Page 10 - World Journal of Laparoscopic Surgery

Efficacy and Safety of Electrothermal Bipolar Vessel Sealer vs ENSEAL in Total Laparoscopic Hysterectomy for Large Uterus
that TLH is a feasible and safe technique even in an enlarged uterus no significant difference (p = 0.9) noted in the duration of
with various benefits and fewer intraoperative complications when surgery between the groups. A study by Aytan et al. also
compared to the open method. A seven-year-long study by Sinha et noted that operative time was the same in all three groups
al. done in Mumbai, India concluded that TLH could be performed that used LigaSure, HALO PKS cutting forceps, and ENSEAL,
even in an enlarged uterus with no increase in complication rates respectively. Another prospective trial was done on 132 patients
and short-term recovery. Garry et al. did EVALUATE hysterectomy in Turkey by Yüksel et al. who compared the efficacy of LigaSure
study in 2004, which noted that LH had a significantly higher vs. ENSEAL and found that operative time was significantly more
risk of major complications and longer operative time but less in ENSEAL group; however, no such differences were noted in
postoperative pain, faster recovery when compared to open the current study. 7,9
hysterectomy. 1,5 The size of the uterus is an important factor in the occurrence
Maintaining hemostasis is fundamental in all surgical of intraoperative hemorrhage and postoperative complications
procedures more so in minimally invasive surgery. The risk of during a laparoscopic hysterectomy, especially with uterus weight
hemorrhage is more especially in the enlarged uterus due to lack >500 gm. Subjects with a history of prior gynecologic surgeries
of exposure and distorted pelvic anatomy. Traditional methods of have an increased risk of complications due to adhesions.
staples and clips have gradually been abandoned due to cost and Kondu et al. did a retrospective evaluation of 38 patients with
technical difficulties. The evolution of laparoscopic hysterectomy uterine weight >1000 g who underwent hysterectomies and
is closely linked to continuous technological advancements in reported no significant difference in both intra-op and post-op
the visual and electrosurgical units. Various energy-based vessel complications in the laparoscopic group compared to the open
sealing technologies have been introduced as these devices method group. 10
allow rapid sequential tissue and vessel sealing, coagulation and Glaser et al. reported that the incidence of bowel and urinary
transection. These advanced bipolar vessel sealing devices have tract injury during laparoscopic hysterectomy were 0.39 and
been widely used as they are easy to use, less time-consuming, and 0.73–1.8%, respectively. Both the groups had no intraoperative
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provide better hemostasis even in a large uterus where the risk of complications in this study. During the postoperative period, no
hemorrhage is greater. cases were reported with bowel complications in our study but one
The purpose of this randomized case–control study was to case in each group reported developed bladder complications. Both
compare one such indigenous electrothermal bipolar vessel sealing the cases had a history of previous C-sections and were reported
device, ALAN vessel sealer with ENSEAL with respect to safety, to have vesicovaginal fistulas, which were further managed by a
efficacy, and perioperative outcomes in the enlarged uterus. urologist.
Before morcellation of an enlarged uterus, the blood supply Secondary hemorrhage is a rare but life-threatening
to the uterus should preferably be controlled. Measures like pre- complication following TLH. Secondary hemorrhage was reported
treatment with a gonadotropin-releasing hormone (GnRH) agonist to occur more following TLH than other hysterectomy approaches
may be necessary to induce uterine tissue shrinkage and decrease in a retrospective observational study done at Paul’s hospital,
vascularity. Injection of dilute vasopressin solution around the Kochi. Another study at the same center reported that cumulative
largest myoma may also help control capillary bleeding. But none incidence of secondary hemorrhage following TLH was 1.3%. 12,13
of these methods was used in our study. Large uterus size, excessive use of energy source, vaginal vault
In 1998, a multicenter randomized trial was done to compare hematoma, or infection could be the possible factors. A total
LH vs TAH. Myoma being the most common indication in the trial, it of three cases of secondary hemorrhage were detected in our
was observed that blood loss was significantly less in the LH group study and were managed conservatively by vaginal packing and
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compared to the TAH group. The present study noted that mean tranexamic acid.
blood loss in ALAN vessel sealer group and ENSEAL group was Leukorrhea was seen in four cases in the Alan vessel sealer
111.40 ± 22.32 and 107.84 ± 20.33 mL, respectively. Both ENSEAL group and three cases in ENSEAL group as secondary to vault
and ALAN vessel sealer devices have an inbuilt feedback system granulation, vaginal vault inflammation, or excessive tissue charring.
that determines the quantity of tissue being sealed and adjusts the All the cases were treated conservatively with a course of oral and
strength of the current accordingly to provide a better hemostatic local antibiotics. Vault dehiscence following TLH is an infrequent
effect. Also in the ALAN vessel sealer group, tissues were held along but devastating complication. Excessive use of thermal energy
the full length of the jaws during coagulation and only at the tip leading to tissue necrosis and devascularization was attributed to
covering one-third of the jaw length while cutting, thereby ensuring being a possible cause. Hur et al. reported that vault dehiscence
precise cutting and minimizing blood loss. was more following TLH and suggested the use of laparoscopic
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A German study by Rothmund et al. compared ENSEAL scissors over thermal energy. No case was reported to have vault
with standard bipolar coagulation. It was noted that blood loss dehiscence in this study.
between both groups was not statistically significant. Another Postoperative complications were similar in both the groups
randomized prospective study by Aytan et al. compared LigaSure and no statistical difference was observed in our study. Katherine et
vs HALO PKS cutting forceps vs ENSEAL and noted more blood al. also observed no significant difference in the complication rate in
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loss in the ENSEAL group compared to other groups. Bicer et al. subjects who underwent laparoscopic hysterectomy regardless of
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compared LigaSure vessel sealer both in small and large uterus uterine weight. The study by Bicer et al. who compared LigaSure in
subjects who underwent LH and noted that blood loss was more both small and large uteri also reported no significant difference in
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in the large uterus group but was not statistically significant. In our the minor and major complications between the groups and their
study, the amount of blood loss was similar in both groups and was finding was on par with the current study. 8
statistically insignificant (p = 0.4). The capital investment and running cost of these vessel sealer
Mean operative time in group A was 56.90 ± 12.45 minutes devices are of economic concern as they have disposable hand
and in group, B was 57.25 ± 13.54 minutes. Hence, there was instruments but ALAN vessel sealer is less expensive due to its

8 World Journal of Laparoscopic Surgery, Volume 14 Issue 1 (January–April 2021)