Evaluation of the harmonic scalpel in open surgery for abdominal aortic aneurysm

Abstract

The harmonic scalpel is a hemostatic device primarily designed for use in laparoscopic surgery. During the last few years, many surgeons have begun to use the harmonic scalpel in open surgery. Several papers have cited the benefits of the device compared with conventional knot-tying techniques; however, no evidence showing the advantages of using the harmonic scalpel in complicated abdominal aortic aneurysm (AAA) surgery has been presented. The aim of the present study is to determine the value of the harmonic scalpel in open operation for AAA. A total of 153 patients who underwent open surgery for AAA at the Department of Vascular Surgery of Guangdong General Hospital, China between January 2001 and December 2010, were retrospectively analyzed. Open surgery performed with the harmonic scalpel on 105 patients was compared with open operation using conventional knot-tying techniques on 48 patients. The operative time, intraoperative blood loss, total postoperative drainage fluid volumes, hospital stay, and postoperative complications between the two groups were compared. The harmonic scalpel group was associated with a shorter operation time (113.2±23.6 min vs. 232.1±39.2 min, P<0.01) and lower intraoperative blood loss (126.1±96.6 ml vs. 592.1±207.2 ml, P<0.01). Postoperative drainage fluid volumes were greater in the conventional surgery group than in the harmonic scalpel group (702.1±192.8 ml vs. 198.5±97.4 ml, P<0.01). The hospital stay was shorter for the harmonic scalpel group than for the conventional surgery group (10.7±3.3 d vs. 16.5±4.7 d, P<0.05). No differences between the postoperative complications or hospital mortality of the two groups were found. The harmonic scalpel is a safe and minimally invasive tool in open surgery for AAA and is associated with shorter operative time, shorter hospital stay, and lower intraoperative blood loss and postoperative drainage fluid volumes compared with conventional knot-tying techniques.

Keywords

abdominal aortic aneurysm / harmonic scalpel / minimally invasive

Introduction

The harmonic scalpel is primarily designed for use in laparoscopic surgery. It shortens the operative time and lowers the complications in studies on thoracic surgery [1], adrenalectomy [2], and abdominal surgery [3], as well as in many other procedures [4,5]. Unlike conventional knot-tying techniques, ultrasonic instrumentation denatures proteins via ultrasonic vibration. The vibration transfers mechanical energy to the tissue, resulting in simultaneous cutting and coagulation. As with all energy technologies, the precise mechanism of action remains unclear, but the effect produces a coagulum of denatured protein and blood clot that occludes adjacent blood vessels and reduces bleeding [6].

During the last few years, many surgeons have begun to use the harmonic scalpel in open operations. Several papers have demonstrated the benefits of the device compared with conventional knot-tying techniques [7-9]; however, no evidence of any advantage of using the harmonic scalpel in complicated abdominal aortic aneurysm (AAA) operations has yet been presented. The aim of the present study is to determine the value of the harmonic scalpel in the open surgery for AAA.

Patients and methods

Between January 2001 and December 2010, 153 patients underwent open surgery for AAA for dissection and vessel hemostatic control at a scheduled time, using either the harmonic scalpel (n = 103) or conventional knot-tying techniques (n = 48). The choice between the types of surgery for a given patient depended on the availability of the equipment. We started using the harmonic scalpel for AAA procedures in April 2006. The model used in the current study was the Ultracision Harmonic Scalpel CS-¹⁴C (Ethicon Endo-Surgery Inc., USA) (Fig. 1). Patients with ruptured AAA were not considered for analysis.

All patients underwent routine preoperative examinations. All operations were performed using general endotracheal anesthesia. An indwelling arterial catheter was used for continuous blood pressure monitoring, and the central venous pressure was monitored via a deep vein puncture tube. Patients were operated on in a supine position. An abdominal incision was made from the xiphoid to the pubic symphysis. The proximal and distal normal anastomotic sites of the aneurysm were dissected. Using a noninvasive vascular clamp, a longitudinal incision was made in the aneurysm after the aneurysm blood vessels were blocked. The intra-aneurysmal hemorrhage was removed to prevent thrombosis. Half of both the proximal and distal sides of the aneurysm was cut (only the front and two sides), and the middle sacral artery and lumbar arteries were sutured. An appropriate diameter and length of the artificial blood vessels were selected for anastomosis. The whole surgery was performed with the assistance of experienced anesthesiologists. After each operation, follow-ups with all patients were conducted over the telephone.

The medical records of the patients enrolled in the present study were taken from the surgery database of the corresponding author and reviewed, and the sex, age, operative time, intraoperative blood loss, total postoperative drainage fluid volumes, hospital stay, and postoperative complications of the patients in the two surgical groups were compared. Statistical analysis was performed using a two-tailed t test, a χ² test, and a Wilcoxon rank sum test. Statistical significance was set at P<0.05. The analyses were performed using SPSS ver. 16.0.

Results

No significant differences between the sex or age of the two groups were observed (P>0.05) (Tableβ1). The harmonic scalpel group was associated with a shorter operative time (113.2±23.6 min vs. 232.1±39.2 min, P<0.01) and lower intraoperative blood loss (126.1±96.6 ml vs. 592.1±207.2 ml, P<0.01). The postoperative drainage fluid volumes were greater for the conventional surgery group than for the harmonic scalpel group (702.1±192.8 ml vs. 198.5±97.4 ml, P<0.01). The hospital stay was shorter for the harmonic scalpel group than for the conventional surgery group (10.7±3.3 d vs. 16.5±4.7 d, P<0.05) (Table 1). No significant differences in postoperative complications or hospital mortality between the two groups were observed (P>0.05) (Table 2).

Discussion

The development of ultrasonically activated coagulating shears in the early 1990s has provided an alternative method of controlling blood vessels. The device divides tissues using high-frequency (55 kHz) ultrasonic energy transmitted between the instrument blades. The active blade of the instrument vibrates longitudinally against an inactive blade over an excursion of 50 µm to 100 µm [10]. This mechanical action disrupts the protein hydrogen bonds within the tissue. Water in the tissue does not boil with the mild increase in temperature; thus, the proteoglycans and collagen fibers in the tissue become denatured and mix with intracellular and interstitial fluids to form a glue-like substance [11]. The harmonic scalpel uses ultrasound technology to denature proteins in the vessel walls and tissues up to 5 mm thick, leading to coagulation. It can cut through tissue while simultaneously causing coagulation.

The harmonic scalpel has been used in laparoscopic procedures even involving major arteries and veins [12]. Multiple studies demonstrated the increased safety of surgery using the harmonic scalpel compared with those performed using conventional knot-tying techniques. Moreover, the use of the harmonic scalpel minimizes blood loss in various surgeries [13,14]. However, its use in complicated AAA operations has not been reported until now. Therefore, the aim of the present study is to determine the value of the harmonic scalpel in an open operation for AAA.

With our initial experience with laparoscopic surgery, we first used the harmonic scalpel in open surgery for AAA in April 2006. The use of the harmonic scalpel was found to significantly shorten the operative time compared with conventional knot-tying techniques (113.2±23.6 min vs. 232.1±39.2 min, P<β0.01). Karvounaris et al. [15] observed a result as much as a 39.7% reduction in the operative time with the use of the harmonic scalpel vs. the use of conventional knot-tying techniques, and Meurisse et al. [16] reported that the average operative time saved with the harmonic scalpel in thyroid surgery was 26 min; these results are similar to those obtained in the current study. Intraoperative blood loss in the AAA open operation using the harmonic scalpel was also significantly decreased compared with the use of conventional knot-tying techniques (126.1±96.6 ml vs. 592.1±207.2 ml, P<0.01). Thus, autologous blood transfusion is no longer needed when the harmonic scalpel is used. Given that the general anesthesia time is also shortened, the use of the harmonic scalpel also accelerates postoperative recovery. The average length of hospital stay was significantly decreased by as much as 5 days. A cost analysis was not conducted as part of our project; however, the decrease in the operative time and length of stay of the harmonic scalpel group may confer the benefit of an overall decrease in hospital fees compared with the conventional surgery group.

A single randomized controlled trial (RCT) involving 200 patients undergoing a laparoscopic cholecystectomy procedure showed that the postoperative drainage volumes decrease when an ultrasonic instrumentation is used [7]. A similar phenomenon was also observed in the current study; the postoperative drainage fluid volumes were greater in the conventional surgery group than in the harmonic scalpel group (592.1±207.2 ml vs. 126.1±96.6 ml, P<0.01). No significant differences in the postoperative complications or hospital mortality between the two groups were observed (P>0.05) (Table 2).

Conclusions

The use of the harmonic scalpel to control the dissection and vessel hemostasis during open surgery for AAA is safe. The operative time and average hospital stay was significantly shortened, and the intraoperative blood loss and postoperative drainage volumes decreased. Meanwhile, postoperative complications and hospital mortality showed no significant increase.

References

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