Peri-Operative Outcomes after Open and Robot-Assisted Radical Cystectomy by Using an Advanced Bipolar Seal and Cut Technology (Caiman®): A Prospective, Comparative and Multi-Institutional Study
Marco Borghesi, Riccardo Schiavina, Alessandro Antonelli, Carlo Buizza, Antonio Celia, Paolo Parma, Bernardino De Concilio, Francesco Mengoni, Daniele Romagnoli, Giacomo Saraceni, Eugenio Brunocilla, and Angelo Porreca
Objective: To report and compare the peri-operative outcomes of patients undergoing open (ORC) and robotic-assisted radical cystectomy (RARC) for bladder cancer performed with a radiofrequency seal and cut device (Caiman®).
Materials and Methods: Data of patients undergoing ORC or RARC between January 2015 and March 2016 at 6 Italian institutions were prospectively recorded and analyzed. Thirty-and 90-day complications were stratified according to the Martin's criteria and graded according to the Clavien-Dindo classification. Data on operative time, blood loss, transfusion rate, complications, and length of stay were evaluated and compared between the ORC and RARC groups.
Results: Thirty-three (66%) and 17 (34%) patients were treated with ORC and RARC, respectively. The median age was 72 (64-78) years. Overall operative time was longer in RARC compared to ORC (389 ± 80.1 vs. 242 ± 62.2 min, p < 0.001), while the estimated blood loss during cystectomy was higher after ORC (370 ± 126.8 vs. 243.3 ± 201.6 ml, p = 0.03). The transfusion rate was significantly higher in the ORC compared to RARC (24.2 vs. 5.9%, p = 0.04). Eight (19%) and 7 (16.7%) patients experienced 30- and 90-day post-operative complications, with no significant difference between ORC and RARC. Length of stay was significantly shorter in RARC group (median 7 vs. 14 days, p < 0.001).
Conclusions: Open and robot-assisted procedures were safely performed by using a new advanced bipolar seal and cut technology (Caiman®). RARC demonstrated to be superior to ORC in terms of bleeding, transfusion rates and length of hospital stay, despite longer operative time.
Comparison between Caiman® and Ligasure® in laparoscopic sleeve gastrectomy: A retrospective study of 200 patients
Pierre Blanc, Camille Pradat, Christophe Breton, Radwan Kassir
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Caiman® versus LigaSure® hemorrhoidectomy: Postoperative pain, early complications, long-term follow-up, and costs
Chiara Eberspacher, Pietro Mascagni, Domenico Di Nardo, Daniele Pironi, Stefano Pontone, Jacopo Martellucci, Gabriele Naldini, Domenico Mascagni
Purpose: Recently, the use of radiofrequency for hemorrhoidectomy has minimized incidence of postoperative complications. Effectiveness of LigaSure® is demonstrated, but it is quite expensive. This study aims to compare LigaSure® with Caiman®, a cheaper instrument that uses radiofrequency for hemorrhoidectomy.
Methods: A total of 35 patients were enrolled in this study between January 2015 and December 2017: 35 (Group A: Caiman®) patients were matched with 35 control patients (Group B) from our historical cohort, treated with LigaSure®. They were checked at 1 week after operation, at 4 weeks, and then after 2, 6, and 12 months. We considered different factors: intraoperative (operative time, number of piles removed, necessity of stiches or ligation), immediate postoperative (pain, bleeding within 4 weeks, incontinence, soiling within 4 weeks, healing time of anal wounds, return to working activities), and with a long-term follow-up.
Results: There were no statistically significant differences between the 2 groups in analyzed intraoperative data: operative time (Group A 35 minutes vs Group B 33 minutes; P = .198) and stitches used. Postoperative data were comparable too, in particular pain (Group A 1 day Visual Analog Score = 6.25 vs Group B = 5.4, P = .178; Group A 1 week Visual Analog Score = 2.7 vs Group B = 1.14, P = .22) and bleeding (Group A = 2 vs Group B = 4; P = .2).
Conclusions: According our initial experience, Caiman® can be a safe and cheaper alternative to LigaSure® for hemorrhoidectomy.
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Use of the radiofrequency Caiman® Aesculap® Grasper in three different laparoscopic urologic procedures with video
Elena Soto-Vega, Juan Ramon Torres-Perez, Carlos Arroyo
Introduction: The Caiman® grasper is a radiofrequency instrument that allows cutting and sealing of tissues and blood vessels, with the added benefit of a distal closure that allows a stable pressure in its 26.5mm long tip, with a less than 1mm thermic injury of the adjacent tissues, with energy regulation depending on the tissue characteristics, allowing to seal up to 7mm vessels. All the above makes dissection easier and diminishes surgical time, making the laparoscopic procedures safer and faster, including urologic surgeries.
Objective: We present a video with three different urologic laparoscopic procedures with this radiofrequency grasper as an initial experience.
Material and methods: This less than 8-minute video includes: a transperitoneal laparoscopic vesico-bladder fistula repair due to an iatrogenic obstetric hysterectomy, the second part is a transperitoneal laparoscopic radical nephrectomy of a central kidney cancer, and finally an extraperitoneal radical prostatectomy. All the surgeries were performed using the Caiman® grasper.
Discussion: Even though this is the initial experience with this Caiman® sealing grasper, it proved to be efficient in upper and lower urinary tract surgeries, making the procedures safe and faster.
Conclusions: The Caiman® grasper is a useful laparoscopic instrument for vascular control, dissection and opening of the upper and lower urinary tract, with a mixed use of cutting and grasping instrument, which might make these and other procedures easier and more efficient.
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Evaluation and comparison of contemporary energy-based surgical vessel sealing devices
Dr. Zhamshid Okhunov, Mr. Renai Yoon, Dr. Achim Lusch, Mr. Kyle Spradling, Mrs. Melissa Suarez, Dr. Kamaljot S. Kaler, Dr. Roshan Patel, Mrs. Christina Hwang, Dr. Kathryn E Osann, Prof. Jiaoti Huang, Dr. Thomas K Lee, and Dr. Jaime Landman
We evaluated and compared 5 currently available energy-based vessel sealing devices (VSD) to assess typical surgical metrics. Methods: We tested the Caiman® 5 (C5), Harmonic Scalpel Ace Plus (HA), Harmonic Ace +7 (HA7), LigaSure® (LS) and Enseal G2 (ES) on small (2-5mm), medium (5.1-7mm) and large (7.1-9mm) vessels were obtained from 16 Yorkshire pigs. Vessels were randomly sealed and transected. We recorded sealing and transection time, charring and carbonization, thermal spread and bursting pressures (BP). Specimens were sent for histopathologic evaluation of seal quality and thermal spread. Results: A total of 246 vessels were evaluated; 125 were arteries and 121 were veins. There was no difference in BP for small size arteries. For medium arteries the C5 provided the highest BP (proximal and distal jaw), followed by HA7, ES, LS and HA (1,740, 1600, 1,165, 1,165, 981 and 571 mmHg respectively, HA<C5-D(<.001); HA<C5-P(<.001); HA<ES(.002); HA<HA7(.002); HA7<C5-P(.026); ES<C5-P(.026); LS<C5-P(.001); LS<C5-D(.014)). For large arteries C5 and LS provided highest BP followed by HA7, ES and HA (1,676, 530, 467, 467 and 254 mmHg, respectively, C5<HA(<.001); C5<HA7(.006); C5<ES(.006); C5<LS(.012);). There were no bursting pressure failures for the C5, HA7 and LS up to 9mm vessels. For medium and large size arteries HA had bursting failure of 20% and 40% respectively. The ES was significantly less efficient with small, medium and large arteries with bursting failure rates of 10%, 40% and 80% respectively. Conclusions: In this study, the C5 outperformed all other devices. However, all of the devices provide a seal that was superphysiologic in that all burst pressures were > 250 mm Hg.
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Rationale, bench testing and in vivo evaluation of a novel 5 mm laparoscopic vessel sealing device with homogeneous pressure distribution in long instrument jaws
Stefan Eick, Brandon Loudermilk, Erik Walberg, Moritz N Wente
Background: In 1998, an electrothermal bipolar vessel sealing (EBVS) system was introduced and quickly became an integral component of the surgical armamentarium in various surgical specialties. Currently available EBVS instrumentsuse a scissor-like jaw configuration and closing mechanism, which causes decreasing compression pressure from the proximal to the distal end of the jaws. A new EBVS system is described here which utilizes a different instrument jaw configuration and closing mechanism to enable a more homogeneous pressure distribution despite longer instrument jaws.
Methods: Results of jaw pressure distribution measurements as well as sealing experiments with subsequent burst pressure measurements ex vivo on bovine uterine arteries are demonstrated. Furthermore, an in vivo evaluation of the new EBVS system in a canine and porcine model including histological examination is presented.
Results: The device revealed an even pressure distribution throughout the whole jaw length. The ex vivo burst pressure measurements revealed high average burst pressures, above 300 mmHg, independent of the outer diameter (1 to 7 mm) of the tested vessels. Histological evaluation of sealed vessels 21 days postoperatively demonstrated sealed and fused vessels without adjacent tissue damage.
Conclusions: The even pressure distribution leading to a sufficient tissue sealing in combination with the novel closing mechanism and extended jaw length differentiates the novel device from other available EBVS systems. This might offer a reduction of the overall procedure time, which should be further evaluated in a clinical study.
Impact of radiofrequency energy on intraoperative outcomes of laparoscopic colectomy for cancer in obese patients
Diletta Cassini, Michelangelo Miccini, Matteo Gregori, Farshad Manoochehri, Gianandrea Baldazzi
Nowadays laparoscopic approach is accepted as a valid alternative to open surgery for the treatment of colorectal cancer. Several studies consider this approach to be safe and feasible also in obese patients, even if dissection in these patients may require a longer operative time and involve higher blood loss. To facilitate laparoscopic approach, more difficult in these patients, several energy sources for laparoscopic dissection and sealing, has been adopted recently. The aim of this study is to investigate the possible intraoperative advantages of radiofrequency energy in terms of blood loss and operative time in obese patients undergoing laparoscopic resection for cancer. All patients who underwent laparoscopic surgery for colorectal cancer from January 2010 to December 2015 were registered in a prospective database. Patients with a body mass index BMI (kg/m2) ≥30 were defined as obese, and patients with a BMI (kg/m2) <30 were defined as non-obese. All 136 obese patients observed were divided retrospectively into 2 groups according to the devices used for dissection: 83 patients (Historical group: B) on whom dissection and coagulation were performed using other energy sources (monopolar electrocautery scissors, bipolar electrical energy, ultrasonic coagulating shears) and 53 patients who were treated with electrothermal bipolar vessel sealing (Caiman® group: A). In group A, the Laparoscopic Caiman® 5 (Aesculap AG, Tuttlingen, Germany) was the only instrument employed in the whole procedure. The study examined only three types of operation: right colectomy (RC), left colectomy (LC), and anterior resection (AR). Preoperative data were similar for RC, LC, and AR in both groups (A and B). The mean operative time was statistically shorter in the Caiman® group than in the Historical group [104 vs 124 min (p 0.004), 116 vs 140 min (p 0.004), and 125 vs 151 min (p 0.003) for RC, LC, and AR between group A and B, respectively]. Also intraoperative blood loss results significantly lower in the Caiman® group than in the historical one [52 ml vs 93 for RC (p 0.003); 65 vs 120 ml for LC (p 0.001); 93 vs 145 ml for AR (p 0.002) between group A and B, respectively]. No intraoperative complications were recorded in either group. The mean conversion rate was 4.4% (6 patients). There were no statistical differences in intensive care unit (ICU) stay, functional outcomes, mean hospital stay and overall morbidity rate between the two groups. There was no mortality in either group. The use of the Caiman® EBVS instrument shows significant advantages with respect to a small number of intraoperative parameters. We can conclude that use of this radiofrequency device, in the laparoscopic approach, offers advantages in terms of lower intraoperative blood loss and shorter operative time in obese patients with colorectal cancer.
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Abstract Caiman® 5
Clinical impact of a surgical energy device in advanced ovarian cancer surgery including bowel resection
Guiseppe Vizzielli, Carmine Conte, Massimo Romano, Anna Fagotti, Barbara Costantini, Claudio Lodoli, Salvatore Gueli Alletti, Khaled Gaballah, Fabio Pacelli, Alfredo Ercoli, Giovanni Scambia and Valerio Gallotta
Aim: To evaluate the clinical impact of the use of the Caiman® articulating energy device in advanced ovarian cancer (AOC) including rectosigmoid resection [e.g. modified posterior exenteration (MPE)]. Patients and Methods: This was a prospective single-institution observational study with women undergoing MPE where all soft-tissue dissections and vessel ligations were performed using the Caiman® device. Intraoperative and postoperative surgical data were collected. Bladder function after nerve-sparing surgery was analyzed before and 6 months after surgery. Results: Forty patients were registered in the study. The median time for specimen removal using Caiman® was 86 min (range=70-120 min). Major vessel ligation was successful in all patients with a median of a single (range=1-4) Caiman® application to seal major vessels. No intraoperative or postoperative complications or bladder dysfunctions associated with the use of Caiman® were noted. Conclusion: Caiman® can be safely used in AOC surgery and may save time through faster dissection. However, comparative studies with other energy devices are needed to confirm this finding.
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Publication Caiman® 12 Articulating