With obesity rates on the rise across the U.S., the demand for bariatric surgery is greater than ever before. According to the American Society for Metabolic & Bariatric Surgery (ASMBS), an estimated 220,000 patients with morbid obesity underwent bariatric surgery in 2008, up from 12,775 in 1998.1,2
Surgeons are increasingly using laparoscopic versus open techniques to perform these procedures. In 2005, an estimated 74.5 percent of gastric bypass patients underwent laparoscopic gastric bypass (LGB) surgery versus open surgery. Researchers have found that patients who undergo LGB surgery have shorter hospital stays and experience fewer postoperative complications compared with patients who undergo open procedures.3
Bariatric surgeon Robert V. McKeen, MD, FACS, has specialized in laparoscopy throughout his 10 years of practice, performing thousands of laparoscopic procedures, including LGB surgeries. To meet the growing demand, he expanded his practice to include two facilities — Forest Surgery Center and Good Samaritan Hospital in San Jose, Calif. — where he performs both LGB surgery and the Lap-Band procedure.
McKeen had been using an electrosurgical device to cut, seal and dissect tissue and vessels during these procedures, but was concerned that the heat generated by the device would damage surrounding structures. This has become a growing concern among laparoscopic surgeons. During a survey on electrosurgical complications conducted by the American College of Surgeons, 18 percent of surgeons reported that they had inflicted an electrosurgical burn on a patient during a laparoscopic procedure.4
“We are dissecting near fragile tissue areas, such as the esophagus, so it’s crucial that we prevent any kind of inadvertent injury,” says McKeen. “The ideal device would allow us to dissect very close to the tissue surface without causing thermal damage.”
Another issue is precision. Because conventional devices require electrical or ultrasonic energy to pass through the tissue, it can be challenging for the surgeon to control and direct the heat generated by the devices. This can pose a significant problem in laparoscopy, where surgeons are required to perform high-precision procedures in tight spaces with limited visibility of the surgical fields.
“During these procedures we must dissect both large and small vessels, but the seal and cut devices that I had tried in the past did not have the precision required for fine vessel work. As a result, there can be enough bleeding to obscure the surgical field,” says McKeen.
Furthermore, conventional devices can be challenging to learn, time-consuming to set up and cumbersome to use. Some feature multiple components including large generators, power cords, foot pedals/switches and hand-pieces. In an ambulatory care setting, where efficiency is a top priority, these factors pose a significant challenge for both surgeons and OR staff.
“I don’t like having a lot of clutter in the OR and some of these devices have various parts and pieces that have to be assembled and programmed prior to use,” says McKeen. “They take up a lot of space and create more work for everyone.”
In early 2008, McKeen sought out a new technology for tissue and vessel sealing and cutting that would enhance patient safety, provide greater precision during complex LGB procedures and maximize efficiency.
He found a solution when he began using tissue welding technology. Unlike conventional electrosurgical devices, tissue welding uses only direct heat and pressure to seal and divide soft tissue and vessels. Because no electrical or ultrasonic energy is required to pass through the patient, devices that employ tissue welding technology heat only the tissue and vessels that come in contact with them. This provides the surgeon with greater control and precision and improves patient safety by minimizing collateral damage.
“Tissue welding has a clear patient safety benefit,” says McKeen. “I can perform a clean dissection without a lot of heat transfer up around the esophageal gastric junction and along the stomach area, where there are both fine and larger blood vessels. This minimizes bleeding in the surgical field, allowing me to dissect very close to the tissue surface.”
McKeen found that by using tissue welding in place of his previous electrosurgical device, he could improve the precision of the most advanced bariatric procedures.
“It can be quite challenging to perform a clean dissection of the esophageal gastric fat pad for a Lap-Band procedure, but tissue welding does the trick because of its precision,” said McKeen. “I can perform fine dissections in very fragile areas of tissue. As a result, I’m more comfortable and confident in the procedure itself.”
Because of their simple, straightforward approach, devices that employ tissue welding technology are easy to set up, operate and store, saving valuable operating room and procedure time. The system that McKeen and his team use consists of a disposable shears and a compact power supply. They simply plug the shears into the generator and the device is ready for use.
“Tissue welding is easy to use, so the learning curve was minimal,” says McKeen. “My OR staff loves it because it’s simple to set up and there’s not a lot of clutter. It has saved all of us a great deal of time and effort.”
References
1. ASMBS Fact Sheet: Metabolic & Bariatric Surgery, http://www.asmbs.org/Newsite07/media/fact-sheet1_bariatric-surgery.pdf.
2. Nguyen NT., et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg.; 140,12:1198-202; discussion 1203, Dec. 2005.
3. Weller WE., Rosati C. Comparing outcomes of laparoscopic versus open bariatric surgery. Ann Surg; 248, 1:10-5, Jul. 2008.
4. Tucker, RD. Laparoscopic electrosurgical injuries: survey results and their implications. Surg Laparosc Endosc.; 5, 4:311-7, Aug. 1995.