Energy options in minimally invasive pediatric surgery
Since the advent of laparoscopic surgery in the early 1980s by gynecologists, we have struggled to provide safe energy to divide tissues and seal vessels safely. Over the last 20 years major advances have been made and there are now major players in the marketplace that provide vessel sealing technology to both adult and pediatric patients through reasonably safe instruments. There are key aspects of a safe and usable energy device that vary widely from one instrument to another. Effectiveness of seal, speed of the seal, spread of energy (collateral damage), heat of the instrument after activation, plume of smoke or steam that obscures the operative field, and the ‘feel’ or usability of the instrument in the surgeon’s hands all contribute to the applicability and ultimate adoption of a device.
The energy options in minimally invasive pediatric surgery include monopolar energy, bipolar energy, and ultrasonic shears. Each has its benefits and drawbacks. Monopolar (hook cautery) is by far the least expensive but also has a large plume of smoke associated with it and a large amount of spread of energy to adjacent structures. Bipolar energy comes in a variety of platforms and seems to have the least spread, heat production, and plume but is expensive and some platform’s seal times are slow. Ultrasonic energy is also expensive and may have an edge on some bipolar platform’s seal time but the jaws are quite hot and there is a large amount of steam produced from the seal. In general, monopolar sealing is much more variable and so the durability of the seal is less consistent when compared to the advanced energy devices which all have very safe and reproducible seals for physiologic pressures. One product engineer told me in confidence, and so I feel it’s safe to tell you, that the size of vessel that many manufacturers are ‘rated’ to seal is nowhere near what they can actually seal. That being said, don’t be stupid, ok?
In the US the market share is dominated by the Ligasure (Medtronic – bipolar energy) and the Harmonic Scalpel (Johnson and Johnson – ultrasonic shears). There are other devices that are vying for adoption: Sonicision (Medtronic – cordless ultrasonic shears), Enseal (Johnson and Johnson – bipolar) Thunderbeat (Olympus – bipolar and ultrasonic combination), and the JustRight Sealer (Bolder Surgical – bipolar with decreased seal times and energy (read: spread, heat, etc) and a 3 mm instrument). I know that is a lot to take in. There are plusses and minuses to each and each should be applied by the surgeon’s experience and comfortability as well as tailored to each case.
Specific Applications
Only the JustRight Sealer was developed for pediatric patients and so the others have been adopted in pediatric practice. Because of this, there are specific cases where the strengths or weaknesses come into play. The JustRight sealer is the only 3 mm sealer on the market and is peerless when it comes to neonatal laparoscopy and thoracoscopy. The obvious downside of the sealer is that it does not have a cutting option, it seals and the tissue is ‘distracted’ (read: torn) and it is pricier than other sealers. There is a learning curve but the instrument is really impressive once you are used to it. The upsides are striking and they use much lower energy than adult bipolar instruments which means less plume, less heat, less spread, and ridiculously fast seal times – somehow. It is my go-to instrument for any case that uses shorter instrument lengths (comes in 20 cm shaft length).
The hook cautery shines for cases where spread of heat doesn’t matter – think laparoscopic cholecystectomy – the liver is very forgiving. Its cost consciousness balances out many of its shortcomings however, when encountering a big vessel or in a small space and spread, plume, or a cool instrument is important, look elsewhere.
In my mind, the Ligasure is the workhorse of the 5 mm instruments. The other currently available 5 mm options (Thunderbeat, Enseal, etc) come down to preference and what you’re used to. I haven’t heard a convincing argument from them on why I should switch.
Ultrasonic shears are very good when you need an active jaw to enter tissue – think partial nephrectomy. One of my colleagues also uses it (cool side down) for Heller myotomies though I have not been impressed with that application. I don’t know anyone who has a strong preference between Ethicon’s and Covidien’s shears – the cordless option is nice in theory but a bit heavy in my experience.
All in all, there are many options on the table for pediatric surgeons to choose among. For our smaller patients nothing beats the JustRight Sealer and I’m eager to see their future developments – more to come on this soon! Until then, my choice is the Ligasure for any 5 mm case given how versatile and relatively safe it is.