Ann Thorac Surg 2007;83:2228-2230
© 2007 The Society of Thoracic Surgeons
Case Reports
Patent Ductus Arteriosus Ligation: The LigaSure System May Be Unreliable
Corina R. Zamfir, MDa,
Magali Vernet, MDb,
Mathilde Funes de la Vega, MDc,
Emmanuel Sapin, MDa,*
a Department of Paediatric Surgery, Paediatric Hospital–CHU de Dijon–Université de Dijon-Bourgogne, Dijon, France
b Department of Anaesthesiology, Paediatric Hospital–CHU de Dijon–Université de Dijon-Bourgogne, Dijon, France
c Department of Pathology, Paediatric Hospital–CHU de Dijon–Université de Dijon-Bourgogne, Dijon, France
Accepted for publication December 27, 2006.
* Address correspondence to Dr Sapin, Service de Chirurgie Pediatrique, CHU de Dijon, 10, Bd Mal de Lattre de Tassigny-B.P.77, Dijon Cedex, 908-21079, France (Email: emmanuel.sapin{at}chu-dijon.fr).
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Abstract
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Surgical ligation of a patent ductus arteriosus (PDA) in small premature infants may be performed with open thoracotomy or video-assisted thoracoscopic surgery (VATS). The LigaSure vessel sealing system (Valleylab/Tyco Healthcare, Boulder, CO) is increasingly being used because of its effectiveness in promoting coagulation. Moreover, for PDA ligation using VATS, the LigaSure system seems more practical than vascular clips. Among 81 children, including 43 premature infants weighing less than 1000 grams operated on for PDA in our institution, one 9-month-old boy weighing 7600 grams underwent PDA ligation using a LigaSure grasp. The perioperative aspect of the closed ductus was satisfactory. The following day, however, ultrasound control revealed recanalization of the ductus, and the child had to undergo a second operation. At operation, the ductus wall adventia and media appeared to have retracted to both extremities, leaving the intima exposed and pulsating under the blood pressure. The PDA ligation was repeated, but in conditions of severe hemorrhage. The LigaSure system works by fusing collagen in the tissue. However, because the ductus wall has less collagen than any other vessels in the body, the LigaSure vessel sealing system is not reliable for PDA ligation.
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Introduction
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Patent ductus arteriosus (PDA) is the most common congenital cardiac lesion in premature infants. When medical treatment fails or is contraindicated, the different therapeutic options are transcatheter coil occlusion and surgical repair by video-assisted thoracoscopic surgery (VATS) or open thoracotomy ligation. VATS techniques have been used in children since the 1970s. Improvements in video technology and endoscopic instruments have led to the increased use of VATS procedures in children. VATS PDA ligation is a standardized procedure that is frequently performed even in very-low-birthweight premature infants.
The LigaSure vessel sealing system (LVSS) (Valleylab, Tyco Healthcare, Boulder, CO) is currently used on vessels up to 7 mm in diameter, especially with laparoscopic surgery. Considering our surgical experience with PDA in preterm infants, we performed a ligation using the LVSS rather than vascular clips. The aim was to use the system in a VATS procedure through a 5-mm port.
Surgical ligation of a PDA was indicated in a 9-month-old boy, weighing 7600 grams, who was found to have a 4-mm symptomatic PDA at ultrasonography. Through a left muscular-sparing thoracotomy, the PDA was gently dissected all around and the LigaSure LS 1200 Precise grasp was applied. The immediate result, as well as that observed after 10 minutes, was satisfactory. The postoperative auscultation in the recovery room did not find any continuous murmur.
The next day, however, ultrasonography revealed recanalization of the ductus. The same day, a second thoracotomy was performed and blood flow through the sealed PDA, as revealed by the ultrasound scan was noted. The adventia and media ductus wall had retracted to both extremities, leaving the intima exposed and pulsating under the blood pressure. The PDA was closed with two 9-mm titanium clips and a simple ligating 6-0 monofilament suture. The operation, however, caused severe bleeding, evaluated at 500 mL. This was considered life threatening and a blood transfusion was necessary. The patient’s postoperative course was uneventful, as was the follow-up.
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Comment
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Following on from the widespread use of VATS in pediatric thoracic surgery [1, 2], VATS PDA ligation is starting to be used more and more frequently [3–5]. It offers the advantage of decreased chest wall trauma and postthoracotomy scoliosis by avoiding rib spreading and minimizes the risk of nerve injury and rupture of intercostal ligaments. VATS cameras and optics also allow improved visualization compared with the limited visual field permitted by minithoracotomy [6]. Several authors have reported that VATS PDA ligation can be done safely, with no contraindication related to the patient’s age or weight [3, 4]. PDA ligation with VATS is performed with vascular clips, either endoscopic clips through the port [4] or 9-mm titanium clips applied by a classic clip-grasp through the central incision after removal of the trocar [6].
The length of the scar resulting from the application of the titanium vascular clips is not very different from that produced by the skin incision used for thoracotomy. In these conditions, we tried to reduce the length of the skin incision necessary for the introduction of the classic clip-grasp by using a LVSS. The LVSS has been successfully used for coagulation of the pulmonary artery in lobectomies and laparoscopic surgery [2, 7, 8]. We were encouraged to use the LVSS device through a 5-mm port, but because we had no experience of LVSS in PDA ligation, we preferred to perform the ligation through an open thoracotomy. Being the first experience, it was necessary to ensure that any unforeseen incident could be dealt with easily.
The LVSS is an electrothermal device that applies a precise amount of bipolar energy to vessels walls while they are being held in tight apposition under controlled pressure to produce a unique seal of partially denatured protein [8]. It achieves the seal by changing the nature of the vessel wall: the collagen and the elastin fuse and reform into a single structure, obliterating the lumen. It improves ease of dissection and may take the place of surgical vascular clips. The LVSS is currently used on vessels up to 7 mm in diameter, especially in laparoscopic surgery. The seal is comparable in strength to mechanical ligation. No foreign bodies, such as suture material or clips, remain in the body.
The LVSS is gaining popularity, especially in pediatric surgery, because it can be used safely for abdominal, thoracic, or urologic procedures. It confines the thermal energy transfer to within 2 mm of the point of application, which reduces potential injury to the vagus and recurrent laryngeal nerves. The grasp of the LVSS can be inserted through a port of 5 mm in diameter, allowing its use for VATS PDA ligation.
Study of the histology and changes in the tissue structure of developing human PDA have shown the proliferation of internal and medial connective tissue and the deposition of ground substances [9]. In fetuses ranging from 7 months’ gestation to 48 hours after birth, and in premature babies, the ductus arteriosi retains a fetal aspect. The main characteristics are increasing fragmentation of the internal elastic lamina and the development of large areas of ground substance, also called the zone of delamination, where elastin is dissociated from collagen. The ground substance that accumulates in the intercellular spaces is a mucoid material [10]. The ductus wall has less collagen than normal arteries. These histologic findings make the ductus wall different from the wall of arteries or veins. Perhaps these histologic findings explain the failure of the LVSS in sealing PDA.
In conclusion, we suggest that given the specific histologic structure of the ductus arteriosus, the LVSS is not a safe reliable procedure for PDA ligation.
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Acknowledgments
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We thank Philip Bastable for his expert technical assistance.
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References
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Abstract
Introduction
