MMCTS
(September 15, 2008). doi:10.1510/mmcts.2007.003111
Copyright © 2008 European Association for Cardio-thoracic Surgery
Procedure
Electrothermal bipolar tissue sealing systems in lung surgery
Mario Santini*,
Giovanni Vicidomini,
Alfonso Fiorello,
Paolo Laperuta and
Luigi Busiello
Thoracic Surgery, Second University of Naples, Piazza Miraglia 2, 80138 Naples, Italy
* Corresponding author: Tel.: +39-081-5665228; fax: +39-081-5665230 mario.santini{at}unina2.it
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Summary
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Various techniques have been proposed to reduce intraoperative blood loss in surgery. We report our experience with the use of LigaSure, a new electrothermal bipolar tissue sealing system, in lung surgery. This system has been already applied with good results in other surgical fields. However, the experience reported in the literature with the use of this technique in lung surgery is limited. Our clinical series with LigaSure (160 procedures in a 4-year period) is the largest reported to date. Technical aspects, clinical results and an overview of the literature are presented. We believe that LigaSure is an easy and safe technique, suitable for lung surgery. It could be a valid alternative or complement to staplers for several procedures, also in the thoracoscopic setting. Furthermore, it seems to allow functional lung tissue preservation and reduction of surgical supplies costs.
Key Words: Diathermy • Hemostasis techniques • LigaSure • Lung surgery • Tissue sealing
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Introduction
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Hemostasis in surgery is still a challenging problem. Several techniques are available to reduce intraoperative blood loss. In particular, standard bipolar diathermy is able to coagulate small vessels up to 3 mm in diameter, but it has some disadvantages, including sticking, charring and significant thermal spread [1, 2].
In the last years, an innovative electrothermal bipolar tissue sealing system (LigaSure, ValleyLab Inc., Boulder, CO, USA) has been introduced in general surgery, both open and laparoscopic [3–8, 9]. The use of this sealing system allows the surgeon to obtain a better vessel sealing with minimal thermal spread to the surrounding tissues. However, the potential role of this technique is still undefined and the experiences reported in literature are limited. We report our 4-year clinical experience with LigaSure in lung surgery.
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Surgical technique
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The system
The LigaSure vessel sealing system allows hemostasis by vessel compression and obliteration through the emission of bipolar energy. This technique is different from the conventional coagulating methods since it does not achieve vessel sealing by tissue carbonization (Video 1).
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Video 1 (Reproduced with permission from ValleyLab Inc., CO, USA). The LigaSure seal cycle. The system detects the thickness of tissue to be coagulated and automatically defines the amount of energy required and the delivering time. The heat generated from the bipolar energy determines the fusion of collagen and elastin in vessel walls and a subsequent tissue reformation with creation of a permanent seal zone. An acoustic signal informs the surgeon when the vessel obliteration is complete and its dissection is possible. Furthermore, LigaSure has a minimal thermal effect on the tissues surrounding the sealing line.
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The system includes different components (Photo 1).
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Photo 1 LigaSure system includes: 1) an electrosurgical generator able to detect the characteristics of the tissue closed between the instrument jaws; it delivers the exact amount of energy needed to seal it permanently; 2) several types of instruments, both for open or thoracoscopic surgery, that seal and, in some cases, divide the tissue.
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Preliminary experimental phase
In an earlier experimental phase we evaluated the vessel and airways sealing capabilities of the LigaSure system in lungs of adult dead pigs and analyzed the pathological effects and thermal damage of this technology on the surrounding lung tissue. For these purposes, we quantitated the sealing capacity of this sealing system on pulmonary vessels, bronchi and peripheral lung tissue, detecting the burst pressure for each anatomical structure (Photos 2– 7).
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Photo 2 Evaluation of LigaSure sealing capacity on pulmonary vessels. LigaSure was used to seal pulmonary arteries and veins ranging from 1 to 7 mm in diameter.
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Photo 3 Evaluation of LigaSure sealing capacity on pulmonary vessels. The vessels were divided with scissors distal to the sealing line. Then, a catheter was inserted in a vessel proximal to the suture line, that was flushed with saline.
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Photo 4 Evaluation of LigaSure sealing capacity on pulmonary vessels. The pressures were measured by a water-flow meter and the burst pressure was detected when a fluid leak was noted through the sealing line. A hydrostatic pressure of 150 mmHg was considered as ‘critical pressure’.
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Photo 5 Evaluation of LigaSure sealing capacity on bronchi. LigaSure was used to seal bronchi from 1 to 7 mm in diameter. In this case, the catheter was connected to an air-flow meter. Then, the bronchus was placed in a basin filled with saline and inflated with air. The burst pressure was recorded when air leaks appeared through the sealing line. A pneumatic pressure of 60 mmHg, a value threefold higher than the maximal physiologic airway pressure, was considered as ‘critical pressure’.
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Photo 6 Evaluation of pneumatic resistance of section margins after lung wedge resection by LigaSure. LigaSure was used to seal the base of the lung wedge, and then the resection was performed with scissors distal to the sealing line. The weight of lung resected varied from 0.2 g to 1.4 g.
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Photo 7 Evaluation of pneumatic resistance of section margins after lung wedge resection by LigaSure. The lobe which had undergone the wedge resection was placed in a basin filled with saline and the burst pressure was recorded in the same manner described for the bronchi evaluation.
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The use of this coagulation technique in the swine model showed an excellent sealing effect on pulmonary vessels. This technique can be safely used on vessels  7 mm in diameter, as reported in previous studies based on the use of the system in general surgery [3, 5, 6, 8] (Graph 1) and in a study by Lacin et al. [10], showing the perfect sealing effect of LigaSure on sheep pulmonary vessels.
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Graph 1 Resistance of pigs pulmonary vessels to the ‘critical pressure’ (150 mmHg). For all groups of arteries and veins, the average burst pressure was higher than the critical pressure, and all the vessel suture lines were resistant to a pressure higher than 150 mmHg.
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The effects of the sealing system on bronchi were not so satisfactory. Our results show a good resistance of bronchi sealed by LigaSure, with a diameter up to 2 mm. The sealing effect was unpredictable for larger bronchi (Graph 2). The good results obtained in smaller bronchi were confirmed by the assessment of suture margins after wedge resection performed by LigaSure (Graph 3). Histological examination confirmed the minimal thermal spread to the surrounding tissues (Photo 8).
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Graph 2 Resistance of pigs bronchi to the ‘critical pressure’ (60 mmHg). For the three groups of bronchi with diameter ranging from 1 mm to 3 mm, the average burst pressure was higher than the critical pressure; for the other groups the average burst pressure was lower than the critical pressure. Furthermore, the percentage of LigaSure suture lines resistant to the critical pressure was 100% in the 1-mm and 2-mm groups and it progressively decreased in the groups with a higher diameter. None of the bronchi with 6 mm or 7 mm diameter reached the critical pressure.
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Graph 3 Resistance of wedge resection margins to the ‘critical pressure’ (60 mmHg). For all groups, the average seal burst pressure was higher than the critical pressure and the percentage of suture margins resistant to the critical pressure decreased slightly from 95% (0.2 g group) to 68% (1.4 g group).
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Photo 8 Histological evaluation of LigaSure effect on the surrounding tissues. The maximal depth of thermal damage was <2 mm (average value: 1.1 mm).
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Surgical procedures
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From June 2003 to June 2007 we used the LigaSure system in 160 patients undergoing lung surgery through thoracotomy or video-assisted thoracoscopic surgery (VATS) (Table 1).
The system was used for minor lung resection (Videos 2–5), pleuro-pulmonary adherences, lung fissures dissection (Video 6), bullectomies (Videos 7, 8). In one case, LigaSure was used during a lobectomy for cancer, in order to preserve a LIMA artery graft (Schematic 1). Moreover, LigaSure can be used to seal air leaks resulting from the use of endoscopic staplers (Video 9).
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Video 2 LigaSure lung nodule resection through thoracotomy. Among the LigaSure advantages is the ability to perform ‘rounded’ resections with parenchymal saving.
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Video 3 Thoracoscopic resection of a lung nodule by LigaSure. LigaSure allows satisfying limited lung resection with a minimum risk of air leaks and/or bleeding even in the thoracoscopic setting. In the VATS procedures, we used the LigaSure Atlas forceps handset, that has both vessel-sealing and tissue-dividing capabilities. The radiographic appearance of this nodule suggested its benign nature. The histologic examination showed a lung hamartochondroma.
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Video 4 LigaSure lung resection using the new Impact forceps. This new forceps allows the surgeon to seal and cut lung tissue simultaneously during thoracotomy. In order to minimize air leaks, the amount of lung tissue divided with a single LigaSure cycle should be lesser than that with a single stapler cartridge. Small bites into the lung tissue consent better air-tight resection margins.
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Video 5 Thoracotomic lung resection performed by LigaSure and stapler. LigaSure can be used in association with staplers, in order to facilitate and fasten surgical procedures. In this case, LigaSure allowed the isolation of a lung nodule located very close to the pulmonary hilum.
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Video 6 Lung fissure dissection by LigaSure. The use of LigaSure for lung fissure separation minimizes the risk of fastidious persistent air leaks.
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Video 7 LigaSure bullectomy in VATS. LigaSure is particularly useful when large bullae are extensively adherent to the parietal pleura. In this case, part of the bulla's wall was left attached to the chest wall.
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Video 8 LigaSure bullectomy through thoracotomy. LigaSure allows the resection of the bulla's base, with maximum parenchymal saving.
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Schematic 1 LigaSure was used for a lobectomy in a patient with a LIMA artery graft. It allowed a radical upper lobectomy for cancer, leaving a minimum part of parenchyma adherent to the LIMA graft.
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Video 9 Air-leak sealing by LigaSure. In this case, we used LigaSure for a parenchymal leakage closure after endoscopic stapling.
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Results
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In all patients, hemostasis obtained by LigaSure was effective, with minimal perioperative bleeding. There was no mortality. The values of surgical parameters (operating time, postoperative drainage stay, postoperative hospitalization) were similar to those for conventional methods (Table 2). Five patients had prolonged air leaks (>7 days) that resolved on their own. No complications, including wound infections, pneumonia and cardiac dysrhythmia, were seen in the patients. The histological evaluation of the surgical specimens showed a minimal thermal spread in the tissues surrounding the sealing lines in all the cases.
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Discussion
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During the last years, several techniques have been used to improve efficacy and safety of conventional coagulating methods [11, 12]. One of the most recent is LigaSure bipolar vessel sealing system that allows local hemostasis by vessel compression and obliteration through the emission of a bipolar energy. This sealing system has a minimal thermal effect on the tissues surrounding the sealing line.
The experience with LigaSure system is limited, particularly in thoracic surgery [13–17]. Our previous study was the first biphasic evaluation of this tissue sealing system, both pre-clinical on pig lungs and clinical on human patients [17]. First of all, the results of our experience indicate that LigaSure is a suitable system for wedge lung resection. They confirm the conclusions of a study by Tirabassi et al. [14] based on the swine survival model; these authors found that sealing of lung tissue by this system was similar to that by endoscopic staplers, and the burst strengths of lung resection margins obtained with both methods was equal to that of normal lung tissue. Furthermore, our experimental results suggested that this sealing system is not suitable for the suture of large bronchi, as required in the case of major lung resections.
Our experience with LigaSure in human patients is larger than others reported in literature. The first case report was by Shigemura et al. [13]; afterward, the same research group reported the use of this sealing system exclusively in video-assisted thoracoscopic procedures [15]. Albanese et al. [16] used successfully the system for thoracoscopic lobectomy in small children with congenital lung lesions. We applied this coagulation technique either through thoracotomy or video-assisted thoracoscopy. In our study, the use of this sealing technique improved the ablation of pleural adhesions and the hemostasis during lung resections, reducing the use of conventional coagulation methods. We observed no perioperative major bleedings. Also the sealing effect on the pulmonary tissue was satisfactory; only five patients who had undergone bullectomy had prolonged air leaks that did not require additional procedures. Compared to staplers, in patients undergoing non-anatomical lung resection this system allows a better tailoring of surgical margins, thus saving functional lung tissue, and avoids the use of multiple reloadable cartridges, thus reducing the costs of disposable surgical supplies. We have calculated that, for each patient undergoing non-anatomical lung resection, we spend much less using LigaSure rather than staplers ( 270 vs. 600, respectively). Another advantage is the minimal thermal spread to the tissues surrounding the sealing line; the pathological evaluation of the specimens obtained in both phases of our study showed that the maximal depth of thermal damage was <2 mm (average value: 1.1 mm). This satisfactory result is better than that obtained by Yim et al. [11], using a different method, based on saline-enhanced thermal sealing. On the other hand, LigaSure has showed few disadvantages, including the learning curve, the shortness of the jaws and the need for frequent jaws cleaning to avoid malfunction.
On the basis of our experience, we conclude that LigaSure could be a valid alternative to staplers for non-anatomical lung resections, also in the thoracoscopic setting. For other indications (lysis of pleural adhesions, bullectomies), stapler remains the gold standard but LigaSure can be used as supplementary technique, able to facilitate and fasten the surgical procedure (especially in the presence of thick and extensive pleuro-pulmonary adherences). However, larger series with long-term results and accurate evaluations of costs/benefits ratio are needed to confirm our findings.
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Footnotes
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 The authors declare that they have no financial relationship with the manufacturer of LigaSure (Valleylab Inc., Boulder, CO, USA) 
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References
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Summary
Introduction
