Different types of energy source surgical instruments used in key-hole bowel surgery

Having a laparoscopic (key-hole) approach in surgery to remove a section of a diseased bowel, either caused from a benign or cancerous lesion is becoming increasingly common. There are three kinds of surgical instruments available for this procedure; these are monopolar electrocautery scissors (MES), ultrasonic coagulating shears (UCS) and electrothermal bipolar vessel sealers (EBVS). This review aims to examine the effectiveness and safety of these three instruments. The findings showed that UCS results in less blood loss when compared to MES. Operating time was shorter when EBVS was used compared to MES. No marked difference was observed between UCS and EBVS. No difference in complications between all three instruments were reported in the findings. However, it is recognised that more trials are needed to support the evidence provided in this report.

Authors' conclusions: 

The limitations of this review is the small number of trials and heterogeneity of the studies included. With the current evidence it is not possible to demonstrate which is the best instrument in laparoscopic colectomy. Hopefully more data would follow and subsequent updates of this review could become more informative.

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Background: 

Colectomy is a common procedures for both benign and malignant conditions. Increasingly more colectomy has been performed laparoscopically and there are several available instruments being used for this procedure. Of which three common dissecting instruments are: monopolar electrocautery scissors (MES), ultrasonic coagulating shears (UCS) and electrothermal bipolar vessel sealers (EBVS). 

Objectives: 

The aim is to assess the safety and effectiveness of these instruments.

Search strategy: 

Studies were identified from PubMed, EMBASE, Cochrane Controlled Trials Register, Cochrane Colorectal Cancer Group Trials Register.  Major journals were specifically hand searched.  All randomised controlled trials were included.

Selection criteria: 

All patients underwent elective laparoscopic or laparoscopic-assisted right, left or total colectomy or anterior resection for either benign or malignant conditions were included in the study.

Data collection and analysis: 

Two reviewers independently selected studies from the literature searches, assessed the methodological quality of the trials and extracted data. The three primary outcomes were: overall blood loss, complications and operating time.

Main results: 

Six randomised controlled trials including 446 participants. Two trials compared three types of instruments (MES vs UCS vs EBVS). One trial compared MES and UCS. One trial compared UCS and EBVS. One trial compared 5 mm versus 10 mm EBVS. One trial compared the technique of laparoscopic staplers and clips versus EBVS in pedicle ligation during laparoscopic colectomy. The limitation of this review is the heterogeneity of the trials included. The measured outcomes were covered by one to three studies with small number of participants. With this in mind, there was significant less blood loss in UCS compared to MES. The operating time was significantly shorter with the use of EBVS than MES. No difference between UCS and EBVS apart from EBVS appeared to be handling better than UCS in one study. Haemostatic control was better in UCS and EBVS over MES. No definite conclusion on the cost difference between these three instrument but this would lie in the balance between the instrument cost and the operating time. The handling of 5 mm EBVS was better than 10 mm and its main advantage was trocar flexibility. Laparoscopic staplers/clips used for pedicle ligation in colectomy associated with more failure in vessel ligation and cost more when compared to EBVS.

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