Ultrasonic Coagulation Source & scissors
Grasped tissue is coagulated with frictional heat generated by ultrasonic vibration; the tissue is then cut by mechanical friction.
Harmonic scalpel (Ethicon EndoSurgery)
BLAs have used the Ultracision Harmonic Scalpel (Generator GEN22/32 -no longer on the market) in over 400 colectomies and 500 Nissen fundoplications over the last five years. As testiment to its reliability, we have had no electrical or mechanical problems and it wass only recently that we had to replace our two hand piece transducers (H2TUV/H3TUV). Our new 300 generator Harmonic is much more efficient.
The old hand piece or LCS/C5 sits comfortably in the hand and is very easy to use. The active blade is curved and is very good for fine dissection eg., dissecting out the origin of a vascular pedicle, dividing mesorectum, grasping a bleeding vessel. We also use them to manipulate bowel, in fact we only remove the hand piece from the peritoneal cavity to place a vascular clip or divide the bowel! We have never had thermal bowel injury. We have perforated small bowel with the tip of the active blade on two occasions. Both were spotted and repaired.
It is very easy to rotate the shearses with your index finger - essential for any piece of equipment. The scissors reliably seal vessels up to 3mm. It is also fine for dividing mesenteric vessels (expect some bleeding when dividing a lymphnode rich Crohn's diseased mesentery). We do not rely on it seal major vascular pedicles whatever the size and use clips. Don’t allow debris to collect in the scissor mechanism. Regularly clean the activated scissors in a small volume of water in a metallic bowl.
Should you encounter any problems with the Harmonic shears, keep them and give them to your local rep. The number cause for shear failure is the limited lifespan of the HP054 lead. On average our leads have had a lifespan of almost 500 cases.
Although they are substantially faster and seal slightly larger vessels (5mm) BLA do not think that the new hand activated shears (Harmonic ACE) offer any major advantage in routine resections to offset the increased cost, particularly as it is impossible for the operating surgeon to activate the scissors with a fully pronated or supinated forearm eg., when working deep in the pelvis. This may change when the newly designed shears is available.
Harmonic ACE does offer some advantage (30 mins) in terms of speed when performing a subtotal colectomy for benign disease.
Whilst most medical appliances get more and more expensive, Harmonic has fallen in price by 2/3 over the last year. Now is the time to purchase one. Speak to your procurement manager. Ethicon Endo-Surgery also offer some good deals for upgrading old systems to the new 300 generator (product code GEN04).
This is very similar in design to the Ultracision & Harmonic scalpel. You can also get curved scissors like LCs/C5. The hand pieces are ergonomically designed and fit comfortably within the hand. Although we have only used it in a handful of cases, hand fatigue doesn’t seem to be a problem! It was also very effective and easy to use.
Its major selling point is that it is autoclavable and therefore potentially, significantly cheaper and cost effective (the transducer is reusable and said to last for approx 200 cases). The individual SonoSurg scissors (£2,740 inc VAT) are again said to last for about 20 cases.
They also allow the surgeon the option of using conventional monopolar diathermy which is useful when you get some bleeding. This feature also speeds up the division of peritoneum.
Its reusability means that it will need to go to CSSD between cases (a major problem when you are quick and undertake three or four resections on a list or your CSSD breaks things/looses component parts).
A final and perhaps its most important selling point is that it can be connected to an Olympus UHI insufflator to provide for automatic plume extraction and so maintain a clear view.
We would strongly suggest that you try it out, preferably until you need to replace the scissor unit!
Contact details; KeyMed Ltd, KeyMed House, Stock Road, Southend-on-Sea, Essex, SS2 5QH. Tel., 01702 616333, email@example.com www.keymed.co.uk or your local tertiary manager.
Lotus (Laparoscopic Operation by Torsional UltraSound).
Whilst, this is the favored choice of all procurement managers (its the cheapest) we have found that it is not a particularly good dissector for colorectal cases, particularly when used within the pelvis. The major drawback lies in its rotational mechanism of action. It doesn’t have a curved dissector or axial rotation and it opens utilising a rotating action i.e. it is not a good dissector where fine precision is required.
It is however very good (very quick and effective) for dividing omentum e.g. as in a hiatus hernia repair or in conducting a subtotal colectomy for Ulcerative Colitis in a thin person with a short abdomen. We have also found that when working at length/depth or employing torque, the hand piece tends to come apart. We have also experienced the tip of the active blade fracturing and breaking off in situ!
Hopefully this is all going to change with the introduction of the new Series 3 Shears "Torsion" in the spring of 2006. SRA Developments have recognised their products limitations and have added finger switch control (fairly easy to activate with index finger), acoustic axis rotation (only 180 degree) and a curved dissecting blade and jaw. The latter is now riveted and hopefully it will nolonger be prone to fracture.
The handle is also much more robust and will, unlike its predecessor allow the application of torque. It looks and feels very good. Each hand piece is priced at approx £ 259.
At the moment the generator is more expensive than Harmonic. However, the transducers/leads come free.
SRA have also introduced an ultrasonic hook at £50; the video looks very good.
We have used this product in a small number of cases and found that on each occasion it worked very well. Whilst the 180 degree rotation limits its ease of use, this is readily overcome by changing the degree of pronation/supination ie., you need to learn how to use it. Length was not an issue within the pelvis (APER case); longer shears came out in August 2007. It also coped very well with the superior rectal artery. We also thought that it cut cleanly through the bladder (partial cystectomy) with little collateral thermal damage - quite impressive.
We would suggest that it is well worth a try. If you have used it, let us know how you got on and we will share your comments.
Contact details; S.R.A. Developments Ltd, BremridgeHouse, Ashburton, Devon, TQ13 7JX. Tel:01364 652426. Email: firstname.lastname@example.org www.sra-developments.co.uk or contact their national sales manager David Wright for a demonstration 07966508404.
LigaSure (Tyco Healthcare)
Now that this energy source is available as a 5mm instrument LigaSure LAP (Product No. LS1000) with curved Maryland jaws (allows for fine dissection) it is probably worth looking at. Its selling point is its "unique" combination of high energy and pressure (hand squeeze not required) seals/fuses vessels up to 7mm in diameter i.e. it will take the inferior mesenteric, middle colic and ileocolic vessels (very useful in a subtotal colectomy for colitis etc). This sound not unlike ACE!
One potential advantage over Ultracision is that you do not need to fully dissect out the vessel before dividing it. However, the surgeons that use it (Jeff Milsom included) seem to recommend two side by side seals before finally dividing the vessel between the seals i.e. 3 applications. http://www.ligasure.com/video/lapcole_milsom_qt.html
Although we have never used Ligasure in colorectal surgery, we think that the bulky hand piece may compromise its utility. Please let us know. However, it works and is very popular. We have found it useful in nephrectomy.
Information, including publications and abstracts on the use of LigaSure LAP in colectomy and nephrectomy is available www.ligasure.com/
Contact details; Tyco Healthcare UK Ltd, 154 Fareham Rd, Gosport, Hamshire, PO13 0AS. Tel., 01329 224000. email@example.com
Bristol Laparoscopic Associates would strongly suggest that you try all the generators listed and see which one you prefer. Then try and get the best financial deal that you can. If you have high volume demand for hand pieces you should expect to get a good discount and if you are lucky, you may be able to get a generator free.
A viable alternative is to use a Kelly dissecting forceps (Storz 30321 MDS) without a ratchet and monopolar diathermy!
We would advise caution in the use of any of the above energy sources in dividing adhesions for fear of causing lateral spread thermal damage to the bowel. We prefer to use sharp scissor disection. Our preference being 5mm curved scissors (Ethicon Endo-Surgery 5DCS)