Temperature safety profile of laparoscopic devices: Harmonic ACE (ACE), Ligasure V (LV), and plasma trisector (PT).

BACKGROUND: Reports of iatrogenic thermal injuries during laparoscopic surgery using new generation vessel-sealing devices, as well as anecdotal reports of hand burn injuries during hand-assisted surgeries, have evoked questions about the temperature safety profile and the cooling properties of these instruments. METHODS: This study involved video recording of temperatures generated by different instruments (Harmonic ACE [ACE], Ligasure V [LV], and plasma trisector [PT]) applied according the manufacturers' pre-set settings (ACE setting 3; LV 3 bars, and the PT TR2 50W). The video camera used was the infrared Flex Cam Pro directed to three different types of swine tissue: (1) peritoneum (P), (2) mesenteric vessels (MV), and (3) liver (L). Activation and cooling temperature and time were measured for each instrument. RESULTS: The ACE device produced the highest temperatures (195.9 degrees +/- 14.5 degrees C) when applied against the peritoneum, and they were significantly higher than the other instruments (LV = 96.4 degrees +/- 4.1 degrees C, and PT = 87 degrees +/- 2.2 degrees C). The LV and PT consistently yielded temperatures that were < 100 degrees C independent of type of tissue or "on"/ "off" mode. Conversely, the ACE reached temperatures higher than 200 degrees C, with a surprising surge after the instrument was deactivated. Moreover, temperatures were lower when the ACE was applied against thicker tissue (liver). The LV and PT cooling times were virtually equivalent, but the ACE required almost twice as long to cool. CONCLUSIONS: The ACE increased the peak temperature after deactivation when applied against thick tissue (liver), and the other instruments inconsistently increased peak temperatures after they were turned off, requiring few seconds to cool down. Moreover, the ACE generated very high temperatures (234.5 degrees C) that could harm adjacent tissue or the surgeon's hand on contact immediately after deactivation. With judicious use, burn injury from these instruments can be prevented during laparoscopic procedures. Because of the high temperatures generated by the ACE device, particular care should be taken when it is used during laparoscopy.

Robotic assisted laparoscopic radical prostatectomy: a review of the current state of affairs.

Open retropubic radical prostatectomy is the gold standard treatment for localised prostate cancer. However, the procedure has inherent morbidity associated to it. Therefore, less invasive surgical techniques have been sought, one such alternative is robotic-assisted laparoscopic radical prostatectomy. The advantages provided by robotic technology have the potential to minimise patient morbidity while improving both functional and oncological outcomes. Although it is a recent technological advancement, robotic surgery has shown an increasing rate of adoption worldwide. Currently more than 30,000 patients have undergone this procedure worldwide. We present a review of the available literature on robotic-assisted laparoscopic radical prostatectomy.

Sequential use of Prepidil and extra-amniotic saline infusion for the induction of labor in nulliparous women with very low Bishop scores.

OBJECTIVE: To evaluate the efficacy of sequential use of Prepidil (prostaglandin E2 gel) and extra-amniotic saline infusion for the induction of labor in nulliparous women with very low Bishop scores. STUDY DESIGN: Nulliparous women with singleton gestations, intact membranes and a cervical Bishop score of < or = 2 who received Prepidil gel and extra-amniotic saline infusion sequentially for the induction of labor between July 1996 and July 1998 were studied. RESULTS: Thirty-one women met the inclusion criteria. Indications for induction included post-dates (six of 31), pre-eclampsia (ten of 31), diabetes (three of 31), oligohydramnios (three of 31), intrauterine growth restriction (two of 31) and non-reactive non-stress test (NST) (seven of 31). The average time from onset of induction to delivery was 38.1 +/- 13.5 h. Vaginal delivery was achieved in 80.6%. Women requiring > 2 doses of Prepidil had a higher risk of delivering abdominally (OR = 3.5). Three of seven (42.9%) women with labor induced for non-reactive NST but only three of 24 (12.5%) with labor induced for other indications had a Cesarean section delivery (p < 0.001). CONCLUSIONS: Nulliparous women with very unfavorable cervices can be counselled that they have an 80% chance of vaginal delivery using sequential Prepidil and extra-amniotic saline infusion as an induction method, with 90% delivering within the first 48 h.

Expectant management of severe preterm preeclampsia: is intrauterine growth restriction an indication for immediate delivery?

OBJECTIVE: Expectant management of severe preterm preeclampsia is gaining widespread acceptance in clinical practice. The objective of our study was 2-fold-to determine the frequency of fetal deterioration with expectant management of severe preterm preeclampsia and to evaluate whether the presence of intrauterine growth restriction on admission is associated with a shorter admission-to-delivery interval or more deliveries resulting from nonreassuring fetal status in comparison with pregnancies with preeclampsia but without intrauterine growth restriction. STUDY DESIGN: This was an observational study of women with singleton pregnancies at <34 completed weeks' gestation who were admitted to the hospital with the diagnosis of severe preeclampsia and managed expectantly. Fetal status on admission, admission-to-delivery interval, indication for delivery, and neonatal outcome were examined. RESULTS: Forty-seven women were studied during a 3-year period (1996-1999). Gestational age at admission was 29.8 +/- 2.6 weeks. The mean admission-to-delivery interval for the entire group was 6.0 +/- 5.1 days; in 42.5% delivery was for fetal indications. In comparison with the absence of intrauterine growth restriction, the presence of intrauterine growth restriction at admission resulted in a significantly shorter admission-to-delivery interval (3.1 +/- 2.1 vs 6.6 +/- 6.1 days; P <.05). Most fetuses with intrauterine growth restriction (85.7%) were delivered before 1 week. Although 57% of fetuses with intrauterine growth restriction were delivered for fetal indications, versus 39% of fetuses without intrauterine growth restriction, these rates were not found to be significantly different. Neonatal outcomes, as reflected by Apgar scores, number of admissions to and duration of stay in the neonatal intensive care unit, and neonatal mortality rates, were similar. CONCLUSION: Pregnancies complicated by severe preterm preeclampsia and the presence of intrauterine growth restriction at admission may not benefit from expectant management beyond the 48 hours needed for betamethasone to act. Furthermore, all patients may benefit from close fetal monitoring before delivery because of the high rate of intervention for deteriorating fetal status.

Case report: endometrial cancer implanting in the laparotomy scar.

A 58-year-old woman underwent abdominal hysterectomy and bilateral salpingo-oophorectomy for stage Ib, grade 2 endometrial adenocarcinoma followed by external pelvic irradiation. Five years later she presented with a 7 cm solitary infraumbilical incisional tumor recurrence that was resected. Histology of the tumor implant was similar to that of the primary cancer. The patient was then started on progestin therapy with no evidence of recurrence for four years. To our knowledge this is the fourth reported case of endometrial cancer implanting in an abdominal scar.