Almost since the inception of laparoscopic cholecystectomy, surgeons have been employing devices that concentrate electrical or vibrational energy to heat and thereby cauterize arteries. However, for more than 7 years, Brij Agarwal, MD, MBBS, MS, and colleagues have been avoiding the use of these energy devices. Dr. Agarwal is a senior surgeon at Sir Ganga Ram Hospital in New Delhi, one of India's leading hospitals.
Dr. Agarwal presented a study testing his reasoning here at the Society of American Gastrointestinal and Endoscopic Surgeons 2008 Annual Scientific Session and Postgraduate Course. The study group consisted of 74 patients randomly selected from Sir Ganja Ram Hospital's laparoscopic cholecystectomy candidates. Energy devices were not used during surgery on these patients. Another 79 patients were randomly assigned to a control group and did have energy used for cauterization during their procedures. All candidates were operated on by fully qualified laparoscopic surgeons, and there were no elimination criteria.
"If we are cutting in the right area in the right plane, God has given us areas where there is no bleeding," Dr. Agarwal told Medscape General Surgery. "This is taught to basic medical students." He pointed out that, especially around diseased organs, there are often easily identifiable areas where there is an absence of veins. All one has to do is clamp the artery supplying that area, and there will be no bleeding as the tissue is cut. It then follows that if there is no bleeding, there is no need for cauterization, and no need for energy devices to heat and possibly damage the surrounding areas such as the intestine or the bile duct.
Both the study and control groups had similar demographic and disease profiles. For instance, 16 patients in the control group had a mucocele condition compared with 14 in the study group. Fourteen patients in the control group had an empyemata gallbladder, whereas 12 in the study group did.
The laparoscopic surgeons encountered no additional technical difficulty with the study group and found that they required no additional instruments to complete the surgery. All patients in the study group went home between 4 and 6 hours after surgery. None of the patients in the study group had any complications compared with patients in the control group. Of the patients in the control group, 11 had biliary leaks vs 2 in the study group. Seven of the patients who were subjected to energy devices required rehospitalization vs none in the study group. Finally, two patients in the control group died from sepsis, whereas all members of the study group survived. The damage caused by cauterization is slow in developing and can manifest 3 or 4 days after surgery.
Paul Curcillo, MD, FACS, vice chair, Department of Surgery, Drexel University, Philadelphia, Pennsylvania, told Medscape General Surgery that "eliminating the use of energy from laparoscopic surgery would eliminate many of the concerns we have — you'd eliminate arcing, you'd eliminate spread, you'd eliminate damage to surrounding structures." Dr. Curcillo said he is in the process of slowly eliminating energy from his own surgical practice, and "hopefully [will] get to [Dr. Agarwal's] point some day."
Dr. Agarwal and Dr. Curcillo have disclosed no relevant financial relationships.
Society of American Gastrointestinal and Endoscopic Surgeons 2008 Annual Scientific Session and Postgraduate Course: Abstract P141. Presented April 9–12, 2008.
Reviewed By Dr. Ramaz MItaishvili
