. There were no intraoperative complications apart from gall bladder perforation in two cases during dissection from the liver bed while the postoperative recovery was smooth in all patients. Patients started oral feeding after 11.30 ± 3.01 h. The mean time for discharge was 25.47 ± 7.49 h, ranging from 14 to 48 h. Postoperative ultrasound for all cases showed no evidence of minor or major bile leaks or CBD injuries. Conclusion: This is the first report to evaluate the use of HS as a sole instrument during LC in the pediatric age group. HS is a safe and efficient instrument that can be used alone in gallbladder dissection as well as in controlling cystic duct and artery during LC in children.

Tissue pad degradation of ultrasonic device may enhance thermal injury and impair its sealing performance in liver surgery.

BACKGROUND: Ultrasonic devices are widely used in many surgical fields, including hepatectomy; however, the negative effects of tissue pad degradation of ultrasonic devices, including those in liver surgery, remain unknown. The Harmonic® 1100 (H-1100) scalpel has advanced heat control technology than previous models, such as the Harmonic® HD1000i (H-HD1000i). We hypothesized that, because of its advanced temperature-control technology, the H-1100 scalpel would show less tissue pad degradation, resulting in superior sealing performance, compared to that with the H-HD1000i scalpel. AIM: To elucidate ultrasonic device tissue pad degradation effects on instrument temperature and sealing performance using ex vivo porcine liver/vessel models. METHODS: Two different harmonic scalpels were used and compared: A newer model, the H-1100 scalpel, and an older model, the H-HD1000i scalpel. Using ex vivo porcine livers, each instrument was activated until the liver parenchyma was dissected. The device temperature (passive jaw temperature) was measured after every 10 consecutive activations, until 300 transections of the porcine liver were performed. Tissue pad degradation was evaluated after 300 activations. Sealing performance was evaluated using excised porcine carotid vessels; vessel sealing speed and frequency of vessel burst pressure below 700 mmHg were determined after 300 transections of porcine liver parenchyma. RESULTS: The temperature of the H-HD1000i scalpel was approximately 10°C higher than that of the H-1100 scalpel, and gradually increased as the number of activations increased. The median passive jaw temperature of the H-HD1000i scalpel was significantly higher than that of the H-1100 scalpel (73.4°C vs 65.1°C; P < 0.001). After 300 transections of porcine liver parenchyma, less tissue pad degradation was observed with the H-1100 scalpel than with the H-HD1000i scalpel (0.08 mm vs 0.51 mm). The H-1100 scalpel demonstrated faster vessel-sealing speed (4.9 sec. vs 5.1 sec.) and less frequent vessel burst pressure < 700 mmHg (0% vs 40%) after 300 activations than the H-HD1000i scalpel; however, the difference did not reach statistical significance (P = 0.21 and P = 0.09, respectively). CONCLUSION: In an ex vivo porcine hepatectomy model, the H-1100 scalpel shows lower passive jaw temperature and maintains its sealing performance by avoiding tissue pad degradation compared to that with the H-HD1000i.