Double Bipolar Sealing of the Pulmonary Artery Improves the Bursting Pressures

Abstract

Background In every anatomic lung resection, branches of the pulmonary artery have to be divided. In open surgery, this can be done with ligatures or staplers. In endoscopic surgery, only an endostapler can be used. By routing we ligate the vessels double. Bipolar sealing had yielded promising results, so we wanted to know if we can improve the bursting pressures especially in case of larger vessels by double sealing.

Methods Experiments were performed on preparations of the left pulmonary artery extracted at the slaughterhouse. A pressure sensor was implanted at the central end to provide digital measurement of the pneumatic load on the vessel seal and thus establish bursting pressure in each case. Vessels were sealed with MARSEAL 5 (Gebrüder Martin GmbH & Co KG, Tuttlingen, Germany) and SealSafe G3 electric current. The vessels investigated were separated into three sizes: 1 to 6 mm, 7 to 12 mm, and >12 mm. The groups (n = 12 in each) were investigated for each vessel size—Group 1: ligature; Group 2: single seal; Group 3: double seals separated by gap of 0.5 cm; and Group 4: double seals separated by gap of 1.0 cm. Mean bursting pressure (mbar) was calculated for each group. Differences between groups were calculated with Mann–Whitney U test; differences with p < 0.05 were considered significant.

Results The ligated vessels in the 1 to 6 mm group showed the highest bursting pressures (mean 515.7 ± 39.6 mbar). Mean bursting pressure in the single seal group was 231.6 ± 47.5 mbar. This was not significantly different from the group with double seals placed 0.5 cm apart. However, bursting pressures were significantly higher in the group with double seals placed 1 cm apart (p < 0.001). Mean value in this case was 308.5 ± 44.5 mbar. In the 7 to 12 mm vessels, mean bursting pressure was highest with ligation at 361 ± 67.1 mbar but was significantly higher in both groups with double bipolar seals (180.3 ± 52.1 mbar with 0.5-cm separation and 277.0 ± 64.5 with 1-cm separation) than in the single seal group (102.7 ± 16.1 mbar). In large vessels (>12 mm), mean bursting pressures were low (66.3 ± 12.7 mbar) with single seals but were significantly higher with double seals (162.3 ± 35.8 mbar [0.5-cm separation] and 137.3 ± 22.9 mbar [1-cm separation]).

Conclusions In the ex vivo model of the pulmonary artery, double seals revealed significantly higher bursting pressures than single seals. If there is enough vessel length, the two seals should be placed 1 cm apart.

Keywords

bipolar sealing - pulmonary artery - MARSEAL - bursting pressure - double seal

• References

• 1 Brzeziński J, Kałużna-Markowska K, Naze M, Stróżyk G, Dedecjus M. Comparison of lateral thermal spread using monopolar and bipolar diathermy, and the bipolar vessel sealing system ThermoStapler™ during thyroidectomy. Pol Przegl Chir 2011; 83 (07) 355-360
• 2 Ghirardini G, Mohamed M, Bartolamasi A. , et al. Minimally invasive vaginal hysterectomy using bipolar vessel sealing: preliminary experience with 500 cases. J Obstet Gynaecol 2013; 33 (01) 79-81
• 3 Lakeman MM, Roovers JP. Electrosurgical bipolar vessel sealing versus conventional clamping and suturing for vaginal hysterectomy: a randomised controlled trial. BJOG 2013; 120 (06) 777
• 4 Lyons SD, Law KS. Laparoscopic vessel sealing technologies. J Minim Invasive Gynecol 2013; 20 (03) 301-307
• 5 Overhaus M, Schaefer N, Walgenbach K, Hirner A, Szyrach MN, Tolba RH. Efficiency and safety of bipolar vessel and tissue sealing in visceral surgery. Minim Invasive Ther Allied Technol 2012; 21 (06) 396-401
• 6 Kirschbaum A, Kunz J, Steinfeldt T, Pehl A, Meyer C, Bartsch DK. Bipolar impedance-controlled sealing of the pulmonary artery with SealSafe G3 electric current: determination of bursting pressures in an ex vivo model. J Surg Res 2014; 192 (02) 611-615
• 7 Lacin T, Batirel HF, Ozer K, Demirutku A, Ahiskali R, Yuksel M. Safety of a thermal vessel sealer on main pulmonary vessels. Eur J Cardiothorac Surg 2007; 31 (03) 482-485 , discussion 485
• 8 Tsunezuka Y, Waseda R, Yachi T. Electrothermal bipolar vessel sealing device LigaSureV for pulmonary artery ligation—burst pressure and clinical experiences in complete video-assisted thoracoscopic major lung resection for lung cancer. Interact Cardiovasc Thorac Surg 2010; 11 (03) 229-233
• 9 Lesser TG, Wolfram F, Boltze C. Sealing of pulmonary arteries with LigaSure: in vivo and ex vivo examinations. J Thorac Cardiovasc Surg 2013; 145 (06) 1525-1528
• 10 Sugi K, Kaneda Y, Satoh Y, Murakami T. Use of the bipolar vessel sealing system in lung resection [in Japanese]. Kyobu Geka 2003; 56 (07) 551-554
• 11 Kirschbaum A, Sasse T, Palade E. Burst pressures of the central pulmonary artery after bipolar vessel sealing—examination in an ex vivo model [in German]. Zentralbl Chir 2014; 139 (03) 342-345