Ultrasonic energy systems and advanced bipolar devices for dissecting, sealing and coagulating tissue and blood vessels offer enhanced safety, less tissue trauma and bleeding, and the potential for greater physician satisfaction — all of which can add up to improved efficiency for your facility. Let's look at the capabilities, costs and potential benefits of the newest generation of devices.

Ultrasonic offerings
Ultrasonic energy differs from monopolar, bipolar and advanced bipolar systems in the mechanism by which it works. Electrical current doesn't flow through or to the patient — it stays within the instrumentation itself — so you don't need to use dispersive electrodes. Instead, cutting, cavitation and coagulation happen when a ceramic blade vibrates incredibly quickly — about 55,500 times a second. Because electricity generates these vibrations, heat, dissection and coagulation occur at lower temperatures than with electrosurgery. That means heat distribution is better controlled — minimizing the risk of excessive tissue damage (beyond the inherent damage of dissection), letting you use it more safely near vital organ structures — and tissue plume is reduced.

The newest ultrasonic systems are available in a versatile range of instrument styles that include 5mm blades in hook, straight and curved versions, as well as grasper and dissector designs that physicians commonly use. Surgeons can therefore work around a variety of anatomical structures and angles without fear of causing damage to the surrounding tissue. A wider range of handle designs is also available, so surgeons can use what's most comfortable for them (in addition to the right length for the procedure at hand).

The size of the working jaws can coagulate and seal vessels up to 5mm (an improvement over old systems). Additionally, depth of penetration is very precise and can simultaneously cut and coagulate with minimal spread of energy, resulting in less lateral tissue damage.

Software modules allow a range of settings that can be activated intraoperatively, meaning a high-power setting can be used when dense tissue is encountered, then returned to a lower-power setting to control hemostasis — without compromising continual cutting. And the sensitive software will cause blade failure or a system error if the surgeon overdoes it on the pressure.

COST CONSCIOUS
How Much To Upgrade?

WASTE NOT Disposables can significantly add to laparoscopic surgery's per-case costs.

The new ultrasonic and advanced bipolar systems let surgeons grasp, articulate, cut and seal safely, and all in 1 step. The combination of safety and efficiency was a benefit we thought was more than worth the price when we upgraded the technology at my facility.

Generator units alone for ultrasound and advanced bipolar systems run $20,000 to $30,000, which is about what you'd expect for the improvements offered by the overhauled software modules inside. The cost you'll really need to ponder has to do with the disposable instruments that do the cutting, sealing and coagulating. This figure can range from $300 to $1,000 per case, depending on the instrument and manufacturer.

And this is where you have to stack your business hat on top of your scrub cap. Consider the patient safety advantages along with your contracts and reimbursements for various minimally invasive abdominal surgeries. Determine just how many procedures across all specialties you could use this instrumentation for — and get all the surgeons who would use it to agree on the technology you're going to choose — so you can hopefully snag a deeper volume discount on disposables pricing.

A word of caution: Clear some extra shelf space in your supply storage area, because all those disposables are going to need a place to stay. The wide variety of handles, tips and jaws are a real boon to patient safety, procedure efficiency and physician ergonomics, but they'll need to be allotted individual placement, as you don't want staff to pick the wrong item for a case. Not only will OR staff have to learn how to assemble, attach and operate the new instruments, they'll have to know definitively which one's which — given the expense, you certainly don't want anyone to pull and open the wrong item.

— Vangie Dennis, BSN, RN, CNOR, CMLSO

Bipolar advancements
Traditional bipolar electrosurgery systems offered upgraded safety over monopolar systems — but surgeons still had little in the way of control over energy flow, which could lead to excessive thermal tissue injury. And coagulation wasn't optimal. Advanced bipolar systems might offer some improvements over the old standbys.

Surgeons can cut and seal at the same time, durably and more accurately, and vessel lumens can be sealed so that they can withstand burst pressures up to 750mmHg. Instrument jaws have a smaller depth of bite (under 1mm) and may come with fine, blunt tips, but vessel-sealing capacity is greater. That means lumens up to 7mm can be sealed with decreased trauma to tissue while retaining better grip ability.

LOOKING OUT Different handle sizes, lengths and designs relieve ergonomic stresses and improve surgeon satisfaction.

Versatile instrument styles with longer jaw-sealing lengths that can articulate and access various types of anatomy during minimally invasive abdominal procedures are available, so surgeons can more quickly cut and seal long stretches of tissue.

As with ultrasonic systems, the advanced bipolar options let surgeons customize their instruments according to procedure and personal comfort, thanks to a variety of ergonomic handles available in several lengths.

Surgeons can also use variable energy modes to focus tissue dissection on certain planes, creating discrete windows or cuts as desired. Temperature control consists of material coatings on the active electrodes and thermostats to signal back to the device that the maximum tissue temperature has been reached, so there's more control in cutting and dissection, with a lower risk of tissue damage and none of the sticking associated with earlier versions of bipolar systems.

Finally, as with the ultrasonic systems, the advanced bipolar sealing systems can sense tissue impedance and automatically shut down if it's detected, preventing the transfer of excessive energy that could lead to thermal injury.

Combined efforts
One new system lets you use ultrasound or advanced bipolar: Not only can you switch between the 2 energy modalities, the integrated device actually allows for simultaneous output. The result? The efficiency of rapid, targeted tissue cutting and dissection, right alongside reliable sealing of larger-lumened vessels.

Another new system employs temperature-controlled thermal energy with rapid cycle times and bladeless cutting to minimize tissue damage and avoid impedance. It can also be used safely in fluid surgical environments and be combined with traditional electrosurgery to provide added flexibility during procedures of all types.

Upgrading's upside
Whatever next-generation system you choose, you get more targeted cutting of tissue, less trauma to and char of internal structures, and better, more reliable sealing of vessel lumens. These are invaluable improvements, and can result in faster procedures and quicker discharges (because worries about thermal burns and internal bleeding will be lessened).

Another factor to consider is surgeon satisfaction: The different handle sizes, lengths and designs can really go a long way toward relieving the ergonomic stresses brought on by maneuvering laparoscopic instrumentation into difficult-to-reach areas during procedures. Providing state-of-the-art technology at your center increases physician satisfaction while also optimizing patient outcomes.