Prospective, randomized trial of bipolar electrosurgery vs ultrasonic coagulation for division of short gastric vessels during laparoscopic Nissen fundoplication

Background: Division of the short gastric vessels (SGV) during laparoscopic Nissen fundoplication (LNF) may improve outcome. Several techniques are available for SGV division. The aim of this study was to compare in a prospective randomized trial bipolar electrocautery with cutting blade versus ultrasonic coagulation of the SGV during LNF. Methods: In all, 86 consecutive patients undergoing LNF were prospectively randomized into two similar groups that underwent division of the SGV, respectively, using bipolar cutting forceps (BPCF) or harmonic coagulating shears (HCS). Operative time, bleeding episodes, complications, equipment problems, and surgeon's subjective scoring of satisfaction and ease of use were assessed. Results: Mean (+/-SD) time for fundic mobilization and division of the SGV was not significantly different between the two groups (BPCF = 20 +/- 12 min vs. HCS = 22 +/- 12 min). Bleeding events, estimated blood loss, surgeon satisfaction, and subjective ease of use were similar, and no transfusions were required. Complications in the BPCF group included a delayed gastric perforation requiring reoperation and two gastric serosal burns repaired intraoperatively. There was one splenic capsular tear using the HCS and one splenic capsular tear using the BPCF, both of which were controlled intraoperatively. The number of functional equipment problems were few and statistically similar. In the authors' institution, the per case total costs with capital expenditures amortized over 100 cases indicate savings of approximately $202/case with use of the BPCF versus the HCS. Regression analysis demonstrated a significant correlation between body mass index (BMI) and total case length and time for division of the SGVs. Conclusions: The BPCF and HCS appear to be equally efficacious for SGV division during LNF. Judicious application of both energy forms and heightened vigilance for gastric serosal injury are required with use of both the BPCF and HCS in cases of tight gastrosplenic adhesions or short SGVs. The BPCF carries a potential cost advantage over the HCS in the authors' institution. The BMI directly correlates with time required to divide SGVs and total length of LNF.