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Excision of a scalp arteriovenous malformation using Thunderbeat™: The safe way forward?
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MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2016) xx, 1e2
CORRESPONDENCE AND COMMUNICATION Excision of a scalp arteriovenous malformation using Thunderbeat: The safe way forward? Dear Sir, In recent years, advanced energy devices have started to supersede traditional methods of staples, clips or ties, allowing the surgeon to achieve rapid tissue dissection without compromising haemostasis. One such device is Thunderbeat (TB, Olympus Medical Systems Corp. (Tokyo, Japan)), which delivers combined ultrasonic and electrically generated bipolar heat energy, enabling both sealing and cutting of vessels up to 7 mm diameter in one step.1,2 The Thunderbeat device has been shown to reduce the need for instrument exchange, thereby decreasing operative time, following laparoscopic hysterectomy.3 The device has also been used successfully in laparoscopic hemicolectomies, including sealing and division of the inferior mesenteric artery.4 No bleeding, organ injuries, or thermal injuries related to Thunderbeat have been reported. To date, the use of Thunderbeat technology in excision of vascular malformations has not been reported. We present the case of a 29 year old male with a 12 year history of an enlarging, pulsatile right parietal scalp swelling. His complained of debilitating pulsatile tinnitus. Diagnosis of a high flow AVM was confirmed using MR angiography, which also allowed identification of the nidus and multiple feeding vessels arising from the superficial temporal and the posterior auricular arteries (Figure 1). Following discussion in the Vascular Anomalies Multidisciplinary Team meeting, it was decided to offer this patient surgical excision in view of his symptoms. Under general anaesthesia, with the patient positioned supine on a head ring, a curvilinear hemicoronal incision was made around the posterior edge of the lesion. Skin flaps were raised using sharp dissection and monopolar Colorado needle diathermy. The Thunderbeat was used to seal and ligate feeding vessels measuring up to 1 cm in
Figure 1 MR Angiography (coronal view) displaying the extracranial AVM, deriving its supply via branches of the right superficial temporal artery.
diameter successfully, and no ties or clips were required (Figure 2). The device also proved useful in dissecting the margins of the lesion, allowing for simultaneous dissection and haemostasis. Care was taken to protect the surrounding skin from thermal damage. The operative time for excision and closure of the AVM in this case was 120 min. The incision was closed over a suction drain and the patient was discharged after 48 h. He has made an uneventful postoperative recovery.
Figure 2
Intra-op use of Thunderbeat device.
http://dx.doi.org/10.1016/j.bjps.2016.06.014 1748-6815/ª 2016 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. Please cite this article in press as: Amin O, et al., Excision of a scalp arteriovenous malformation using Thunderbeat: The safe way forward?, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/10.1016/j.bjps.2016.06.014
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MODEL
2
Correspondence and communication
Figure 3
AVM lesion in situ (left) and excised (right).
AVMs are high flow vascular lesions and severe haemorrhage is a major concern during excision.5 We successfully used the Thunderbeat to achieve secure simultaneous ligation and division of feeder vessels in this scalp AVM (Figure 3). The use of the device significantly reduced our operative time as no ties or clips were necessary. The instrument was also used for simultaneous marginal dissection and haemostasis of the edges of the lesion. Although other devices are available, recent in vivo studies comparing the performance of Thunderbeat with other energy based devices demonstrated faster tissue dissection, whilst maintaining a comparable safety profile.1,2 We plan to use the Thunderbeat for our future AVM excisions and will report back on our experience.
Conflicts of interest statement The authors have no conflict of interest to declare.
References 1. Seehofer D, Mogl M, Boas-Knoop S, et al. Safety and efficacy of new integrated bipolar and ultrasonic scissors compared to conventional laparoscopic 5-mm sealing and cutting instruments. Surg Endosc 2012;26(9):2541e9.
2. Milsom J, Trencheva K, Monette S, et al. Evaluation of the safety, efficacy, and versatility of a new surgical energy device (THUNDERBEAT) in comparison with harmonic ACE, LigaSure V, and EnSeal devices in a porcine model. J Laparoendosc Adv Surg Tech 2012;22(4):378e86. 3. Fagotti A, Vizzielli G, Fanfani F, et al. Randomized study comparing use of THUNDERBEAT technology vs standard electrosurgery during laparoscopic radical hysterectomy and pelvic lymphadenectomy for gynecologic Cancer. J Minim Invasive Gynecol 2014;21(3):447e53. 4. Milsom J, Trencheva K, Sonoda T, Nandakumar G, Shukla P, Lee S. A prospective trial evaluating the clinical performance of a novel surgical energy device in laparoscopic colon surgery. Surg Endosc 2014;29(5):1161e6. 5. Kumar R, Sharma G, Sharma B. Management of scalp arteriovenous malformation: case series and review of literature. Br J Neurosurg 2012;26(3):371e7.
Omed Amin Alexandra R. Molina Joannis Constantinides Aina V. Greig Department of Plastic Surgery, St Thomas’ Hospital, London SE1 7EH, United Kingdom E-mail address: [email protected] 17 June 2016
Please cite this article in press as: Amin O, et al., Excision of a scalp arteriovenous malformation using Thunderbeat: The safe way forward?, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/10.1016/j.bjps.2016.06.014
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2016) xx, 1e2
CORRESPONDENCE AND COMMUNICATION Excision of a scalp arteriovenous malformation using Thunderbeat: The safe way forward? Dear Sir, In recent years, advanced energy devices have started to supersede traditional methods of staples, clips or ties, allowing the surgeon to achieve rapid tissue dissection without compromising haemostasis. One such device is Thunderbeat (TB, Olympus Medical Systems Corp. (Tokyo, Japan)), which delivers combined ultrasonic and electrically generated bipolar heat energy, enabling both sealing and cutting of vessels up to 7 mm diameter in one step.1,2 The Thunderbeat device has been shown to reduce the need for instrument exchange, thereby decreasing operative time, following laparoscopic hysterectomy.3 The device has also been used successfully in laparoscopic hemicolectomies, including sealing and division of the inferior mesenteric artery.4 No bleeding, organ injuries, or thermal injuries related to Thunderbeat have been reported. To date, the use of Thunderbeat technology in excision of vascular malformations has not been reported. We present the case of a 29 year old male with a 12 year history of an enlarging, pulsatile right parietal scalp swelling. His complained of debilitating pulsatile tinnitus. Diagnosis of a high flow AVM was confirmed using MR angiography, which also allowed identification of the nidus and multiple feeding vessels arising from the superficial temporal and the posterior auricular arteries (Figure 1). Following discussion in the Vascular Anomalies Multidisciplinary Team meeting, it was decided to offer this patient surgical excision in view of his symptoms. Under general anaesthesia, with the patient positioned supine on a head ring, a curvilinear hemicoronal incision was made around the posterior edge of the lesion. Skin flaps were raised using sharp dissection and monopolar Colorado needle diathermy. The Thunderbeat was used to seal and ligate feeding vessels measuring up to 1 cm in
Figure 1 MR Angiography (coronal view) displaying the extracranial AVM, deriving its supply via branches of the right superficial temporal artery.
diameter successfully, and no ties or clips were required (Figure 2). The device also proved useful in dissecting the margins of the lesion, allowing for simultaneous dissection and haemostasis. Care was taken to protect the surrounding skin from thermal damage. The operative time for excision and closure of the AVM in this case was 120 min. The incision was closed over a suction drain and the patient was discharged after 48 h. He has made an uneventful postoperative recovery.
Figure 2
Intra-op use of Thunderbeat device.
http://dx.doi.org/10.1016/j.bjps.2016.06.014 1748-6815/ª 2016 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. Please cite this article in press as: Amin O, et al., Excision of a scalp arteriovenous malformation using Thunderbeat: The safe way forward?, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/10.1016/j.bjps.2016.06.014
+
MODEL
2
Correspondence and communication
Figure 3
AVM lesion in situ (left) and excised (right).
AVMs are high flow vascular lesions and severe haemorrhage is a major concern during excision.5 We successfully used the Thunderbeat to achieve secure simultaneous ligation and division of feeder vessels in this scalp AVM (Figure 3). The use of the device significantly reduced our operative time as no ties or clips were necessary. The instrument was also used for simultaneous marginal dissection and haemostasis of the edges of the lesion. Although other devices are available, recent in vivo studies comparing the performance of Thunderbeat with other energy based devices demonstrated faster tissue dissection, whilst maintaining a comparable safety profile.1,2 We plan to use the Thunderbeat for our future AVM excisions and will report back on our experience.
Conflicts of interest statement The authors have no conflict of interest to declare.
References 1. Seehofer D, Mogl M, Boas-Knoop S, et al. Safety and efficacy of new integrated bipolar and ultrasonic scissors compared to conventional laparoscopic 5-mm sealing and cutting instruments. Surg Endosc 2012;26(9):2541e9.
2. Milsom J, Trencheva K, Monette S, et al. Evaluation of the safety, efficacy, and versatility of a new surgical energy device (THUNDERBEAT) in comparison with harmonic ACE, LigaSure V, and EnSeal devices in a porcine model. J Laparoendosc Adv Surg Tech 2012;22(4):378e86. 3. Fagotti A, Vizzielli G, Fanfani F, et al. Randomized study comparing use of THUNDERBEAT technology vs standard electrosurgery during laparoscopic radical hysterectomy and pelvic lymphadenectomy for gynecologic Cancer. J Minim Invasive Gynecol 2014;21(3):447e53. 4. Milsom J, Trencheva K, Sonoda T, Nandakumar G, Shukla P, Lee S. A prospective trial evaluating the clinical performance of a novel surgical energy device in laparoscopic colon surgery. Surg Endosc 2014;29(5):1161e6. 5. Kumar R, Sharma G, Sharma B. Management of scalp arteriovenous malformation: case series and review of literature. Br J Neurosurg 2012;26(3):371e7.
Omed Amin Alexandra R. Molina Joannis Constantinides Aina V. Greig Department of Plastic Surgery, St Thomas’ Hospital, London SE1 7EH, United Kingdom E-mail address: [email protected] 17 June 2016
Please cite this article in press as: Amin O, et al., Excision of a scalp arteriovenous malformation using Thunderbeat: The safe way forward?, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/10.1016/j.bjps.2016.06.014