Histological study on the influences of an ultrasonic scalpel on skeletonized vessel wall.

OBJECTIVE The objective of this study was to histologically clarify the difference of vascular wall damage when an ultrasonic scalpel is used in varied ways in the vicinity of a vessel. SUBJECTS AND METHODS 1) The surface of sodium carbonate-containing jelly was manually brushed with the edge of a dissecting hook type Harmonic Scalpel (HS), and the thickness of the air bubble layer was measured to investigate the range to which the vibrations of the instrument reached. 2) The internal thoracic artery (ITA), radial artery (RA) and vein skeletonized were cut bluntly or brushed using HS ex vivo, and tissue damages were observed histologically. 3) The depth of thermal degeneration (TD) of residual stumps of ITAs skeletonized by HS using an output power level (level) of 2 and the quick touch method at the time of coronary arterial bypass grafting (CABG) were investigated histologically. RESULTS 1) The mean thickness of the air bubble layers by single brushing was 3.7, 3.7 and 3.1 mm at level 4, 3 and 2, and no significant difference. When brushed 5 times, it was 6.9, 5.5 and 6.7 mm, respectively, showing marked increases compared with single brushing. 2) A: One side of the RA stump cut with a dissecting hook at level 2 was nicely occluded by a degenerated protein coagulum, but the contralateral had no coagulum. An ITA cut by a shear type blade at level 3 showed that both stumps were nicely occluded, but the vessel wall was introverted and fragmented. B: ITAs brushed 5 or 10 times at level 2 showed that TD occurred in tunica externa, the mean depth of 100 or 203 microm, and never exceeded the external elastic lamella. RAs brushed 10 times at level 2 and 3 showed that TD and air bubble generation occurred in the tunica externa, and the mean depth was 203 and 203 microm. However, TD exceeded the external lamella in some cases at level 3. Veins brushed 10 times at level 3 showed that TD spread to all layers. 3) The depth of TD in ITAs skeletonized clinically by HS was 400 to 530 microm, and apart from the external elastic lamella. CONCLUSIONS 1) Though the air bubble layer was very thick in jelly, it was observed only in tunica externa ex vivo. 2) For coagulation and cut of small blood vessels, it is vital to press an HS blade edge onto the vessel so as to press equally both portions to be cut. There is a possibility of a fragmented and introverted vessel wall into the lumen. 3) By dissecting ITA and RA using HS at level 2 and the quick touch method, TD can be limited to the depth of the connective tissue of tunica externa.