Comparison of four energy-based vascular sealing and cutting instruments: A porcine model.

AIM: To compare the safety and efficacy of four energy-based vascular sealing and cutting instruments. METHODS: Blood vessels of various types and diameters were harvested from four pigs using four instruments: Harmonic ACE (Ethicon Endo-Surgery, Cincinnati, OH), LigaSure V and LigaSure Atlas (Valleylab, Inc., Boulder, CO; a division of Tyco Healthcare), and EnSeal vessel fusion system (SurgRx, Inc. Redwood City, CA). The diameters of the vessels, speed and adequacy of the cutting and sealing process, and bursting pressures were compared. An additional set of specimens was sealed and left in situ for up to 4 h after which the vessels were harvested and histopathologically analyzed for the degree of thermal injury. RESULTS: The bursting pressures were significantly higher with EnSeal compared to all other instruments (p < 0.0001). The sealing process was significantly shorter with Harmonic ACE and significantly longer with LigaSure Atlas (p <0.0001). The mean seal width was larger with the LigaSure Atlas compared to the other instruments, and it was smaller with EnSeal and Harmonic ACE. Less radial adventitial collagen denaturation was present with EnSeal and LigaSure V than with the other two instruments; there were no significant differences in collagen denaturation although proximal thermal injury to the smooth muscle in the media of the vessel wall was less common with LigaSure Atlas than with the other instruments; however, the numbers were too small for statistical analysis. CONCLUSIONS: The bursting pressures with EnSeal were significantly higher than with all the other instruments. Harmonic ACE was the fastest sealing instrument and LigaSure Atlas was slowest. EnSeal created less radial thermal damage to the adventitial collagen of the vessels and LigaSure Atlas created less thermal damage to the media of the vessels. The clinical significance of these findings is unknown.

Management of nonhealing perineal wounds.

The manifestations of perianal Crohn's disease vary from primary lesions such as skin tags and fissures, to diffuse septic destruction of tissue and sphincter muscle. These manifestations are often persistent and refractory to surgical treatment; however, a more disappointing scenario is when the treatment itself results in a chronic wound. The ideal approach for management involves basic surgical principles, careful patient selection, and realistic expectations. Choice of appropriate procedure, effective elimination of sepsis, thorough evaluation to rule out concomitant systemic disease, and appropriate use of fecal diversion are each an important principle. If proctectomy is necessary, several strategies such as intersphincteric dissection, avoidance of fecal contamination, and appropriate wound closure, are effective in diminishing the postoperative morbidity of an unhealed perineal wound. When an unhealed perineal wound develops in a patient with Crohn's disease, the initial management is conservative. When surgical treatment is necessary, success depends on careful patient selection, optimizing the patient's condition, elimination of sepsis, and choice of an effective technique for healing.