OR WAIT 15 SECS
In this first installment of a regular series, a doctor test-drives two surgical tools and finds them friendly and functional.
Dr. Greenberg is Chief, Division of Gynecology, Brigham & Women’s Faulkner Hospital, and Associate Professor, Harvard Medical School, Boston, Massachusetts.
The central challenge in minimally invasive surgery is figuring out how to do more with less. Restricted by the closed walls of the abdomen, surgeons need to find clever workarounds for common problems when traditional solutions are inadequate. A typical example is retraction. When working in the pelvis, even with a patient in Trendelenburg position, the bowel and omentum are frequently unwelcome guests to the surgical field party. Lacking a surgical resident or stuffed lap pads, surgeons typically introduce laparoscopic “fan” retractors through 5-mm or 12-mm ports and expand the instruments to provide manual retraction of the bowel. That technique is straightforward and effective but ties up both a port and a hand in accomplishing a task that is only tangentially related to the surgical focus. The T’Lift (VECTEC) is a low-tech solution to this high-tech problem.
The design and appearance of T’Lift are so simple that you might expect to find it at a hardware store rather than in an operating room (OR). The device consists of cut fishing line, a needle to get the T’Lift where you want it, and a plastic tag to keep it there. More specifically, the three separate components are: a 2-mm non-resorbing, biocompatible thermoplastic string with a cut that opens into a “T” at one end, a hollow 2-mm introducer needle, and a plastic slide clamp.
Here’s how the device works: The “T” end of the plastic thread is straightened and inserted into the introducer needle. The needle loaded with the T’Lift is passed through the abdominal wall and then through the tissue to be retracted (for bowel retraction, passing the device through the epiploica rather than the bowel wall is recommended). Once the tip of the needle is through the target tissue, the T’Lift is advanced forward until the “T” is deployed. The introducer needle is then withdrawn, leaving the “T” end through the tissue and the other end outside the abdomen. The outside end is then retracted until the tissue is where the surgeon wants it and the lock is secured against the outside of the abdominal wall. Each T’Lift will retract up to 1500 g (3 lb). To remove it, the device is loosened and cut. The “T” end is grasped with a laparoscopic instrument and removed through any port.
In the OR, T’Lift was as simple and straightforward to use as it appears. It was quick and easy to deploy and it did exactly what it was designed to do: retract. It was simple to remove. In the case of the T’Lift, WYSIWYG (what you see is what you get).
Because I am rarely 100% satisfied, I did have two complaints/suggestions. The first is concerning the T’Lift’s color. The translucent wheat-pasta beige has no impact on functionality but it could become a huge issue if the device got lost in the abdomen. For that reason, I think the manufacturer should switch to a more vibrant color that would be easier to spot, should an errant piece of the device drop before it is removed. Second, I was disappointed to get only 2 devices in a pack. With a cost of goods that can’t be more than 4 or 5 cents, give me four devices, please.
I think that the T’Lift is brilliantly uncomplicated. A lot of us may want to believe we could have thought of this and should have thought of this, but we didn’t.
T’Lift is a simple answer to a sometimes challenging problem. While it is unlikely to dramatically alter minimally invasive surgery, it is a neat device to have in your surgical armamentarium. Its list price is a bit steep for only 2 devices but list prices are rarely the same as average sale price and, with increased sales, the price should come down. T’Lift is easy to stock, easy to use, and definitely worth a try.
NEXT: THE PKS BiLL >>
Shortly after the initial reports of the first laparoscopic supracervical hysterectomies in the early 1990s, Dr. Jacques Dequesne of Switzerland described his experience with amputating the uterine fundus using a new electrosurgical loop called the LEC loop.1 This mostly improvised device consisted of a modified 10-cm piece of tungsten wire that could be wrapped around the cervical isthmus and grasped with metal-tipped forceps to allow a monopolar current to be passed through the wire for cutting purposes.1
The first 30 procedures with the LEC went well and soon a new family of surgical devices was born with names like Lap Loop, LiNA Loop, and SupraLoop. These devices were variations of monopolar wires designed to divide the cervix, with each iteration introducing a slight improvement. In this loopty-loop world, everything seemed kind of the same … until BiLL came along.
By most visual criteria, the resemblance between Olympus’s Bipolar Laparoscopic Loop (BiLL) and other surgical loops is uncanny. But appearances can be deceiving and similarities often belie enormous underlying differences. As with other loops, BiLL is a single-use, 5-mm device and its core component is a wire surrounded by an insulated introducer shaft that slides over the wire to expand and contract the loop’s diameter. However, unlike other loops, BiLL uses Olympus’s PK technology with its G400 generator and it is bipolar rather than monopolar. For readers who do not think this is a big deal, let’s review how this device works.
After the broad ligaments have been divided, the bladder pushed caudad and the uterine vessels secured, the loop is passed over the uterine fundus and snared around the cervix at the level at which amputation is desired. The positioning of the loop is checked. The generator is activated while the loop is gradually contracted by pulling the top of the wire up while pushing down on the introducer shaft, thereby forcing the energized filament to slice through the tissues like a hot knife through butter. Knowing exactly the path your electrical current is traveling can be the difference between a 10-second cervical amputation and damage to the colon, iliac, or other nearby structures.
In use in the OR, PKS BiLL performed just like every other laparoscopic cutting loop I have ever used: quickly, cleanly, and hemostatically. Maybe it was a tad slower and smokier than the monopolar loops I have tried. But, even if this was the case-and I am not sure it was-the peace of mind gained by using a bipolar device rather than a monopolar wire was well worth it. As far as loops go, I cannot envision a better one.
Knowing that bipolar configurations generally confer a superior safety profile and seeing that every other loop product on the market is monopolar, I can only conclude that the engineering contortions needed to produce this device must not be too straightforward. As a committed bipolar-is-better-than-monopolar surgeon, I am very impressed with this technological “tweak” and I think it is huge advance for patient safety. This is a game-changer.
I am not convinced that laparoscopic cutting loops in any configuration truly represent a great bang for our Affordable Care Act buck. They are all fast and save time, but as to value, I remain a skeptic. However, if you are a loop aficionado there is little doubt in my mind that Mr. BiLL is your man. Given the potential for injuries (and there is an impressive list of them with monopolar loops in the FDA’s Manufacturer and User Facility Device Experience [MAUDE] database: www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm), I cannot see why anyone would use a monopolar wire when a bipolar loop alternative is available. This one is a no-brainer.
1. Dequesne D, Schmidt N, Frydman R. A new electrosurgical loop technique for laparoscopic supracervical hysterectomy. Gynaecol Endosc.
The views of the author are personal opinions and do not necessarily represent the views of Contemporary OB/GYN. Dr. Greenberg personally tests all the products he reviews. He reports no conflicts of interest with these products or the companies that produce them. He reports receiving royalties from Hologic, consulting fees from Channell Med and Ethicon, and conducting contracted research for Mind Child, Inc.