Abstract
Background and Objectives:
Multiple vessel-sealing devices are available for use during laparoscopy. The objective of this study is to determine what surgeon-level and device characteristics influence the choice of advanced energy device during gynecologic laparoscopy.
Methods:
This is a national cross-sectional study of gynecologic surgeons conducted via social media, utilizing an online, publicly-available, anonymous survey. Gynecologic surgeons who had completed residency training were approached for participation in the survey. Survey completion was voluntary and involved no further follow-ups. The web-based survey consisted of six questions with the option to answer three additional questions if time permitted. The institutional review board determined that this study qualified for exemption.
Results:
There were 92 respondents who participated in the survey. Of these, 81 completed the survey and were included in the analysis. Female respondents were younger and more frequently reported a glove size of 6.5 or less. Surgeon-level characteristics, including gender, age, glove size, case volume, region, and practice setting, were not significantly associated with preferred energy devices. Device availability in the operating room was the only characteristic associated with preferred energy devices (P-value = .0076). Other device-level characteristics such as optimal thermal spread, reduced plume, ease of use, device reliability, and teachability had no statistically significant association with preferred energy devices.
Conclusion:
Multiple advanced energy devices are available for use during gynecologic laparoscopy. These devices have varying energy profiles, thermal spread, and device size. Despite this diversity, only device availability in the operating room influenced the surgeon's preferred device selection.
Keywords: Energy devices, Ergonomics, Gynecology, Laparoscopy
INTRODUCTION
The advent of vessel-sealing devices and subsequent widespread adoption has facilitated the innovation of laparoscopic surgery. Advanced bipolar devices such as LigaSureTM (Medtronic, Minneapolis, MN), PK GyrusTM (Olympus, Center Valley, PA), and ENSEALTM (Ethicon, Cincinnati, OH) are popular, in addition to the Harmonic® sealer (Ethicon, Cincinnati, OH) that utilizes ultrasonic technology. Each instrument possesses distinct energy properties and device characteristics that may render them more suitable for specific procedures or providers.1 Factors such as lateral thermal spread, vessel-sealing capability, burst pressure, and degree of plume generation could impact the selection of the most appropriate device.1
Previous research has focused on the safety and cost aspects of these devices. One trial compared single-use energy devices with reusable bipolar forceps/monopolar scissors during total laparoscopic hysterectomy and found that single-use energy devices significantly reduced operating room time and total intraoperative direct costs.2 Another study directly compared two bipolar electrosurgical devices and concluded that ENSEALTM was associated with increased surgeon-perceived workload and device failure rate but did not affect clinical and surgical outcomes such as estimated blood loss and complication rates.3 Furthermore, a randomized study that compared three bipolar platforms demonstrated no significant differences in mean operative time, blood loss, or hospitalization time.4
There remains no advanced sealing device that outperforms the others regarding patient outcomes. However, data suggests that devices may put select groups of surgeons at risk of work-related injury. A prospective study found that surgeons with smaller hands experienced a more significant ergonomic workload during repetitive laparoscopic device use.5 Additionally, a higher proportion of women, compared to men, reported experiencing pain or muscle fatigue when using advanced energy devices.6
This study aimed to identify how surgeon characteristics, device properties, and practice location may influence the choice of energy devices during gynecologic laparoscopy.
METHODOLOGY
We developed an open, web-based survey that consisted of six questions with the option to answer three additional questions if time permitted. Gynecologic surgeons who had completed residency training were approached for participation in the survey. This survey was distributed via social media (Twitter) from February 1, 2023 to April 30, 2023 utilizing a QR code that invited all surgeons who performed gynecologic laparoscopy. Survey completion was voluntary, and no further follow-up was conducted. No personal identifiable information was collected or stored. The institutional review board (IRB) determined that this study qualified for exemption.
The survey instrument sought information regarding surgeon characteristics, including gender, age, glove size, and case volume. Survey respondents were asked to indicate their preferred energy device for vessel-sealing during laparoscopic surgery and to select which energy devices were ergonomic for use during a traditional laparoscopic case lasting at least 2 hours. Six energy devices were included as options: LigaSureTM, ENSEALTM, Harmonic®, Olympus PK®, Olympus ThunderbeatTM, and Aesculap Caiman® (Braun Medical, Bethlehem, Pennsylvania).
Respondents were then invited to answer additional questions to investigate how device characteristics and practice setting may influence their preferred energy device. Using a Likert scale from 1 (not at all) to 7 (a great deal), respondents were asked to indicate how much each factor contributed to selecting an energy device during surgery. These factors were optimal thermal spread, reduced plume, surgeon ergonomics/ease of use, device reliability, teachability, and availability in the operating room. Respondents were asked about the geographic region and type of practice, including academic medical centers, private practice, government/military/VA, community-based hospitals, and others. The survey instrument used did not allow for respondents to review or change their responses after completion of the survey. This instrument did not allow for collection of data regarding unique visitors to the first page of the survey. The survey instrument utilized a temporary local cookie which allowed for completed responses to be encrypted and transmitted, but IP addresses were not recorded.
Bivariate analyses were conducted in SAS® (SAS, Cary, NC) to examine potential relationships between surgeon-level characteristics, device-level characteristics, and preferred energy device.
RESULTS
There were 92 survey respondents, 81 of whom completed the survey and were included in the analysis (Table 1). Most survey respondents identified as female (n = 65, 80.25%). Most respondents were aged 25 – 34 (n = 36, 44.44%), had a glove size less than 6.5 (n = 56, 69.14%), and identified an academic hospital as their primary practice setting (n = 55, 69.62%).
Table 1.
Survey Respondent Demographics
| Characteristic | N = (%) |
|---|---|
| Gender | |
| Male | 16 (19.7) |
| Female | 65 (80.2) |
| Age (yrs) | |
| 25 – 34 | 36 (44.4) |
| 35 – 44 | 29 (35.8) |
| 45 – 54 | 12 (14.8) |
| ≥ 55 | 4 (4.9) |
| Glove size | |
| ≤ 6.5 | 56 (69.1) |
| > 7 | 25 (30.8) |
| Case volume | |
| < 10 | 35 (43.2) |
| 10 – 24 | 32 (39.5) |
| ≥ 25 | 14 (17.2) |
| Region | |
| West | 7 (8.8) |
| Midwest | 22 (27.8) |
| South | 21 (26.5) |
| Northeast | 28 (35.4) |
| International | 1 (1.2) |
| Practice setting | |
| Academic | 55 (69.6) |
| Private | 9 (11.3) |
| Govt/Military/VA | 4 (5.0) |
| Community | 10 (12.6) |
| Other | 1 (1.2) |
Of the energy devices included in this survey, LigaSure was most frequently identified as a preferred energy device (n = 46). Other commonly selected devices included Harmonic (n = 25) and ENSEAL (n = 7). Olympus PK (n = 2) and Olympus Thunderbeat (n = 1) were less commonly selected devices. Bivariate analyses of surgeon characteristics found no association between gender, age, glove size, practice setting, region, or case volume and preferred energy device (Table 2). Availability in the operating room was the only characteristic associated with preferred energy devices (Table 3). Logistic regression analysis confirmed that device availability remained the only variable that predicted device selection (p = 0.011).
Table 2.
Bivariate Analyses of Surgeon Characteristics and Preferred Energy Device
| Characteristic | LigaSure N = (%) |
ENSEAL N = (%) |
Harmonic N = (%) |
Olympus PK N = (%) |
Olympus Thunderbeat N = (%) | Other N = (%) |
P-value |
|---|---|---|---|---|---|---|---|
| Gender | |||||||
| Female | 36 (52.9) | 6 (8.8) | 20 (29.4) | 2 (2.9) | 1 (1.5) | 3 (4.4) | 0.972 |
| Male | 10 (58.8) | 1 (5.9) | 5 (29.4) | 0 (0) | 0 (0) | 1 (5.9) | |
| Age | |||||||
| 25 – 34 | 18 (48.6) | 2 (5.) | 12 (32.4) | 2 (5.4) | 0 (0) | 3 (8.1) | 0.455 |
| 35 – 44 | 16 (51.6) | 5 (16.1) | 9 (29.0) | 0 (0) | 1 (3.2) | 0 (0) | |
| 45 – 54 | 10 (76.9) | 0 (0) | 3 (23.1) | 0 (0) | 0 (0) | 0 (0) | |
| 55+ | 2 (50.0) | 0 (0) | 1 (25.0) | 0 (0) | 0 (0) | 1 (25.0) | |
| Glove size | |||||||
| ≤ 6.5 | 29 (49.2) | 6 (10.2) | 18 (30.5) | 2 (3.4) | 1 (1.7) | 3 (5.1) | 0.719 |
| > 6.5 | 17 (65.4) | 1 (3.8) | 7 (26.9) | 0 (0) | 0 (0) | 1 (3.8) | |
| Practice setting | |||||||
| Academic | 28 (50.9) | 6 (10.9) | 16 (29.1) | 2 (3.1) | 1 (1.8) | 2 (3.1) | 0.730 |
| Private | 5 (55.6) | 0 (0) | 4 (44.4) | 0 (0) | 0 (0) | 0 (0) | |
| Govt/Military | 1 (25.0) | 0 (0) | 3 (75.0) | 0 (0) | 0 (0) | 0 (0) | |
| Community | 7 (70.0) | 0 (0) | 1 (10.0) | 0 (0) | 0 (0) | 2 (20.0) | |
| Other | 1 (100.0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
| Region | |||||||
| West | 4 (57.1) | 2 (28.6) | 0 (0) | 0 (0) | 0 (0) | 1 (14.3) | 0.607 |
| Midwest | 12 (54.5) | 1 (4.5) | 7 (31.8) | 1 (4.5) | 1 (4.5) | 0 (0) | |
| South | 13 (61.9) | 0 (0) | 6 (28.6) | 1 (4.8) | 0 (0) | 1 (4.8) | |
| Northeast | 12 (42.9) | 3 (10.7) | 11 (39.3) | 0 (0) | 0 (0) | 2 (7.1) | |
| International | 1 (100.0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
| Case volume | |||||||
| < 5 | 8 (57.1) | 1 (7.1) | 5 (35.7) | 0 (0) | 0 (0) | 0 (0) | 0.389 |
| 5 – 9 | 15 (65.2) | 2 (8.7) | 6 (26.1) | 0 (0) | 0 (0) | 0 (0) | |
| 10 – 14 | 7 (41.1) | 2 (11.8) | 6 (35.3) | 0 (0) | 1 (5.9) | 1 (5.9) | |
| 15 – 19 | 5 (62.5) | 0 (0) | 2 (25.0) | 0 (0) | 0 (0) | 1 (12.5) | |
| 20 – 24 | 6 (66.7) | 0 (0) | 2 (22.2) | 1 (11.1) | 0 (0) | 0 (0) | |
| 25 – 29 | 2 (40.0) | 0 (0) | 2 (40.0) | 0 (0) | 0 (0) | 1 (20.0) | |
| 30+ | 3 (33.3) | 2 (22.2) | 2 (22.2) | 1 (11.1) | 0 (0) | 1 (11.1) | |
Table 3.
Association of Device Characteristics and Preferred Energy Device (Mean)
| Characteristic | LigaSure | ENSEAL | Harmonic | Olympus PK | Olympus Thunderbeat | Other | P-value |
|---|---|---|---|---|---|---|---|
| Optimal thermal spread | 5.51 | 5.00 | 5.48 | 5.50 | 5.00 | 6.00 | 0.636 |
| Reduced plume | 4.47 | 3.83 | 3.86 | 4.50 | 3.00 | 4.67 | 0.553 |
| Surgeon ergonomics | 5.11 | 5.17 | 5.21 | 6.00 | 5.00 | 6.00 | 0.322 |
| Device reliability | 6.05 | 5.67 | 6.04 | 7.00 | 4.00 | 6.75 | 0.501 |
| Teachability | 5.35 | 4.50 | 5.15 | 6.50 | 4.00 | 5.75 | 0.796 |
| Availability in operating room | 6.41 | 5.67 | 5.41 | 7.00 | 3.00 | 6.25 | 0.069 |
There was a statistically significant difference between smaller- and larger-handed surgeons in the relative effect of surgeon ergonomics on device selection, with smaller-handed surgeons assigning more significant value to this device characteristic (Table 4). When selecting an ergonomic energy device for use during a laparoscopic case, fewer smaller-handed surgeons selected LigaSure and ENSEAL compared to larger-handed surgeons. There was no statistically significant difference between smaller- and larger-handed surgeons in Harmonic, Olympus PK, or Olympus Thunderbeat selection.
Table 4.
Association of Glove Size between Value of Ergonomics and Perception of Ergonomic Devices
| Glove Size < 6.5 | Glove Size > 6.5 | P-value | |
|---|---|---|---|
| Effect of surgeon ergonomics on device selection (Median) | 6 | 5 | 0.029 |
| Ergonomic for use during a 2-hour laparoscopic case | |||
| LigaSure (N =) | 32 | 21 | 0.026 |
| Harmonic (N =) | 31 | 10 | 0.235 |
| ENSEAL (N =) | 5 | 7 | 0.040 |
| Olympus PK (N =) | 3 | 1 | 1 |
| Olympus Thunderbeat (N =) | 4 | 0 | 0.306 |
| Aesculap Caiman (N =) | 0 | 0 | – |
| None of these devices (N =) | 8 | 3 | 1 |
DISCUSSION AND CONCLUSIONS
This study found that surgeon-level characteristics did not correlate with the preferred energy device used during gynecologic laparoscopy. Factors such as thermal spread, plume generation, ease of use, device reliability, and teachability did not influence the surgeon's preference for an energy device. The only significant factor associated with the choice of energy device was the availability of the device in the operating room.
A growing body of literature describes the impact of surgeon characteristics with ergonomic strain during minimally invasive surgery. A recent meta-analysis found that over 80% of gynecologic surgeons who perform laparoscopy reported musculoskeletal symptoms, with 30% seeking treatment and 3% requiring work-hour modifications.7 One study on laparoscopic device use, including LigaSureTM, ENSEALTM, and Harmonic scalpel, found that more women than men reported physical complaints and inappropriate device fit. However, this difference was no longer significant after controlling for glove size, age, case volume, and duration.6 While we found no difference in preferred energy devices between male and female respondents, this may indicate a tendency for most energy devices in production to be a similar size and therefore pose a similar ergonomic workload. A study investigating grip strength decline with repetitive use of LigaSureTM, ENSEALTM, and HALO PKSTM (Olympus, Center Valley, PA) found that more women than men found all three devices too large.5 This difference appears to be driven primarily by hand size rather than surgeon sex.
In contrast, a survey study of gynecologic oncologists found shorter height and smaller glove size were associated with increased strain, but did not identify any association between physical strain and the perceived fit of laparoscopic instruments.8 Furthermore, the results found that females had over 7 times the odds of having pain after controlling for height, glove size, and age. Our study found that female respondents tended to have smaller glove sizes and that smaller-handed surgeons valued device ergonomics more than larger-handed surgeons. However, this was not reflected in a difference in preferred energy devices.
Many studies have described the functional properties of advanced energy devices; however, there are few comparative clinical studies of these devices.9 Device-level characteristics such as vessel burst pressure, seal time, and plume are primarily studied in ex vivo studies; thus, their clinical relevance may not be as significant. This is reflected in our findings that no device-level characteristic apart from availability in the operating room influenced the choice of preferred energy device. This finding has substantial implications for biotechnology and medical device companies seeking to develop and distribute new energy devices for laparoscopy. Device properties may play a lesser role in uptake by surgeons at different facilities.
Strengths of our study include the breadth of energy devices included for consideration in our survey. Including surgeon characteristics such as glove size and case volume, build upon prior research investigating these factors. Furthermore, the distribution of this survey via social media enabled us to reach a broad demographic of respondents, including participants from all regions of the United States practicing in various clinical settings. As with other survey studies, our results may be limited by response accuracy, as demonstrated by the 11 responses with survey incompletion. Most survey respondents were aged 25 – 34 and female, limiting the generalizability of this study to the larger population of gynecologic laparoscopists.
In conclusion, this study indicates that device-level characteristics do not influence surgeon selection of an energy device during gynecologic laparoscopy. While previous studies have suggested that hand size may influence ergonomic workload, our study did not detect a preference discrepancy for energy devices. Future research on device ergonomics should investigate a larger spectrum of device sizes. Moreover, additional studies are indicated to determine how regional availability and marketing may influence the uptake of various devices for minimally invasive surgery.
Footnotes
Acknowledgements: none.
Disclosure: none.
Conflict of interests: none.
Funding sources: none.
Data availability statement: The data that support the findings of this study are available from the corresponding author, Dr. Lulu Yu, upon reasonable request.
Informed consent: Dr. Lulu Yu declares that written informed consent was obtained from the patient/s for publication of this study/report and any accompanying images.
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