Table 3.

Main advantages and disadvantages of common energy devices in laparoscopic and robotic gynecologic surgery

Energy source	Advantages	Disadvantages	Notable study findings
Conventional monopolar electrosurgery	Versatility of tissue effects (vaporization, fulguration, desiccation, coaptation) Widespread availability Cost-effective	Potential for stray current injuries Capable of sealing small vessels (< 2 mm) Requires a return electrode (located away from the surgical site) Higher risk for lateral thermal spread	CM was associated with shorter operative time during colpotomy in TLH compared to HS, but resulted in significantly greater lateral thermal damage
Conventional bipolar electrosurgery	Lower voltage required to achieve the desired tissue effect and risk of stray current injury (due to the proximity of the 2 electrodes/jaws); Ability to seal larger vessels vs monopolar devices ($\le$ 5 mm)	Lack of versatility of tissue effects (neither vaporization nor fulguration is possible) Requirement of another device to transect the dissected tissue Limited to vessel sealing ($\le$ 5 mm) Tissue adherence to the electrodes Lateral thermal spread (less vs. monopolar)	CB was as efficient as LS during laparoscopic salpingo-oophorectomy
Advanced bipolar devices (LS, PK, ENS, ALAN, MS, BiCision)	Seals vessels up to 7 mm Feedback-controlled energy Integrated vessel sealing and cutting mechanism Low lateral thermal spread	Costs Availability Bulky jaw in some models	Laparoscopic hysterectomy: ALAN demonstrated the lowest pooled mean operative times ENS was associated with the lowest pooled mean blood loss and shortest hospital stay Laparoscopic supracervical hysterectomy: LS, ENS and BiCision were associated with significantly reduced blood loss, shorter operative time and hospital stay (vs. CB or UD) Laparoscopically assisted vaginal hysterectomy: Pooled mean blood loss, operative time and hospital stay were the lowest using PK Hysterectomy via transvaginal NOTES: LS showed significantly reduced operative time vs. CB (without additional procedures) Laparoscopic myomectomy: the use of LS was associated with a shorter hospital stay compared to PK
Ultrasonic devices	Seal vessels and transect tissues simultaneously Less tissue necrosis and charring Minimal smoke and lateral thermal spread	Slower coagulation (vs. advance bipolar devices) Limited tissue dissection (vs monopolar scissors) Higher post-activation instrument tip temperatures (vs. advance bipolar devices) Blade fatigue	Endometrial and cervical cancer staging: significantly higher number of lymph nodes harvested with HS vs. CE Laparoscopic myomectomy: significantly shorter global operative time, less intraoperative blood loss, postoperative pain score and a shorter hospital stay with HS vs. CE Colpotomy: HS was associated with less lateral thermal damage vs. CM
Thunderbeat™	Combines ultrasonic and bipolar energy Fast cutting and dissecting tissues Seals up to 7 mm vessels High burst pressure Minimal lateral thermal spread	Bulky handpiece Costs	TB was less time-consuming during LRH with lymph node dissection and was associated with less postoperative pain compared to conventional energy
CO2 laser	High precision with minimal lateral thermal spread No electrical current through tissue	Costs Availability Training Specialized setup required	Robotic surgery: Total hysterectomy: less lateral thermal spread vs. CM Myomectomy: shorter hospital stay vs. HS

CB conventional bipolar, CE conventional electrosurgery, CM conventional monopolar, ENS EnSeal, LS LigaSure, MS MarSeal, NOTES natural orifice transluminal endoscopic surgery, PK plasmakinetic system, TB thunderbeat