Laparoscopic Dissection Techniques

INTRODUCTION
Dissection is defined as the separation of tissues with
hemostasis. It consists of a sensory visual and tactile
component, an access component involving tissue mani
pulation, and instrument maneuverability. These are
combined to achieve exposure, i.e., developing a suitable
space for seeing and handling target structures.
Precision and meticulous hemostasis is essential
requirement in minimal access surgery (MAS). Endoscopic
dissection, in contrast to dissection in conventional surgery,
possesses several limitations. Threedimensional direct
visions are replaced by twodimensional indirect visions
in laparoscopic surgery. Illumination and the video image
quality are still limited despite recent advances in video
systems such as digitization and threechip endocamera.
Movement of the functional tip of laparoscopic instruments
is restricted along with the kinematics response. The loss
of tactile sensation in endoscopic surgery is yet another
limiting factor.
Endoscopic dissection and manipulation of tissue within
a confined space require a twohanded approach, assisting
and dissecting both task are performed by surgeon himself.
A passive assisting instrument (usually a grasper) provides
countertraction and exposure for the active dissecting
instrument. The active instrument may be nonenergized
(e.g., scissors and scalpel) or energized with electricity
(diathermy), ultrasound, or light energy.
TYPES OF LAPAROSCOPIC DISSECTION
A variety of mechanisms have been used to divide tissue and
enable hemostasis. They all involve some form of physical
energy being applied to the appropriate tissue. The amount
of energy required for dissection depends on the type and
constituency of the tissue. The properties of tissues may vary
in different directions and for different disease states. This in
totality influences the choice of the modality for dissection.
The ideal dissection technique requires a modality that
can accomplish meticulous hemostasis and will be tissue
selective without causing inadvertent tissue damage. It
must be safe for both patient and surgical team when in
regular use and when inactive in storage. In this respect,
Laparoscopic Dissection
Techniques
builtin safety measures are mandatory. An ideal dissecting
modality should be efficient in both power delivery and in
space requirement. The modality must be costeffective also.
The initial expenditure needed to acquire and setup the
necessary equipment must be taken into account along with
subsequent operational and maintenance costs.
In reality, there is no single “ideal” dissecting modality for
entireminimalaccesssurgicalprocedures.Inactualpractice,
a combination of energy forms is applied with selection of
the most appropriate one at each particular phase or type of
the operation.
The available modalities for dissection in MAS include:

■ Blunt dissection

■ Sharp scalpel and scissors dissection

■ Highfrequency radiowave electrosurgery

■ Radiofrequency ablation

■ Ultrasonic dissection

■ Highvelocity and highpressure waterjet dissection

■ Laser surgery
Blunt Dissection
Instrument Used

■ Closed scissors tips used as blunt dissector

■ Scissor points used to separate by spreading the jaw

■ Grasper—straight and curved

■ Inactive suction cannula

■ Heel of inactive electrosurgery (hook or spatula)

■ Pledget
Methods

■ Distraction

■ Separation

■ Teasing

■ Wiping
Pledget Dissection
Endoscopic pledget dissection was first introduced in the
University of Dundee in 1987. A special endoscopic pledget
or peanut swab 5.0 mm ratcheted holder, manufactured
by Storz (with strong jaws and inward facing tongs at the
Prof. Dr. R. K. Mishra

110 SECTION 1: Essentials of Laparoscopy
Fig. 1: Pledget dissection. Fig. 2: Tissue stripping and dissection.
end of the jaws for security), is used in a manner similar to
that employed in open surgery. The holder grasping, the
pledget, is introduced inside a reducer tube through an
11.0mm cannula. The blunt dissection is safe and is used
to open planes and expose structures especially when the
anatomy is obscured by adhesions. The movement consists
of forward and backward wipes accompanied by clockwise/
counterclockwise rotation of the pledget swab. It is also
useful for controlled small bleeder by compressions before
this is secured by clipping or electrocoagulation. The pledget
swab is particularly useful for blunt dissection in Calot’s
triangle during cholecystectomy. It is economical, simple to
use, and maintains a dry operative field while performing
dissection. This type of dissecting modality is also utilized in
hemostatically separating gallbladder from its bed, bladder
from the uterus, or the rectum from the sacral attachment
(Fig. 1).
Removal of pledget must be carried out under vision
to ensure that the swab is inside the reducer tube before
withdrawal of the instrument, otherwise there is a real risk of
losing the small pledget swab in the peritoneal cavity.
The pledget is an invaluable tool for the rapid dissection
of loose areolar planes when it is wiped or pushed against
the line of cleavage to separate the tissues.
Pledget is useful in maneuvers to control minor
hemorrhage. The pledget can be placed over the bleeding
point to apply pressure. When used on an oozing operative
field, it adsorbs some of the blood and may clarify the
anatomical position.
It is important to follow routine practice to minimize loss of
the peanut swab inside the abdomen:

■ Always use a reducer tube to insert and remove the swab.

■ Employ a safe system (ratchet and elastic band) to
maintain the grip of instrument used for insertion.

■ Keep the pledget in view from insertion to retraction
into the introducer tube. Be sure it is retrieved into the
introducer, not the cannular end.
Tissue Stripping and Tissue Distraction
These are other safe and effective forms of blunt dissection.
The latter is applied for seromyotomy. Insignificant
hemostatic capability is the main disadvantage of blunt
dissection (Fig. 2).
Sharp Dissection
Sharp scalpel is used mainly for division by cutting. Although
inexpensive, its use is restricted in laparoscopic surgery. The
lack of hemostasis, the potential of injury from the tip when
inserting through the port, and the kinematics problems
restrict its use to common bile duct division.
Scissors Dissection
It is one of the most frequent methods in laparoscopic
surgery. It offers the benefits of being cheap, safe, and precise
operator determined action. However, being nonhemostasis
renders it far from ideal as a dissecting modality (Fig. 3).
Electrosurgical Dissection
Electrosurgery is the most convenient way of dissection in
MAS combined with most risky method of dissection. Most
of the complication in laparoscopic surgery is due to use of
energized instrument (1%) (Fig. 4).
Before understanding the principle of electrosurgery,
following definitions should be known:

■ Current: Flow of electrons

■ Circuit: Pathway for flow of electrons

■ Voltage: Force that causes electron to flow

■ Resistance: Obstacle to the flow of electron.
There are two basic principles of electricity:
1. Electrical current ultimately flows to ground
2. It always follows the path of least resistance.

111
CHAPTER 8: Laparoscopic Dissection Techniques
Fig. 3: Scissor dissection. Fig. 4: High-frequency electrosurgical generator.
Fig. 5: Frequency range of electrosurgery.
High-frequency Electrosurgical Dissection
Our household appliances have the 50–60 Hz frequency.
This frequency is beneficial because if faulty instrument has
current and inadvertently someone touches, then he will
be thrown away and the person getting shock will be safe.
If the frequency is >100 kHz, muscle and nerve stimulation
ceases whereas all other property of electric current is still
there. Highfrequency electrosurgery is the application of
highfrequency currents (in the frequency range of 300 kHz
up to several MHz) to coagulate, fulgurate, spray coagulates,
or ablates tissue. Knowledge of how this and other physical
modes interact with biological materials is becoming
increasingly important to the surgeon for safe and consistent
surgery (Fig. 5).

■ Standard electrical current alternates at a frequency of 50
cycles per second (Hz)

■ Nerve and muscle stimulation ceases at 100,000 cycles
per second (100 kHz)

■ Electrosurgery can be performed safely at frequencies
above 100 kHz.
High-frequency Monopolar Electrosurgery
The monopolar circuit is composed of the generator, active
electrode, patient, and patient return electrode. The patient’s
tissue provides the resistance, producing heat (Fig. 6).
Monopolar diathermy is used in endoscopic surgery for
coagulation and for dissection (cutting). During monopolar
diathermy,currentisconductedfromtheinstrumentthrough
the tissues to a skin pad (neutral electrode) connected back
to the generator. Heating occurs at site of small crosssection
and low electrical conductivity. A high current density occurs
in the tissue in immediate contact with the instrument and
heat is generated.
Burn = Intensity of current × Time/area
Burn is directly proportional to the intensity of current.
Intensity of current can be adjusted by the knob provided in
the generator’s control panel. If the intensity setting is more,
the burn will be more. Intensity actually denotes ampere or
number of electrons that flows through the pathway.
Burn is also directly proportional to time. Time is paddle
application time. Surgeon should always keep in mind
that continuous activation of paddle can result in many
complications. Intermittent activation is always better than
continuous activation (Figs. 7 and 8).
Burn is inversely proportional to area. One of the major
problem in electrosurgery is patient will get burn at the site
where area is narrowest. This may cause remote injury with
the use of monopolar diathermy. The surgeon should hold
the tissue with the point of instrument to catch the minimum
amount of tissue at one time. If a bunch of tissue is caught,
there is always fear of remote injury.
Patient return electrodes: Silicon and metal patient return
plates are available. The silicon is better because it does
not have any sharp edge and the resistance is less (Fig. 9).
Patient return electrode is required only in unipolar
electrosurgery because the patient’s body is a part of circuit
and the patient return plate will take the current back to the
generator. If the patient return plate is not attached properly

Fig. 6: Circuit of monopolar current. Fig. 7: Remote injury.
Fig. 8: Remote injury with electrocautery device. Fig. 9: High-quality patient return plate.
Fig. 10: Patient return plate.
to the body of the patient or the size of the patient return
plate is very small, patient can get electric burn at the point
of attachment of this patient return plate. Ideally, the size of
patient return plate should not be <100 cm2
.
At the time of location of patient return plate attachment,
surgeon should keep in mind the following points (Fig. 10):

■ Choose: Wellvascularized muscle mass to have more
area of contact.

■ Avoid:

z Vascular insufficiency should be avoided because of
high resistance

z Irregular body contours can prevent plate to be in
firm contact

z Bony prominences will not allow the surrounding
skin to be in contact.

■ Consider:

z Plate should be nearer to incision site

z Plateshouldbeplacedaccordingtopatient’sposition,
so it should not be displaced

z Plate should be away from other equipment such as
cardiac monitor.
The effect of highfrequency current on the tissues
depends on:

■ Temperature generated

■ Shape and dimensions of the contact point (broader
damage with broader contact)

113
Fig. 11: Effect of cutting current. Fig. 12: Circuit of bipolar current.
Fig. 13: Bipolar forceps used in laparoscopically-assisted vaginal
hysterectomy (LAVH).
Fig. 14: Tripolar device.

■ Time of activation (short bursts reduce depth and
charring)

■ Distance from the electrode (Fig. 11)

■ Conductivity of the tissue (bleeding results in a change
in conductivity)

■ Power output from the generator (voltage)

■ Amplitude and current wave form time curve of the
signal (cutting or coagulating settings).
Bipolar Diathermy
A bipolar system is inherently safer as the interaction is
restrictedtotheimmediatevicinityofcontactandthecurrent
does not pass through the patient, but instead returns to the
generator via the receiving pole after passage through the
grasped tissue (Fig. 12).
Bipolar Electrosurgery

■ Active output and patient return functions both are at the
site of surgery

■ Current path is confined to tissue grasped between
forceps (Fig. 13)

■ Return electrode should not be applied for bipolar
procedures.
Tripolar Electrosurgery
Bipolar probes are now available for coagulation as well as
for cutting. The cutting system is not strictly bipolar and is
hence referred to as tripolar (Fig. 14).
It has four functions in one and the same instrument namely:
1. Dissecting
2. Grasping
3. Bipolar coagulation
4. Bipolar cut
Use of the Diathermy Hook
These are generally Lshaped or open Cshaped, blunt
ended rods mounted on an insulated handle. The active,
noninsulated part is limited in size. The hook is a delicate

Fig. 15: Different types of hook.
Fig. 16: Depth of desiccation is proportional to paddle application time.
instrument and should be protected during insertion by
manual opening of the cannula valve or use of a reducing
tube. As electrosurgery generates smoke (which is harmful),
many handles of electrosurgical hooks have a suction
attachment at the other end of the handle.
Electrosurgical Hooks (Fig. 15)
Electrosurgical instruments such as the hook are useful as
blunt dissectors prior to activation. They are used to isolate
the tissue to be divided by the current. The tip is passed into
or under a layer of the tissue being dissected, which is then
hooked and tented up (to increase its impedance and thus
limit the spread of current when applied). Small portions of
tissue are tackled, so that an assessment of the tissue caught
on the hook can be made before coagulation or cutting
current is applied to the instrument. The hook can be used
to clear unwanted tissue beside linear structures by passing
the hook into the tissues parallel to the structure and then
rotating it to hook up strands of unwanted tissue. The tissue
to be divided is held away from underlying tissue to prevent
inadvertent damage. Short bursts of coagulating current can
be followed by the use of cutting current, if the tissue has not
already separated. The use of the hook can be summarized
as “hook, look, and cook”
.
The hook or the spatula may be used to mark out and
coagulate a line for division. The heel of the hook is used
with the highfrequency current set to soft coagulation. Short
bursts are applied and the hook moved along to create a
“dotted” line of coagulated tissue. When deeper penetration
is desired, the hook is appropriate instrument. This type of
contact is best reserved for situation where no significant
damage can be caused by current penetration (Fig. 16).
Monopolar electrosurgery has become the most widely
usedcuttingandcoagulatingtechniqueinMAS.Ithasproven
to be versatile, costeffective, and demonstrated superior
efficacy for coagulation. By varying the voltage, current, or
waveform, tissue can be cut cleanly (pure cut); coagulated
to achieve hemostasis (coag mode) or a “blend cut” that
combines these two functions can also be produced. Finally,
a dispersed coagulation mode known as fulguration allows
coagulation of diffuse bleeding (Fig. 17).
Cutting current is lowvoltage highfrequency current.
Due to high frequency, the ions inside the cell get turbulence
and cells brust (explode or evaporize). Cutting current can
be obtained by pressing the yellow paddle of electrosurgical
generator. To cut any structure, it is important that surgeon
should apply the sharp tip of electrosurgical instrument and
the tissue should not be held firmly. At the time of cutting,
it is wise that tissue should be under tension. Ideally, direct
touch with the tissue should be avoided in case of cutting
current. It should be spark wave from some distance
(Fig. 18).
Electrosurgical coagulation is achieved by highvoltage
lowfrequency current. This low frequency is not sufficient to
causetheexplosionofcell,butheatinsidethecellisincreased.

115
Fig. 17: Different types of electrosurgery. Fig. 18: Fulguration.
Due to increased intracellular temperature, the protein
inside the cell coagulates and shrinks. Shrinkage of protein
will cause constriction in the lumen of bleeding vessels
and the vessels are sealed. Permanency of coagulated
tissue and its sealing effect depends upon melted collagen.
At the time of electrosurgical monopolar coagulation, the
temperature of tissue causes the collagen to melt. These
melted collagens solidify again once the active instrument
is off from the tissue. It is important to remember that
if the tissue is burnt more than required, the melted
collagen burns, turns into charcoal, and the sealing strength
of the lumen of any vessel will decrease. Surgeons and
gynecologists should always try to avoid overcooking of the
tissue.
Electrosurgical coagulation is of two types:
1. Fulguration: Fulguration is coagulation current from
some distance (Fig. 18). It is also known as spray mode.
At the time of fulguration, lateral spread of energy is
more than depth. We want to use fulguration everywhere,
where superficial burn is required and deeper injury
may cause damage of underlying structure. The
example of good use fulguration is ablation in cases of
endometriosis and fulguration of gallbladder bed at the
time of cholecystectomy, if there is generalized oozing
from liver. Direct touch with tissue should be avoided
to achieve maximum effect. Fulguration is coagulation
current from some distance.
2. Desiccation: Electrosurgical desiccation occurs when the
electrode is in direct contact with the tissue. Most of the
time with the unipolar or bipolar electrosurgery, we do
desiccation only. The tissue damage in depth and width
is same in desiccation. The extent of collateral damage
in desiccation is more compared to cutting current.
The extent of collateral damage of desiccation can be
minimized by minimizing the paddle application time
(Figs. 19 and 20).
Fig. 19: Desiccation with more collateral damage. Fig. 20: Desiccation with less collateral damage.

Fig. 21: Overshooting should be avoided.
Figs. 22A and B: Direct coupling.
A B
However, monopolar laparoscopic electrosurgery can
compromise patient safety under certain circumstances.
Thermal injury to nontargeted internal organs may occur
firstly, as a result of imprecise mechanical operation
of a laparoscopic instrument and secondly, through
diversion of electrical current to other paths. These stray
current may be released either through insulation failure,
direct coupling, or capacitive coupling. Other problems
encountered include effect on pacemakers, return
electrode burns, toxic smoke, charring of instruments,
and minimal control of energy delivery (Fig. 21).
Bipolar electrodes design although virtually eliminating
complicationfrominsulationfailure,capacitivecoupling,
and direct coupling (Figs. 22 to 24).
The primary electrothermal tissue effect is limited to
desiccation, not cutting. It requires slightly more time
than monopolar coagulation because of lower power
settings and bipolar generator output characteristics.
It is not an effective method of making a “pure cut”
.

■ Hemostasis over a large area is not possible

■ Grasping dense tissue between both the active and
return electrodes is difficult.
Safety during Electrosurgery
Laparoscopic dissection requires more extensive dissection
and thus meticulous hemostasis becomes particularly
important. Any loss of view will result in loss of control and
hence decreased safety. Hemorrhage, even to a minor extent,
tends to obscure their operative field and is to be avoided.
This means that vessels of a size that in open surgery could
be divided without particular attention need to be secured
prior to division when working endoscopically. Dissection
must be more meticulous to proceed smoothly to avoid any
unacknowledged injury.
The magnification produced by the endoscope may
initially confuse the surgeon as to the extent of electrical
injury. However, an inexperienced endoscopic surgeon is
welladvised to convert if he have any doubt about his ability
to control the situation expeditiously.
Safety Considerations in Minimal Access Surgery
The potential for accidental damage with electrosurgery
must always be borne in mind at the time of MAS. Following
are the most commonly encountered problems specific to
the MAS:

■ Overshooting

■ Overcooking

■ Direct coupling

■ Capacitive coupling

■ Insulation failure

117
Fig. 23: Capacitive coupling.
Fig. 24: Burn due to capacitive coupling.
Overshooting: Overshooting means the tip of energized
instrument going beyond the field of vision during
electrosurgery. Overshooting is one of the common mistakes
done by beginners. Surgeon should be careful that if they are
cutting any structure they should apply less force, otherwise
their instrument will overshoot once the structure is cut
and the energized instrument can heat any nearby viscera
leading to perforation.
During initial learning phase of laparoscopy, the trainer
surgeon should keep hold on the hand of trainee at the
time of electrosurgery to prevent any inadvertent injury by
overshooting. At the time of laparoscopic cholecystectomy,
if hook overshoots, it may hit diaphragm or duodenum. If
overshooting is not under the control of surgeon, he should
try to keep the tip of hook toward the anterior abdominal
wall, so that only peritoneum will be injured.
Overcooking: Proper hemostasis requires optimum
applicationofenergyoverthetissue.Duetovisuallimitations
and fear of impending bleeding, laparoscopic surgeons have
a tendency of overcooking. It is important to remember that
instead of more secure coagulation overcooking can create
rebleeding. To understand the effect of overcooking, it is
important to know physiology of tissue sealing.
Coagulation current is highvoltage lowfrequency
current. At this current, the ions inside the cell will move
but it cannot explode. Due to increase in intracellular heat,
the protein inside the cell will be denatured, coagulated,
and shrink. Due to shrinkage of tissue, the lumen of small
bleeder obliterates and bleeding stops. At the same time due
to heat, the collagen of tissue melts and once the paddle of
electrosurgical generator is off, the melted collagen will cool
down and solidify.
Overcooking results in charring of melted collagen
and the sealing strength of tissue is decreased. It could be
understood just by the example of sealing of polythene over
a flame of candle. If you want to seal the polythene bag but
applying more temperature on polythene by putting it over
direct flame, instead of getting sealed, the polythene will
start burning. One should know the sealing temperature
of polythene so that required temperature is applied, the
polythene will melt and once cooled will solidify. Similarly,
the burnt collagen does not have any tissue sealing property
and bleeding may start again if it is overcooked.
Most common causes of overcooking or charring of
tissue are:

■ High power setting of electrosurgical generator

■ Prolonged activation of foot paddle

■ Keeping the jaw closed permanently in contact of tissue

■ Poorly engineered electrosurgical generator.
Direct coupling: If the active electrode touches a noninsulated
metal instrument within the abdomen, it will convey energy
to the second instrument, which may in turn, if the current
density is high enough, transfer it to surrounding tissues
and cause a thermal burn. For example, the active electrode
could come in contact or in close proximity (<2 mm) to a
laparoscope, creating an arc of current between the two. The
laparoscope could then brush against surrounding tissue,
causing a severe burn to the bowel and other structures.
The burns may not be in the visual field of the surgeon and
therefore will not be recognized and dealt with in a timely
fashion.
To prevent direct coupling, the active electrode should
not be in close proximity to or touching another metal
instrument before the generator is activated. Bowel is
particularlysusceptibletothiskindofcollateraldamagefrom
sparks and stray currents. Recognition of this complication
may be delayed until the postoperative period with serious
consequences.Checkthattheelectrodeistouchingthetarget
tissue, and only that tissue, before you activate the generator.
Note that when target tissue is coagulated (desiccated), the
impedance increases and the current may arc to adjacent
tissue, following the path of least resistance.
We should be careful that all metal instruments such as
laparoscopes pass through conductive metal trocars. This
way, if the active electrode touches the instrument, the

Fig. 25: Insulation failure.
current will simply flow from the instrument to the metal
trocar. As long as the trocar is in contact with a relatively
large portion of the abdominal wall, the current will not
concentrate. Instead, it will dissipate harmlessly from the
trocar through the abdomen and back through adjacent
tissue to the return electrode. If the trocar is completely or
partially constructed of plastic, however, the energy may not
be able to dissipate back through the body. The metal within
the trocar will build up a charge, which could eventually arc
to adjacent tissue and back to the return electrode, but at a
harmful level of current. In doing so, it may travel through
the bowel, skin, or even the operator’s hands, causing burns
(Fig. 23).
To avoid direct coupling, surgeon should not activate the
generator while the active electrode is touching or in close
proximity to another metal object.
Capacitive coupling: This now never arise but occurred in
the early days of laparoscopic surgery with the use of plastic
fixation screws to fix metal ports to the abdominal wall,
so as to prevent them from being accidentally pulled out
or pushed when instruments were withdrawn during the
course of an operation.
Thephysicsunderlyingthisinjuryisfairlystraightforward.
Whenevercurrentisappliedthroughaninsulatedinstrument
inserted through a metal trocar (port), some radiofrequency
electric charge is transferred to the metal cannula by every
activation (even if the insulation of the instrument is perfect).
This effect is known as capacitance coupling.
There is absolutely no problem if the metal cannula is
in contact with the full thickness of the abdominal wall,
as the charge accumulated by the cannula is immediately
discharged over a wide contact area (low power density like
the neutral return electrode plate) and hence no damage is
done.
However, if the cannula is isolated from the abdominal
wall, by a plastic screw (acting as an insulator), the cannula
cannot discharge and thus accumulates a substantial charge
with repeated activation of the electrosurgical instrument.
Thus, in essence, it becomes an electric accumulator. Should
at any stage, the tip of the cannula inside the abdomen
touches tissue or bowel, the accumulated charge will
discharge immediately through a single point of contact, i.e.,
with a high power density sufficient to cause an electrical
burn. Since this occurs away from the site of action of the
operation, it is usually overlooked. Capacitive coupling is not
a problem if plastic fixation screws are not used.
The phenomenon of “capacitance” is the ability of
two conductors to transmit electrical flow even if they
are separated by an intact layer of insulation. Capacitive
coupling can occur even in the bestcase scenario, i.e., when
the insulation around the active electrode is intact and the tip
of the electrode is not touching anything metal. If the active,
insulated electrode is wrapped around a towel clamp, or
placed inside a metal trocar sleeve, or comes in close contact
with any conductive substance for an extended period of
time, the current in the active electrode may induce a current
in the second conductor.
As long as the induced current can dissipate easily,
through a large surface of tissue, it would not present
a problem. The danger occurs if the second conductor
contains some insulating material, as in the case of a
metal cannula held in place by a plastic anchor. The
plastic anchor will prevent the energy from dissipating
and increase the likelihood of a thermal burn. Burns from
capacitance current may occur when the surface area is
<3 cm2
or the current density is approximately 7 W/cm2
.
As with direct coupling, the best way to prevent this
phenomenon is to use the active electrode monitoring
system that prevents current from capacitive coupling
from building to dangerous levels. Also, you should avoid
all plasticmetal hybrid instruments, including cannulas,
trocars, and clamps, when doing electrosurgery.
Insulation failure: During a laparoendoscopic procedure,
only about 10% of an insulated instrument is visible on the
video monitor at any one time, which means about 90% of
that electrode remains outside the surgeon’s field of view,
where it can cause the most damage. Whenever a defective
instrument is introduced into the patient, electric current
can escape to contiguous tissue or organs, but the surgeon
is not aware that a thermal burn at a peripheral site has
occurred. It is estimated that 67% of such injuries are not
recognized at the time of surgery. Sadly, manifestations of
these unsuspected injuries do not appear until several days
after the actual surgery and so, when the impaired patient
presents, his or her clinical symptoms are already severe.
Diagnosis is difficult and often delayed and the damage can
be irreversible. Complications include perforated bowel
diaphragm, urinary bladder, permanent disfigurement, fecal
peritonitis cases, etc. (Fig. 25).

119
Continued regular use of cleaning and sterilization can
cause the layer of insulation covering the shaft of the active
electrode to break down. Tiny, visually undetectable tears are
actually more dangerous than large cracks, since the current
escaping from these miniscule breaks is more concentrated
and therefore capable of causing sparks (averaging 700°C).
These sparks can cause severe burns and even ignite fires,
especially in oxygenrich environments. In fact, all insulated
electrodes should be considered suspicious, unless adequate
safety measures are introduced.
Unfortunately, many surgeons unknowingly contribute
totheproblem.Routineuseofthehighvoltage“coagulation”
current may actually compromise insulation integrity. The
higher the voltage, the greater the risk that the current will
break through weak insulation.
Surgeon should always use the lowest voltage. All
electrosurgery systems will allow to use a “coagulation” or
“cutting” waveform of current.
In most cases, we should try to use the cutting current
for both cutting and coagulation. The coagulation mode is
necessary only when you need to fulgurate or stop diffuse
bleeding on highly vascularized tissue. Using the lowest
voltage, it may reduce the wear on the insulation and
minimize the chance that the current can escape through
hairline cracks.
The surgeon should test for insulation defects in the
operating room, after the set has been opened. This step can
significantly reduce the number of accidental electrosurgical
burns because it will prevent a surgeon from inserting a
potentially lethal instrument into the patient’s abdomen.
Insulation that degraded during that final sterilization cycle
cannot be detected until this point in time, so it is critical that
inspection in the operating room itself be made an integral
part of hospital protocol. It is advisable to keep a supply of
singleuse electrodes available to replace any found to be
faulty during the preoperative scan. One can also devise
a vigorous and ongoing inspection plan with a qualified
technician to ensure that all reusable electrosurgical tools
are scanned and reinsulated as needed.
If the instruments are rescanned in the operating
room following surgery, the surgeon can be secure in the
knowledge that no stray electrical current escaped into
adjacent, but unseen sites and so if any postoperative
clinical complications were to arise, he or she could more
easily isolate the cause. Conversely, if the postoperative scan
revealed that insulation was damaged during the procedure,
he or she may elect to take aggressive steps to investigate
further. For documentation purposes, the results of both
scans can be recorded in the patient record.
We should always keep in mind that using the cutting
current minimizes, but does not eliminate the risk of
insulation failure. To really be sure that the insulation is not
compromised, it is recommended to use an electrosurgical
unit that employs active electrode monitoring (AEM)
technology. This technology is called “ElectroShield”
(Electroscope, Inc., Boulder, Colorado) and it virtually
eliminates these types of electrical burns.
The traditional system for inspection in the sterile
processingdepartmentishardlyfoolproofanditsweaknesses
must be addressed. Because the margin for error is so
great, risk managers and physicians alike are insisting on
alternativesthatwillensurepatientsafetyandreduceliability
exposure. AEM protects against thermal burns in two ways.
First, it encases the insulated electrode in a protective metal
shield that is connected to the generator; the entire probe
is also covered with an extra layer of insulation. The extra
conductive and insulating layers ensure that stray current
is contained and flows right back to the generator. Second,
the system monitors the electrical circuit so if stray energy
reaches dangerous levels, the unit shuts off automatically
and sounds an alarm before a burn can occur. Electroscope’s
AEM system operates on a principle similar to ground fault
interrupter (GFI) outlets in our home. It protects against
insulation breaks by grounding electricity in unpredictable
elements, eliminating stray burns to the patient. This is
presently considered the standard of care in endoscopic
electrosurgery.
Surgical Smoke
Dissection with electrocautery produces a great deal of
smoke.Carbonmonoxideatlevelsashighas1,900ppm,many
times higher than the Environmental Protection Agency
Standard of 35 ppm for a 1hour exposure, are produced by
electrocautery in the hypoxic environment of the carbon
dioxidefilled abdomen. Fortunately, carbon monoxide is a
very insoluble molecule and does not cross the peritoneum.
Carbon monoxide absorption is therefore not a problem for
patients undergoing laparoscopy. However, contamination
by carbon monoxide and other toxic or infectious byproducts
of electrocautery may affect the operating room personnel if
the smoke is vented into the room.
When an electrosurgical probe heats tissue and vaporizes
cellular fluid, one byproduct is surgical smoke. We know that
these fumes, which can contain viral deoxyribonucleic acid
(DNA), bacteria, carcinogens, and irritants, are malodorous
and can cause upper respiratory irritation. We do not yet
knowwhethertheyarecapableofcausingcancerorspreading
infectious disease. Surgical smoke can also obscure the
operative site and causes the surgeon to inadvertently touch
the electrode to nontargeted tissue.
Surgical masks do not adequately filter surgical smoke,
the particles are too small. A much better solution is a
smoke evacuation system, a highflow suction, and filtering
device that remove the particles from the air. Two kinds are
available commercially. One uses a handheld nozzle, which
is intended to be positioned at the surgical site.

Fig. 26: Argon electrosurgery.
To avoid complication of laparoscopic electrosurgery,
following important points are:

■ Inspect insulation carefully

■ Use lowest possible power setting

■ Use a low voltage waveform (cut)

■ Use brief intermittent activation versus prolonged
activation

■ Do not activate in open circuit

■ Do not activate in close proximity or direct contact with
another instrument

■ Use bipolar electrosurgery when appropriate

■ Select an all metal cannula system as the safest choice.
Do not use hybrid cannula systems that mix metal with
plastic

■ Utilize available technology, such as a tissue response
generator to reduce capacitive coupling or an active
electrode monitoring system, to eliminate concerns
about insulation failure and capacitive coupling.
Argon Beamer Coagulator
The argon beamer is used in conjunction with monopolar
electrosurgery to produce fulguration or superficial
coagulation (Fig. 26). Less smoke is produced because there
is lesser depth of tissue damage. The system emits a high
energy jet of argon plasma possessing thermal and kinetic
energythatcanbeusedtocoagulateatissuesurfaceincluding
small vessels and lymphatics. Since its introduction, plasma
jet has been used safely in both open and endoscopic cases
in orthopedics, oncology, gastroenterology, liver surgery,
plastic surgery of the abdomen and face, and in thoracic
surgery.
Neutral argon plasma can be utilized as a multi
functional device that has vaporization, coagulation, and
superficial cutting capacities with minimal thermal spread
and acceptable outcomes. The use of neutral argon plasma
appears to be efficacious and safe for laparoscopic surgery
suchasendometriosis,presacralneurectomy,liverresection,
myoma bed bleeding control, etc.
Despite these advantages, the argon beamer suffers from
a very significant drawback in laparoscopic surgery, namely
increasedintraabdominalpressuretopotentiallydangerous
levels due to highflow infusion of argon gas.
Ultrasonic Dissection
Ultrasonic dissectors are of two types: (1) lowpower systems
which cleave water containing tissues by cavitations leaving
organized structures with low water content intact, e.g.,
blood vessels, bile ducts, etc., and (2) highpower systems
which cleave loose areolar tissues by frictional heating and
thus cut and coagulate the edges at the same time. Thus, low
powersystemsareusedforliversurgery(CUSA,Selector)and
do not coagulate vessels. Highpower systems (Autosonix,
Ultracision) are used extensively especially in fundoplication
and laparoscopic colon surgery. It is important to remember
that highpower ultrasonic dissection systems may cause
collateral damage by excessive heating and this is well
documented in clinical practice.
Ultrasonic surgical dissection allows coagulation and
cutting with less instrument traffic (reduction in operating
time), less smoke, and no electrical current.

■ Mechanical energy at 55,500 vibrations/s

■ Disrupts hydrogen bonds and forms a coagulum

■ Temperature by harmonic scalpel (80–100°C)

■ Temperature through electrocoagulation (200–300°C)

■ Less collateral damage, less tissue necrosis.
The ultrasonic shears (harmonic scalpel) is ideal for
dividing and simultaneously sealing small and medium
vessels by tamponade and heat. However, larger vessels,
>2 mm in diameter, need additional measures (clips, tie,
or staple) to control bleeding. Other disadvantages of the
harmonic scalpel include lack of tissue selectivity and
relatively expensive. Ultrasonic dissecting applicators are
also designed in hook, spatula, or ball coagulator shapes
(Figs. 27A and B).
The cavitational ultrasonic aspirator has the advantage of
removing debris and is tissue selective, e.g., divides liver but
spares bile ducts and vessels. It affords safe rapid dissection
with reduction in tissue damage and blood loss compared
to the harmonic scalpel. The problems associated with its
use are evacuation of the pneumoperitoneum together
with vibration and irrigation which cloud the telescope lens
necessitating frequent cleaning (Fig. 28A).
It is not correct that ultrasonic generators are without any
risk. If bowel or blood vessels touch directly to the vibrating
jaw, it can be punctured.
High-velocity Water-jet Dissection
Highvelocity highpressure waterjet dissection involves the
use of relatively simple devices to produce clean cutting of

121
Figs. 27A and B: Ultrasonic generator.
A B
reproducible depth. Other advantages are the cleansing of
the operating field by the turbulent flow zone and the small
amount of water required to complete dissection.
Specific problems were identified with the use of this
modality. The “hailstorm” effect results in excessive misting
which obscures vision. This has been solved to some extent
by incorporating a hood over the nozzle. The nonhemostatic
nature of this modality, difficulty in gauging distance, and
poor control of the depth of the cut are additional drawbacks.
The spraying of tissue fragments renders it also oncologically
unsound. The present use of waterjet dissection is limited to
dissection of solid organs.
Hydrodissection
Hydrodissection uses the force of pulsatile irrigation
with crystalloid solutions to separate tissue planes
(Fig. 28B). The operating field at the same time is kept
clear. Like waterjet dissection, no hemostasis is achievable.
The use of this dissecting modality is restricted to pelvic
lymphadenectomy and pleurectomy in thoracoscopic
surgery. Today, the hydrodissection technique is frequently
used with success in cataract, urologic, and plastic surgery.
Hydrodissection is also used in laparoscopic surgery as an
adjunct to electrocauterization to facilitate the dissection of
fascial planes. The mechanical benefits of hydrodissection
infiltrates the serosal layers with saline, it both creates and
reveals the correct plane between adherent tissues and
subsequently makes separation easier.
Hydrodissection is a safe technique that can be applied
as an adjunct to electrocauterization, which facilitates
dissection in the correct plane during many laparoscopic
surgeries such as cholecystectomy, hernia, colectomy, and
endometriosis surgery. Although hydrodissection does
not have additional benefits in terms of dissection time,
postoperative outcome, or overall survival, it can be useful
for inexperienced surgeons, especially for those in the
learning phase. HydroSurg™ Plus Irrigator is designed to
provide controlled powered irrigation to, and aspiration of
fluids/smoke from, the operative site during laparoscopic
surgical procedures (e.g., laparoscopic cholecystectomy
and laparoscopic gynecological procedures). It may also
be used for resection of filmy adhesions by hydrodissection
and peritoneal lavage. Appropriate fluids include those
which have a specific gravity of approximately 1 (e.g.,
saline). Additional specialty probe tips are available from
Davol including insulated and nonconductive tips for use
with electrosurgery. Suction/irrigation probe tips, when
included, have a nonreflective surface to help avoid laser
beam reflection. With proper adapter, a laser fiber and laser
fiber sheath can be passed through the probe handle and tip.
Laser Dissection
The laser devices release photons which induce molecular
vibration and create heat when they interact with the
tissue and create heat. LASER is an acronym for “light
amplification by stimulated emission of radiation”
(Fig. 28C). Each lasing substance has a unique atomic and
molecular structure and so the waveform and frequency.
Laser light is monochromatic and cannot be separated
into colors when passed through prism. The amount of
power delivered by laser is measured in Watts. The basic
components in a laser unit are a pumping system, lasing
medium, optical cavity, and operating system. The operating
system controls delivery of laser into tissue when activated
by surgeon. The surgeon controls power control knob. There
are many modes of power delivery such as continuous,
pulse, superpulse, and ultrapulse modes.
Theprimarydifferencefromothersourceofenergyisthat
generallytissueisnotdirectlytouchedbysurgicalinstrument.
Thus, the depth of incision is not controlled by pressure
exerted on the tissue but by the power density delivered by
surgeon. The unique property of laser is determined by its
wavelength and tissue absorption. By changing the power
setting, desired tissue effect such as ablation, fulguration,

coagulation, or vaporization can be achieved. These days
laser is not used frequently in general laparoscopic surgery
as they offer no advantages over more user friendly and safer
forms of energized dissection and coagulation systems.
The previous generation of lasers (with gas vapor
chambers) was large, very expensive, and required special
power supply (threephase electricity) and maintenance.
In addition, they lacked portability. The current generation
of solidstate lasers diode array has overcome all these
disadvantages and may well be used for certain applications
of laparoscopic general surgery in the future. Currently,
laser ablation is used largely in gynecological laparoscopic
surgery, e.g., ablation of endometriosis and much less
commonly for the photoablation of secondary tumors of the
liver. The most effective use of carbon dioxide (CO2) laser
beam is laser knife that gives high precision for dissection
over sensitive areas such as bladder, ureter, and major blood
vessels.
The degree and extent of thermal damage produced by
laser depends on the structure, water content, pigmentation,
optical and thermal properties, and perfusion of the tissue.
The properties of a particular laser beam are also other
determinants of heat damage. Therefore, each of the various
types of laser available have a specific clinical application.
In gynecology, the argon laser coagulator is the ideal
method of treating small red endometriotic deposits. Tissue
absorption of light is low and hemoglobin absorption is
high at its operating wavelengths of 488 nm and 514 nm, i.e.,
selective absorption.
The CO2 laser is best suited for extremely superficial
ablation. It is relatively inexpensive (compared to other
lasers) and has the ability to vaporize a very thin surface
of tissue. On the other hand, photocoagulation of vascular
lesions is ineffective using CO2 laser. This type of laser also
has the potential for injuring structures in the abdomen
distant from the site under laparoscopic view.
The contact neodymiumdoped yttrium aluminum
garnet (Nd:YAG) laser virtually eliminates the free beam
effect and is therefore suitable for laparoscopic application.
The thermal injury from contact laser is superficial. No
additional protection is needed for the endocamera since
they are already fitted with infrared filters. However, Nd:YAG
laser dissection was found to be significantly slower and
produced more blood loss than monopolar electrosurgery in
laparoscopic cholecystectomy.
Figs. 28A to D: (A) Harmonic scalpel; (B) Hydro-Surg™ Plus Irrigator; (C) Laser generator; (D) Cryotherapy device.
A B
C D

123
All lasers including potassiumtitanylphosphate (KTP)
and the more recently developed solid state have several
majordrawbacksincommon.Theyareexpensive,inefficient,
produce toxic smoke, nontunable, require specialized
theater, and achieve variable penetration. Safety issues such
as heat cumulative effect, burns due to accidental exposure,
and retinal damage also contribute toward preventing
widespread use of laser.
It is now obvious that from the range of available
dissecting modalities in laparoscopic surgery, none has
proven to be ideal. Utility of a particular modality is dictated
by how close it meets the requirements to achieve safe,
effective, and hemostatic tissue division under the specific
circumstances. The surgeon must be able to use the
appropriate combination of modalities in order to exploit
the benefit each has to offer during dissection.
When properly used, laser, microelectrode, ultrasonic
dissector, tissue response generator, and mechanical
instruments are equally effective in any surgery.
The choice of instrument should be on the instrument with
surgeon that is more comfortable and he has the skill and
experience for that particular instrument.
Cryotherapy and Radiofrequency Ablation
Both are used in the laparoscopic ablation of secondary
tumor deposits in the liver, usually when the lesions are
inoperable for whatever reason, laparoscopic cryotherapy
with implantable probe destroys tumors by rapid freezing to
–40°C or lower.
The lesion revascularizes for a short period (12–
14 hours) on thawing but because the vasculature and the
tumor parenchyma are damaged beyond repair, hemor
rhagic infraction ensues. With radiofrequency thermal abla
tion, a radiofrequency current is transmitted through the
probe implanted in the tumor. The radiofrequency current
causes molecular and ionic agitation which heats the tissues
(much like the microwave) and hence the tumor is heated to
destruction. Both modalities are operated with laparoscopic
contact ultrasonographic scanning.
Cryotherapy device is also used to ablate the endometrial
lining of a woman’s uterus and reduce heavy menstrual
bleeding (Fig. 28D). The cryotherapy device has a slim
probe that inserts through the cervix and then into
the uterus. Once inserted, a freezing agent is released and
the endometrial lining of the uterus is destroyed. The device
is intended to be used in premenopausal women with heavy
menstrual bleeding due to benign (noncancerous) causes
who do not want to become pregnant in the future. Use of
cryotherapy destroys the endometrial lining of the uterus
to reduce menstrual bleeding. In the pivotal clinical study,
76% of women observed a reduction in menstrual blood loss
from an excessive level to normal or less than normal levels.
Tissue Response Electrosurgical Generator
The tissue response generator has unique vessel sealing
ability. These vessel sealing produces significantly reduced
thermal spread compared to existing bipolar instruments.
These generators precisely confine its effects to the target
tissue or vessel with virtually no charring and with minimal
thermal spread to adjacent tissue (Figs. 29 and 30). These
generator uses seal mechanism by sensing body’s collagen to
actually change the nature of the vessel walls by obliterating
the lumen. The collagen and elastin within the tissue melt
and reform to create the seal zone. These electrosurgical
generator works by fusing the collagen in vessel walls to
create a permanent seal. The jaw of electrosurgical forceps
using this technology leaves no foreign material behind to
potentially interfere with future diagnosis. The system uses
the body’s own collagen to reform the tissue, creating a
permanent seal which resists dislodgment.
Tissue response generator has following advantages:

■ It can be used with confidence on vessels up to 7 mm

■ It seals all the tissue bundles without dissection and
isolation
Figs. 29A and B: Tissue response generator (LigaSure™).
A B

Fig. 30: LigaSure™.
Figs. 31A and B: Cavitron Ultrasonic Surgical Aspirator (CUSA).
A
B

■ Reduced sticking and charring

■ Minimized need for multiple applications

■ No dislodged clips

■ No foreign material is left behind.
In 1916, the physicist Lord Rayleigh discovered the effect
of cavitation while investigating damage to a ship’s propeller.
He concluded that the collapse of the bubbles created a
small jet stream of water, which was responsible for the
structural damage. Using a similar principle, high speed
mechanical waves can be used in nonelastic media, such
as water, to create a cavitation effect. If this phenomenon
is applied to waterrich tissues, such as liver, the final effect
is the destruction of all the cells, preserving structures
rich in collagen (low in water), such as blood vessels,
nerves. The Cavitron Ultrasonic Surgical Aspirator (CUSA)
device generates ultrasonic waves in the range of 23 kHz to
produce tissue cavitation(Figs.31AandB). This mechanical
energy is delivered through a hollow 3 mm tip that vibrates

■ It causes minimal thermal spread

■ It has good effect to the target tissue

■ The unique energy output results in virtually no sticking

125
at 23,000 cycles per second. The entire device is embedded
with an irrigator and aspirator in order to dispose off the
tissue debris.
BIBLIOGRAPHY
1. Bagdasarian RW, Bolton JS, Bowen JC, Fuhrman GM,
Richardson WS. Steep learning curve of laparoscopic splene
ctomy. J Laparoendosc Adv Surg Tech A. 2000;10:31923.
2. Basdanis G, Papadopoulos VN, Michalopoulos A, Apostolidis
S, Harlaftis N. Randomized clinical trial of stapled hemorrhoi
dectomy vs. open with LigaSure for prolapsed piles. Surg Endosc.
2005;19:2359.
3. Berman RS, Yahanda AM, Mansfield PF, Hemmila MR, Sweeney
JF, Porter GA, et al. Laparoscopic splenectomy in patients with
hematologic malignancies. Am J Surg. 1999;178:5306.
4. Brunt LM, Langer JC, Quasebarth MA. Comparative analysis
of laparoscopic versus open splenectomy. Am J Surg. 1996;172:
596601.
5. Carbonell AM, Joels CS, Kercher KW, Matthews BD, Sing RF,
Heniford BT. A comparison of laparoscopic bipolar vessel sealing
devices in the hemostasis of small, medium, and largesized
arteries. J Laparoendosc Adv Surg Tech A. 2003;13:37780.
6. Crawford ED, Kennedy JS, Sieve V. Use of the Ligasure Vessel
Sealing System in urologic cancer surgery. Grand Round Urol.
1999;1:107.
7. Delaitre B, Champault G, Barrat C, Gossot D, Bresler L, Meyer C,
et al. Laparoscopic splenectomy for hematologic disease. Study
of 275 cases. French Society of Laparoscopic Surgery. Ann Chir.
2000;125:5229.
8. Dexter SPL, Martin IG, Alao D, Norfolk DR, McMahon MJ.
Laparoscopic splenectomy: the suspended pedicle technique.
Surg Endosc. 1996;10:3936.
9. Diaz J, Eisenstat M, Chung R. A casecontrolled study of
laparoscopic splenectomy. Am J Surg. 1997;173:14850.
10. Dubay DA, Franz MG. Acute wound healing: the biology of acute
wound failure. Surg Clin North Am. 2003;83:46381.
11. Franciosi C, Caprotti R, Romano F, Porta GC, Real G,
Colombo G, et al. Laparoscopic versus open splenectomy:
a comparative study. Surg Laparosc Endosc Percutan Tech.
2000;5:2915.
12. Glasgow RE, Yee LF, Mulvihill SJ. Laparoscopic splenectomy. The
emerging standard. Surg Endosc. 1997;11:10812.
13. Goldstein SL, Harold KL, Lentzner A, Matthews BD, Kercher
KW, Sing RF, et al. Comparison of thermal spread after ureteral
ligation with the Laparosonic ultrasonic shears and the LigaSure
system. J Laparoendosc Adv Surg Tech A. 2002;12:613.
14. Harrell AG, Kercher KW, Heniford BT. Energy sources in
laparoscopy. Semin Laparosc Surg. 2004;11:2019.
15. Heniford BT, Matthews BD, Sing RF, Backus C, Pratt B, Greene FL.
Initial results with an electrothermal bipolar vessel sealer. Surg
Endosc. 2001;15:799801.
16. Horgan PG. A novel technique for parenchymal division during
hepatectomy. Am J Surg. 2001;181:2367.
17. Howard TJ, Mimms S. Use of a new sealing device to simplify
jejunal resection during pancreaticoduodenectomy. Am J Surg.
2005;190:5046.
18. Katkhouda N, Hurwitz MB, Rivera RT, Chandra M, Waldrep DJ,
Gugheneim J, et al. Laparoscopic splenectomy: outcome and
efficacy in 103 consecutive patients. Ann Surg. 1998;228:56878.
19. Katkhouda N, Mavor E. Laparoscopic splenectomy. Surg Clin
North Am. 2000;80:128597.
20. Katkhouda N, Waldrep DJ, Feinstein D, Soliman H, Stain SC,
Ortega AE, et al. Unsolved issues in laparoscopic splenectomy.
Am J Surg. 1996;172:58590.
21. Kennedy JS, Buysse SP, Lowes KR, Ryan TP. Recent innovation
in bipolar electrosurgery. Minim Invasive Ther Allied Technol.
1999;8:959.
22. Kennedy JS, Shanahan PL, Buysse SP, Ryan TP, Pearce JA,
Thomsen S. Large vessel ligation using bipolar energy: a chronic
animal study and histologic evaluation. 7th International meeting
of the Society for Minimally Invasive Therapy; 1999.
23. Kennedy JS, Shanahan PL, Taylor KD, Chandler JG. Highburst
strength feedback controlled bipolar vessel sealing. Surg Endosc.
1998;12:8768.
24. Klingler PJ, Tsiotos GG, Glaser KS, Hinder RA. Laparoscopic
splenectomy: evolution and current status. Surg Laparosc
Endosc. 1999;9:18.
25. Lawes DA, Palazzo FF, Francis DL, Clifton MA. One year
followup of a randomized trial comparing LigaSure with open
haemorrhoidectomy. Colorectal Dis. 2004;6:2335.
26. Meijer DW, Gossot D, Jakimowicz JJ, De Wit LT, Bannemberg JJ,
Gouma DJ. Splenectomy revised: manually assisted splenectomy
with the dexterity device: a feasibility study in 22 patients.
J Laparoendosc Adv Surg Tech A. 1999;9:50710.
27. Meyer G, Wichmann MW, Rau HG, Hiller E, Schildberg FW.
Laparoscopic splenectomy for idiopathic thrombocytopenic
purpura. A 1year followup study. Surg Endosc. 1998;12:
134852.
28. Muller JM, Desambre R, Junghans T, Bohm B. Extended left
emicolectomy using Ligasure Vessel Sealing System. Munich:
116th Surgical Congress; 1999.
29. Park A, Birgisson G, Mastrangelo MJ, Marcaccio M, Witzke D.
Laparoscopic splenectomy: outcomes and lessons learned from
over 200 cases. Surgery. 2000;128:6607.
30. Park A, Marcaccio M, Sternbach M, Witzke D, Fitzgerald P.
Laparoscopic versus open splenectomy. Arch Surg. 1999;
134:12639.
31. Poulin EC, Mamazza J, Schlachta CM. Splenic artery embolization
before laparoscopic splenectomy. An update. Surg Endosc.
1998;2:8705.
32. Romano F, Franciosi C, Caprotti R, Uggeri F, Uggeri F. Hepatic
surgery using the LigaSure vessel sealing system. World J Surg.
2005;29:1102.
33. Santini M, Vicidomini G, Baldi A, Gallo G, Laperuta P, Busiello
L, et al. Use of an electrothermal bipolar tissue sealing system in
lung surgery. Eur J Cardiothorac Surg. 2006;29:22630.
34. Schulze S, Krisitiansen VB, Fischer HB, Rosenberg J. Sealing
of cystic duct with bipolar electrocoagulation. Surg Endosc.
2002;16:3424.
35. Shields CE, Schechter DA, Tezlaf P, Baily AL, Dycus S, Cosgriff
N. Method for creating ideal tissue fusion in softtissue
structures using radiofrequency energy (RF). Surg Technol Int.
2004;13:4955.
36. Shigemura N, Akashi A, Nakagiri T, Ohta M, Matsuda H.
A new tissue sealing technique using the LigaSure system for
nonanatomical pulmonary resection: preliminary results of
sutureless and stapleless thoracoscopic surgery. Ann Thorac
Surg. 2004;77:14158.
37. Shimomatsuya T, Horiuchi T. Laparoscopic splenectomy for
treatment of patients with idiopathic thrombocytopenic purpura.
Comparison with open splenectomy. Surg Endosc. 1999;13:
5636.
38. Steed DL. Woundhealing trajectories. Surg Clin North Am.
2003;83:54755.
39. Stumpf M, Klinge U, Wilms A, Zabrocki R, Rosch R, Junge K,
et al. Changes of the extracellular matrix as a risk factor for
anastomotic leakage after large bowel surgery. Surgery. 2005;
137:22934.

40. Takada M, Ichihara T, Kuroda Y. Comparative study of
electrothermal bipolar vessel sealer and ultrasonic coagulating
shears in laparoscopic colectomy. Surg Endosc. 2005;19:2268.
41. Targarona EM, Balague C, Marin J, Neto RB, Martinez C,
Garriga J, et al. Energy sources for laparoscopic colectomy:
a prospective randomized comparison of conventional
electrosurgery, bipolar computercontrolled electrosurgery and
ultrasonic dissection. Operative outcome and costs analysis.
Surg Innov. 2005;12:33944.
42. Targarona EM, Espert JJ, Balague C, Piulachs J, Artigas V,
Trias M. Splenomegaly should not be considered a contra
indication for laparoscopic splenectomy. Ann Surg. 1998;228:
359.
43. Trias M, Targarona EM, Espert JJ, Balague C. Laparoscopic
surgery for splenic disorders. Lessons learned from a series of 64
cases. Surg Endosc. 1998;12:6672.
44. Walsh RM, Heniford BT, Brody F, Ponsky J. The ascendance of
laparoscopic splenectomy. Am Surg. 2001;67:4853.
45. Watson DI, Coventry BJ, Chin T, Gill PG, Malycha P. Laparoscopic
versus open splenectomy for immune thrombocytopenic
purpura. Surgery. 1997;121:1822.
46. Witte MB, Barbul A. Repair of fullthickness bowel injury.
Crit Care Med. 2003;31:S53846.
47. Yang HR, Wang YC, Chung PK, Jeng LB, Chen RJ. Laparoscopic
appendectomy using the LigaSure vessel sealing system.
J Laparoendosc Adv Surg Tech A. 2005;15:35356.

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