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Ann Thorac Surg 2000;69:1399-1401
© 2000 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Minimal damage during endoscopic latissimus dorsi muscle mobilization with the harmonic scalpel

^a Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan

Address reprint requests to Dr Inaba, Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan

	Abstract

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Background. To reduce wound-related complications, a video-assisted surgical technique has been adopted for the mobilization of the latissimus dorsi muscle. We postulated that thermal damage to the muscle might be minimized by using a Harmonic Scalpel instead of electrocautery during this procedure.

Methods. Canine latissimus dorsi muscles were mobilized through a small incision, assisted by a videoscope. In 6 dogs, dissection with electrocautery was used to mobilize the latissimus dorsi muscle. In 6 other dogs, the Harmonic Scalpel was used. We compared operation times, wound infection rates, histologic changes in the muscles, and ease of handling between these groups.

Results. The operation time was significantly shorter in the Harmonic Scalpel group than in the electrocautery group (61.5 versus 106.5 minutes, p = 0.00014). The Harmonic Scalpel caused less histologic damage to the mobilized muscles and produced less vision-obscuring smoke.

Conclusions. The Harmonic Scalpel shortens the operation, minimizes muscle damage, and facilitates the performance of video-assisted latissimus dorsi muscle mobilization.

	Introduction

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Video assistance has been increasingly adopted to allow mobilization of the latissimus dorsi muscle (LDM) through a small incision. This technique reduces wound-related complications, including wound infection, bleeding, and postoperative pain, which discourage subsequent ambulation [1–3]. However, there is some concern that when video-assisted LDM mobilization is used during cardiomyoplasty, the associated electrocautery may cause thermal damage to the muscle, which is made to contract in synchrony with the heart beat.

The Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) is an ultrasonically activated scalpel that cuts and coagulates tissues at a temperature below 100°C. This device has recently been used for thoracoscopic internal mammary artery harvesting, during which it was found to minimize hyperthermic damage to the internal mammary artery [4]. The Harmonic Scalpel has also been found useful for radial artery harvesting [5]. We therefore postulated that use of the Harmonic Scalpel during video-assisted LDM mobilization might minimize thermal damage to the muscle.

In this study, we used the Harmonic Scalpel during video-assisted endoscopic mobilization of the LDM and compared the resultant degree of muscle damage with that caused by traditional dissection plus electrocautery.

	Material and methods

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Twelve mongrel dogs with body weights ranging from 12.2 to 17.5 kg were used in this study. They received humane care in compliance with the Guide for the Care and Use of Laboratory Animals (NIH publication 85-23, revised 1985).

Animals were anesthetized with ketamine (15 mg/kg intramuscularly) and sodium pentobarbital (35 mg/kg intravenously). They were then mechanically ventilated through an endotracheal tube and positioned in the right lateral position. The left LDM was dissected through a 6-cm skin incision at the left axilla. The skin was held open with heavy traction sutures. First, the LDM was dissected from the thoracic wall under videoscopic assistance. All collateral vessels arising from the intercostal vessels were severed. The thoracodorsal neurovascular pedicle was preserved. The LDM was then dissected from the subcutaneous tissue and freed from the iliac crest, vertebra, inferior scapular angle, and rib attachments. In 6 dogs, this procedure was conducted using scissors and electrocautery. This group was termed the EC group. In the other 6 dogs, the Harmonic Scalpel was used to divide all collateral vessels and to dissect the LDM (Fig 1). This group was termed the HS group. We compared operation times and wound infection rates between these two groups. The edges of the muscles dissected and divided by electrocautery and the Harmonic Scalpel were compared histologically. For this purpose, muscle samples were fixed with formalin, embedded in paraffin, and stained with hematoxylin and eosin.

View larger version (35K): [in this window] [in a new window]   Fig 1. Surgical technique. A blade retractor was inserted, and traction sutures were placed in the skin. The latissimus dorsi muscle was dissected from the thoracic wall under videoscopic assistance. The videoscope and Harmonic Scalpel are depicted.

	Results

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Operation times were 106.5 ± 15.9 minutes (range, 89 to 128 minutes) in the EC group, and 61.5 ± 9.4 minutes (range, 53 to 78 minutes) in the HS group. This difference was significant (p = 0.00014). Two of the 6 dogs in the EC group developed a wound infection, whereas no dogs in the HS group developed a wound infection (p = 0.23).

In the EC group, blood vessels and muscles were coagulated by electrocautery, then severed using scissors. During the operation, electrocautery caused severe muscle twitching, which interrupted the surgical procedure. Visibility through the videomonitor was also obscured by smoke when muscles or vessels were coagulated by electrocautery, and this necessitated repeated smoke evacuation. This in turn led to frequent switching between the electrocautery instrument, the scissors, and the smoke evacuator, because the skin incision and operative field were too small for two instruments to be used together. When coagulation by electrocautery was inadequate, bleeding occurred after the vessels were severed with the scissors.

The Harmonic Scalpel caused no twitching of the muscles, and smoke evacuation was unnecessary because it generated no smoke. Although small amounts of vaporized substances were generated, these did not obscure the operative view. In the HS group, blood vessels and muscles were severed exclusively by the Harmonic Scalpel, and instrument switching was seldom necessary. Vessel severance also produced complete coagulation in the HS group and no bleeding occurred.

In the EC group, the muscles were completely degenerated by the heat for approximately 15 mm from the divided edge. A smaller degree of degeneration was apparent farther into the muscle. Muscle fibers near coagulated vessels were also burned and completely degenerated (Fig 2). In the HS group, muscle degeneration was confined to within 2 mm of the divided edge, and no further spread of degeneration was observed. Normal muscle fiber structure was maintained even near coagulated vessels (Fig 3).

View larger version (125K): [in this window] [in a new window]   Fig 2. Muscle histology in the EC group. (A) Heat-induced degeneration of the muscle fibers extended beyond 15 mm from the edge of the divided muscle. Lesser damage was apparent further into the muscle. The arrow points to the border between degenerated and normal muscles. (B) Muscle fibers near coagulated vessels were severely burned and completely damaged. (Hematoxylin and eosin, x10.)

View larger version (51K): [in this window] [in a new window]   Fig 3. Muscle histology in the HS group. (A) Muscle fiber degeneration was limited to within 2 mm of the edge of the divided muscle. The arrow points to the border between degenerated and normal muscles. (B) Muscle fibers located near coagulated vessels were not damaged. (Hematoxylin and eosin, x10.)

	Comment

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When compared with electrocautery, the Harmonic Scalpel had the advantage of providing a smoke-free view of the operative field. In addition, as tissue can be coagulated and resected at a lower temperature with the Harmonic Scalpel, hyperthermic damage can be minimized. The Harmonic Scalpel has already been applied to harvesting of the internal mammary artery and radial artery during thoracic surgery [4, 5]. Moreover, the Harmonic Scalpel is useful for coagulating and cutting vessels up to 3 or 4 mm in size, which can allow mobilization of the LDM. Our impression was that video-assisted mobilization of the LDM using the Harmonic Scalpel causes minimal damage to the LDM compared with conventional electrocautery.

In this study, histologic examinations showed that muscle damage was less in the HS than in the EC group. Moreover, the operation was much easier to perform because the Harmonic Scalpel caused no twitching of the muscles. Muscle twitching during electrocautery makes the operation technically difficult, and may damage muscles by applying an electrical charge to nerve fibers [6]. Smoke evacuation and resultant frequent switching between instruments, which were necessary in the EC group, were unnecessary in the HS group. Almost no intraoperative bleeding occurred in the HS group. When bleeding occurred because of inadequate electrocautery, it took a long time to stop because the restricted operative field made the application of hemostatic measures difficult. Even slight bleeding disturbs an operation; therefore, the complete hemostasis of small vessels as well as large vessels is significant. These factors all contributed to the significant difference in the operation time between the EC and HS groups.

In summary, the Harmonic Scalpel has the potential to minimize damage to the LDM during video-assisted LDM mobilization through a small incision. If used in making a delayed flap in situ [7], the Harmonic Scalpel can provide an easy and safe surgical procedure. If used in combination with thoracoscopic wrapping of the LDM [8], it may be possible to establish a videoscopic technique for performing cardiomyoplasy through a small incision.

	References

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1. Jones G.E., Eaves F.F. Latissimus dorsi harvest for free and pedicle tissue transfer. In: Bostwick J., Eaves F.F., Nahai F., eds. Endoscopic plastic surgery. St Louis: Quality Medical Publishing, 1995:512-526.
2. Fine N.A., Orgill D.P., Pribaz J.J. Early clinical experience in endoscopic-assisted muscle flap harvest. Ann Plast Surg 1994;33:465-469.[Medline]
3. Matsuoka T., Fujikawa M., Yamamoto H., et al. Breast reconstruction after mastectomy without additional scarring. Ann Plast Surg 1998;40:123-127.[Medline]
4. Ohtsuka T., Wolf R.K., Hiratzka L.F., Wurnig P., Flege J.B. Thoracoscopic internal mammary artery harvest for MICABG using the Harmonic Scalpel. Ann Thorac Surg 1997;63:S107-S109.
5. Posacioglu H., Atay Y., Cetindag B., Saribulbul O., Buket S., Hamulu A. Easy harvesting of radial artery with ultrasonically activated scalpel. Ann Thorac Surg 1998;65:984-985.[Abstract/Free Full Text]
6. Watanabe S., Sato H., Tawaraya K., Tsubota M., Endo M. Advantages and disadvantages of Harmonic Scalpel in thoracic surgery. Jpn J Thorac Surg 1998;51:374-378.
7. Carroll S.M., Carroll C.M.A., Stremel R.W., Heilman S.J., Tobin G.R., Barker J.H. Vascular delay of the latissimus dorsi muscle. Ann Thorac Surg 1997;63:1034-1040.[Abstract/Free Full Text]
8. Kaneko Y., Ezure M., Inaba H., Tambara K., Kohno T., Furuse A. Thoracoscopic cardiomyoplasty. Ann Thorac Surg 1997;63:477-481.[Abstract/Free Full Text]

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