Abstract
Clinical usefulness of using LigaSure™ vessel-sealing devices and the Valleylab™ electrode knife (Covidien, USA) for head and neck cancer
surgery was reported. These instruments were applied to the hemiglossectomy with bilateral neck dissection and immediate reconstruction with
a pectoralis major myocutaneous flap for a 64-year-old woman with squamous cell carcinoma of the right tongue (stage T4aN2bM0). In this case,
LigaSureImpact™ vessel-sealing device was remarkably useful for a short time harvesting PMMC flap with a small amount of intraoperative
blood loss. LigaSureImpact™ vessel-sealing bipolars is useful device in the field of reconstructive surgery in the case of harvesting bulky flap.
Keywords
LigaSureImpact™ vessel-sealing bipolars; Myocutaneous flap; Reconstructive surgery; Head and neck cancer
Introduction
LigaSure™ vessel-sealing system (LigaSure™ VSS) (Covidien, USA) is
a bipolar electrosurgical device that provides hemostasis by denaturing
collagen and elastin from the vessel wall and surrounding connective
tissue. The system evaluates the impedance of the tissue 3,333 times
a second and delivers the appropriate amount of energy needed to seal
the tissue [1-7]. There are two useful vessel-sealing devices for head and
neck surgery and reconstructive surgery, one is the LigaSure Small jaw™
(Small jaw™) [1-4] and the other is the LigaSureImpact™ (Impact™) [5-7].
Small jaw™ is utilized for sealing and cutting up to 14.7 mm thickness
of the connective tissue or muscle, and Impact™ is utilized for sealing
and cutting up to 34.0 mm thickness. However, the limitation of
vessel sealing by Small jaw™ and Impact™ is determined up to 7 mm
in diameter by the US Food and Drag Administration (Figure 1). In
the field of head and neck surgery, Small jaw™ has been shown to be
safe and effective for thyroid surgery and parotiod gland surgery [1-4]
without needing to seal bulky tissue. On the other hand, Impact™ is
an especially useful device for bulky tissue to reduce blood loss and
operating time in general surgery, such as hepatectomy, splenectomy,
and pancreatoduodenectomy [5-7]. Furthermore, the Valleylab™
electrode knife (Valleylab™) with Valleylab™ mode (V mode) is a
newly developed device and can provide a monopolar wave form for
controlled dissection. Three output modes are selected at the handset
with the following buttons: The yellow button enables a cutting function.
The clear Valleylab button enables a hemostasis function while providing
dissection. The blue button enables a coagulation function. A dual slider
control switch adjusts power output (Figure 2) [8].
In this report our clinical experience of an immediate reconstructive
surgery with a PMMC flap by usingImpact™ and Valleylab™ with V mode.
Technical Case Report
A 64-year-old woman was referred to our clinic with chief complaint
of a painful mass in the right side of the tongue in January 2015. She had
felt pain on swallowing foods for 1 month. Clinical examinations,
including CE-CT scan, CE-MRI, Ultrasonography, PET-CT scan and
biopsy, demonstrated squamous cell carcinoma of the right tongue
with expansion to the mouth floor (stage,T4aN2bM0). Also, she was
diagnosed as a hypertension with moderate arteriosclerosis with high
plaque score of carotid artery.
Figure 1: The upper device: Impact™: tissue sealing and cutting
length=34.0 mm.
The lower device: Small jaw™: tissue sealing and cutting length=14.7
mm. For length of vessel sealing, use of Small jaw™ and Impact™ is
limited to seal vessel up to 7 mm in diameter by the US Food and Drag
Administration.
Early in February, hemiglossectomy with right-side total neck
dissection and left-side supraomohyoid neck dissection was performed.
The tissue defect due to tumor ablation was immediately reconstructed
by using a pectoralis major myocutaneous (PMMC) flap due to reduce
operating time for prevention of a thrombosis.
Figure 2: Three output modes are selected at the handset with the
following buttons:
- The yellow button enables a cutting function.
- The clear Valleylab button enables a hemostasis function while
providing dissection.
- The blue button enables a coagulation function.
A dual slider control switch adjusts power output.
At the beginning of surgery, tracheotomy was performed to prevent
postoperative asphyxia, and the skin incision was made by using
Valleylab™ selected V mode combined cutting and coagulation without
a scalpel (Figure 2). Small jaw TM was used for sealing and cutting small
vessels and tissue. The first step to use Small jaw™ is to place the tissue
between the jaws. The adequate radiofrequency energy to seal the tissue
is delivered by grasping the handle in 2-4 seconds. After sealing, pulling
up the cutting lever completes cutting the sealed tissue. However, to
make surely sealing of external jugular vein and facial artery and vein,
conventional ligation with silk thread was applied.
Hemiglossectomy was performed by using Valleylab™ selected V mode.
Deep lingual artery and vein were ligated by silk threads. Operating time
of hemi-glossectomy and neck dissection with pull-through method was
148 minutes, and blood loss was significantly reduced to 106 g.
Then, a short time reconstructive surgery with a PMMC flap was
started. The flap design was a semicircle of 11 × 7 cm including the nipple
at the level of the 6th rib. The flap elevation was started by using Valleylab™
with V mode for skin incision without a scalpel from the right clavicle part
to proximal direction without blood loss (Figure 3). When harvesting a
PMMC flap, Impact™ was used for short time sealing and cutting of its
bulky muscle.
How to use of Impact™ is almost same as Small jaw™. The first step is
to place the tissue between the jaws. The second step is to click the purple
activation button until sealing the tissue completely. Finally, pulling up
the cutting lever completes cutting the sealed tissue (Figure 4). The time
required harvesting a PMMC flap was only 15 minutes caused by Impact™
big jaws, and blood loss was extremely small amount of 4 g. The flap was
inserted to suture with residual oral tissue. Finally, total operating time
was 332 minutes, and intraoperative blood loss was 110 g.
Postoperativelocal and systemic complications were not observed. Four
days after surgery, all drainage tubes were removed.
Figure 3: Bloodless incision by a superfine needle blade selected the
middle V button, V mode of Valleylab™
Figure 4: Bloodless harvesting a PMMC flap with sealing and cutting
muscle using Impact™
Discussion
LigaSure™ VSS consists of a bipolar radiofrequency generator
and forceps which has been used to achieve hemostasis in various
types of surgery. The system applies a precise pressure and energy for
transformation of the collagen and elastin within vessel walls and creating
or making a permanent sealing [1-7]. In thyroid surgery, Small jaw™
significantly reduces the operating time without increasing intra-operative
blood loss, morbidity and/or duration of hospitalization [1-4]. Although
the intraoperative total blood loss in the thyroidectomy using Small jaw™
was significantly lowers than that in it without Small jaw™, postoperative
blood loss was not different [4].
In hepatectomy, splenectomy and pancreatoduodenectomy, Impact™ is
also used to reduce blood loss and operating time [5-7]. The damage in
cell or tissue on the dissection margins of pancreatoduodenectomy using
Impact™ was not observed in the microscopic observation [8].
Furthermore, Valleylab™ with V mode indicated less lateral thermal
spread compared with conventional electrosurgical generator (Force
FXTM, Boulder, CO). This was demonstrated by histological findings
in the animal study using porcine skin, small bowel, and small bowel
mesentery [9]. In head and neck cancer surgery, Valleylab™ with V mode
was used as a monopolar waveform to control dissection with hemostasis
and reduction of the tissue damage [10].
In this clinical experience, we use Valleylab™ with V mode, Small jaw™,
and Impact™ for hemiglossectomy with neck dissection and an immediate
reconstruction with a PMMC flap.
Valleylab™ with V mode monopolar could control cutting and
coagulation which induced to easy skin incision and tissue dissection
with less bleeding and tissue drag. Also, Small jaw™ bipolar was useful
sealing vessel up to 7 mm in diameter and sealing and cutting up to 14.7
mm thickness of the connective tissue or muscle in the neck dissection
and hemiglossectomy with less blood loss. On the other hand, Impact™
bipolar which has approximately 2.3 times sealing length for connective
tissue and muscle comparing to that of the Small jaw™, however, there
were no clinical reports for reconstruction with myocutaneous flap using
Impact™. In this technical case report, Impact™ was indicated one of the
suitable devices for harvesting the bulky flap in short time.
In conclusion, the present surgical devices, LigaSureImpact™ bipolar
and Valleylab™ with V mode monopolar, are remarkably useful devices
with an addition of the well-known LigaSure Small jaw™ in the field of
head and neck surgery.
Funding
None.
Competing Interests
None.
Ethical Approval
Not required.
Patient Consent
Not required.
Article Information
Aritcle Type: Case Report
Citation: Kawaguchi K, Eguchi T, Horie A,
Kumagai K, Hasebe M, et al. (2016) An Immediate
Reconstructive Surgery with a Pectoralis Major
Myocutaneous Flap using the LigaSureImpact™
Vessel-sealing Device- A Technical Case Report.
Int J Dent Oral Health 2(1): doi http://dx.doi.
org/10.16966/2378-7090.158
Copyright: © 2015 Kawaguchi K, et al. This is an
open-access article distributed under the terms
of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Publication history:
Received date: 13 Nov 2015
Accepted date: 7 Dec
2015
Published date: 14 Dec 2015