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PubMed2006

Cervical sensory preservation during neck dissection.

Although the practice of neck dissection has greatly advanced from radical to function-preserving surgery, the impact of the sensory nerve-preserving neck surgery on the pain and quality of life (QOL) of patients has received little study. We evaluated neck morbidity and its impact on QOL associated with selective or modified radical neck dissection with or without preservation of cervical root branches. We conducted a retrospective cohort study comparing 24 patients who had their cervical root branches preserved to 29 patients whose root branches were removed during neck dissection. The spinal accessory nerve was preserved and sex, age, pathologic status, side and extent of neck dissection, and radiotherapy were comparable between groups. The groups were compared based on sensory and motor functions of the neck and shoulder and questionnaires on depression and QOL at follow-up of mean 18.7 (range 12-34) months after surgery. The nerve-preserved patients showed a low incidence and severity of neck and shoulder pain compared to the nerve-removed subjects (p<.05). Loss of sensation was more frequently experienced in the nerve-removed group on the earlobe and the lateral neck of the operated side (p<.05). Depression and QOL scores were higher in the nerve-removed group and significantly correlated with pain intensity. Preservation of the cervical root branches reduces postoperative pain as well as permanent anesthetic areas of the neck. This may also improve the mental state and QOL of patients undergoing neck dissection.

Adult↗

PubMed2005

Short hospital stay after neck dissection.

OBJECTIVE: Cervical lymphadenectomy is a common adjunctive therapy for the treatment of head and neck malignancies. Postoperative care of otherwise healthy patients with isolated neck dissection or in combination with other procedures often requires limited nursing attention after the first postoperative day. At our institution, patients are often taught to manage their drains and discharged home. Therefore, we sought to characterize the subset of patients who will require only overnight hospital care after neck dissection. STUDY DESIGN: We retrospectively reviewed our experience in a tertiary academic medical center over the past 6 years with patients who underwent neck dissection, isolated or with other procedures, and were sent home by postoperative day 1. RESULTS: In all, 23 of 260 patients were identified (8.8%). Two patients were noted to have postoperative seromas, with no other complications noted. CONCLUSION: We conclude that short hospital stay after neck dissection is reasonable for the motivated patient without significant comorbidities. SIGNIFICANCE: This is the first study to examine the feasibility of short hospital stay after neck dissection. EBM RATING: C.

Academic Medical Centers↗

PubMed2004

A simple but useful method of screening for mesenteric ischemia secondary to acute aortic dissection.

BACKGROUND: In spite of recent improvements in treatment for acute aortic dissection, mesenteric ischemia secondary to aortic dissection is still challenging. We propose a simple screening method to detect mesenteric ischemia secondary to acute aortic dissection. METHODS: From 1991 to 2002, 245 patients with acute aortic dissection were admitted to our hospital. Nine (3.7%) of those were complicated with mesenteric ischemia. The clinical records of those 9 patients were retrospectively analyzed. The ratios of the diameter of the superior mesenteric vein (SMV) to that of the superior mesenteric artery (SMA) were calculated in patients with mesenteric ischemia (group M) and in patients without mesenteric ischemia (group C). Blood test data, including results of arterial blood gas analysis, in the 2 groups were also compared. RESULTS: The SMV/SMA ratios in groups M and C were 1.16 +/- 0.33 and 1.78 +/- 0.29, respectively (P=.003). A cutoff value of the SMV/SMA ratio was 1.5 (sensitivity, 88.9%; specificity, 88.9%) with an odds ratio of 64.0. Although there were differences between the 2 groups in glutamate oxaloacetate transaminase, lactate dehydrogenase, creatine phosphate kinase, pH, and lactate values, the measurement of lactate was especially useful (P=.002). CONCLUSIONS: The combination of the SMV/SMA ratio and lactate concentration is a useful screening method to detect mesenteric ischemia secondary to acute aortic dissection.

Aged↗

PubMed2005

Staged bilateral vertebral artery occlusion for ruptured dissecting aneurysms of the basilar artery: a report of 2 cases.

BACKGROUND: Dissecting aneurysm of the basillary artery BA is rare. Although mortality rate is high, management remains controversial. We report 2 cases of dissecting aneurysm of the BA presenting with subarachnoid hemorrhage (SAH), both of which were successfully treated using staged occlusion of bilateral vertebral arteries (VAs). CASE DESCRIPTION: A 64-year-old man and a 34-year-old woman presented with SAH associated with ruptured dissecting aneurysm of the BA. After endovascular occlusion of a single VA, blood flow in the dissected lumen was reduced. However, one aneurysm rebled and the bleb of the other did not change. Vertebral arteries were also occluded using endovascular techniques at 4 and 2 weeks after initial treatment, respectively. On the second intervention, stump pressure ratios of VAs intended for occlusion were 62.5% and 50.6%, respectively. The patients tolerated temporary occlusion of bilateral VAs well. Subsequent permanent occlusion of bilateral VAs resulted in no neurological complication. Complete obliteration of the aneurysmal lumen was demonstrated on magnetic resonance angiography performed 72 and 5 months later, respectively. CONCLUSION: Staged bilateral VA occlusion might be the last recourse to prevent further hemorrhage from BA dissecting aneurysm. The technique can be safely applied when the stump pressure ratio is 50.6% or greater and when the patient tolerates temporary occlusion, which suggests the existence of sufficient collateral flow from the anterior circulation.

Adult↗

PubMed2000

Usefulness of transesophageal echocardiography in the assessment of aortic dissection.

The acute dissection of the ascending aorta requires prompt and reliable diagnosis to reduce the high risk of mortality; in addition, prognosis is influenced by long-term complications. The aim of this article is to discuss transesophageal echocardiography (TEE) and (1) its diagnostic accuracy in the presurgical evaluation of patients, (2) its role in reducing time of diagnosis and surgery, and (3) its ability to reduce hospital mortality. TEE has also been tested as a screening method in the postsurgical follow-up of these patients. The retrospective investigation concerns a sample of 80 cases of acute dissection of the aorta, submitted for surgical intervention from April 1986 to February 1999. TEE has allowed a precise estimation of aortic diameters and optimal visualization of intimal flap and tear entry with a fine distinction between true and false lumen. A direct comparison of the results of TEE and of transthoracic echocardiography has demonstrated that some elements (visualization of flap and diameters in descending aorta, sites of entry and reentry, direction of jet trough intimal tears, phasic intimal flap movement, diastolic collapse of flap on the valvular plane, false lumen thrombosis, coronary involvement, intramural hematoma, and aortic fissuration) were identified only by TEE, whereas other additional diagnostic elements (cardiac tamponade, aortic valve insufficiency, left ventricular function) show a similar pattern of significance. Routine employment of this method has confirmed a reduction of hospitalization time (about 1.5 hours of waiting time), and hospital mortality has changed from 42.8% to 17.3%. In the follow-up of patients operated on for aortic dissection, fundamental information may be obtained from TEE (assessment of the progression of thrombosis in the false lumen with its complete obliteration and modifications in aortic diameter with a consequent, possible worsening of aortic valve insufficiency). In conclusion, our study demonstrated that TEE may provide fast and efficient detection of acute aortic dissection. In the postsurgical follow-up, TEE has confirmed detection of major complications that can influence long-term prognosis and may be proposed as a method with easy access-one that is repeatable and inexpensive for the screening of aortic dissection surgical patients.

Aortic Dissection↗

PubMed2002

Outcome of nonobstructive residual dissections detected by intravascular ultrasound following percutaneous coronary intervention.

The purpose of this study was to assess the outcome of nonobstructive (or non-flow-limiting) residual dissection (RD) after percutaneous coronary intervention. Results of 124 consecutive native coronary lesions with angiographic nonobstructive RD in 97 patients (RD group) were compared with outcomes of 124 lesions without RD in 100 patients (non-RD group), whose characteristics were matched with those of the RD group. RD occurred after stent implantation (81 of 124 lesions, 65%) or balloon angioplasty (43 of 124 lesions, 35%). Angiographic types of RD were type A in 8 lesions (6%), B in 101 (82%), and C in 15 (12%). Stents were implanted in 65% of the lesions in each group. Clinical success (94% in RD group vs 95% in non-RD group, p = 0.77) and the in-hospital major adverse cardiac event rates were found to be similar in the 2 groups (6% vs 3%, respectively; p = 0.33). The late angiographic and clinical outcomes were also comparable. By intravascular ultrasound (IVUS) evaluation of the dissections in the RD group, area stenosis correlated with the incidence of in-hospital major adverse cardiac events (p = 0.023), whereas the final minimal lumen area correlated inversely with the occurrence of restenosis (p = 0.011). An area stenosis > or =58% was the best predictor for the incidence of in-hospital major adverse cardiac events (sensitivity 0.68, specificity 0.68). Most nonobstructive RDs are "favorable" and do not need stent implantation. IVUS evaluation identifies "unfavorable" nonobstructive (or non-flow-limiting) dissections that might be prone to acute occlusion. Nonobstructive dissections can be left untreated when final IVUS reveals an area stenosis of < 60% at the site of a dissection.

Aortic Dissection↗

PubMed1994

The role of comprehensive neck dissection with preservation of the spinal accessory nerve in the clinically positive neck.

BACKGROUND: The most significant prognostic factor in patients with squamous cell carcinoma of the head and neck is the presence of cervical nodal metastases. Radical neck dissection is the standard by which all cervical lymphadenectomy procedures are judged. In the presence of clinically positive nodal metastasis, the benefit of preserving the spinal accessory nerve (SAN) has to be weighed against the possible risk of increased failure in the neck. We performed this retrospective study to determine if preservation of the SAN in patients with clinically evident nodal metastases was associated with increased risk of failure in the dissected neck. PATIENTS AND METHODS: Between January 1, 1984 and December 31, 1991, 378 comprehensive neck dissections were performed in 366 patients with clinically and pathologically positive nodal metastases from squamous carcinoma of the upper aerodigestive tract. We compared survival, neck control rates, and other factors in patients who had a classic radical neck dissection (RND) to those who had modified radical neck dissection sparing only the SAN (MRND I). RESULTS: Actuarial 5-year survival and neck failure rates for the RND group were 63% and 12%, compared to 71% and 8% for the MRND I group (P = NS). Survival and neck failure were not statistically different between the MRND I and RND groups when the analysis controlled for pathologic N stage, presence of extra capsular spread, and the presence of pathologically demonstrated metastatic nodes along the course of the SAN. Nor were there significantly different patterns of neck failure with RND versus MRND. CONCLUSION: Modification RND to preserve an uninvolved SAN in the clinically positive neck does not adversely affect survival or neck control.

Accessory Nerve↗

PubMed1999

Clinicopathological analysis of elective neck dissection for N0 neck of early oral tongue carcinoma.

BACKGROUND: The study aims at evaluation of the efficacy of elective neck dissection as a staging and therapeutic procedure for N0 neck of early carcinoma of the oral tongue by whole organ serial sectioning. METHODS: There were 50 stage I and II patients. The neck dissection specimens were whole organ sectioned in 3-mm intervals for the evaluation of nodal metastasis. RESULTS: There were 18 (36%) patients with subclinical nodal metastasis. The total number of metastatic nodes were 31 (1%) among all 2,826 nodes being examined. The metastatic foci had a median size of 3 mm and occupied a median of 6% of the cross sectional area of the involved nodes. The ipsilateral level II nodes were the commonest (26%) site of metastasis. Metastatic nodes were present in 34% patients who had negative preoperative radiological assessment and in 20% patients who had negative intraoperative frozen section sampling of neck nodes. Patients with subclinical nodal metastasis had a high incidence of regional recurrence (62%) and low survival (27%) when postoperative radiotherapy was not given after elective neck dissection. CONCLUSIONS: Ipsilateral level I,II,III neck dissection is an adequate diagnostic procedure for staging of the N0 neck of early oral tongue carcinoma. Its diagnostic role cannot be replaced by the available pre-operative radiological screening and intra-operative frozen section sampling. However, elective selective neck dissection is an effective but not adequate therapeutic procedure, and post-operative adjuvant radiotherapy and chemotherapy have to be considered for all pathologically positive necks.

Adolescent↗

PubMed2006

[Neck dissection for stage N0 oral cavity carcinoma].

OBJECTIVES: The management of N0 neck remains controversial. The purpose of this study was to evaluate the efficacy of selective neck dissection (SND) in managing N0 neck of oral cavity carcinomas. MATERIAL AND METHODS: A retrospective chart review of 77 previously untreated patients with squamous cell carcinomas of the oral cavity with N0 neck from 1988 to 2001 was performed. Cervical treatments were "wait and see" policy in 7 cases, neck dissection in 56 cases, radiotherapy alone in 14 cases. 77 neck dissections were performed in which 62 were selective and 15 were radical modified. RESULTS: On pathologic examination, the average number of lymph nodes was 10.7 per neck. Occult disease (cN0pN+) was detected in 32.5%, and occult extracapsular spread (cN0pN+R+) was detected in 7.8%. The median follow-up was 43 months. The overall neck recurrence rate in patients with controlled primary disease was 2.4%. Recurrent disease developed in 2.9% of the cNOpN0 neck. Regional control rate of the dissected neck was 94%. No cervical recurrence occurred in 11 patients treated with SND alone. There was no survival or recurrence rate difference in T1T2pN0 patients with or without post-operative radiotherapy. Post-operative radiotherapy could be avoided in 27% of the dissected neck. One, 3 and 5 years overall survival rate were 89.3%, 77.7% and 63.2%. CONCLUSIONS: SND is an effective procedure for staging and treating the clinically negative neck of oral cavity cancer.

Adult↗

PubMed2002

Self-expandable aortic stent-grafts for treatment of descending aortic dissections.

BACKGROUND: Acute aortic dissection is a life-threatening medical condition that is associated with high morbidity and mortality. METHODS: Of 198 patients treated with a self-expanding polyester-covered stent-graft for various pathologic aortic conditions in our institution, we selected 70 consecutive patients with type B aortic dissection who were undergoing treatment. The stent-graft was introduced through the femoral artery in the angiography suite, under general anesthesia with systemic heparinization and induced hypotension. RESULTS: The procedure was performed in 70 patients; of these, 58 had descending aortic dissection and 12 had atypical dissections. The procedure was successful in 65 patients (92.9%), as documented by exclusion of the false lumen of the thoracic aorta. Eleven patients (18.9%) had persistent blood flow in the false lumen of the abdominal aorta due to distal reentries. Five patients (7.1%) underwent conversion to surgery. Insertion of additional stent-grafts was required in 34 patients (48.6%). At 29 months of follow-up, 91.4% of the patients were alive. CONCLUSIONS: Stent-grafts are an important means of treating aortic dissections, which may replace conventional medical treatment of this condition for the majority of patients.

Acute Disease↗

PubMed2002

Revolutionary treatment of aneurysms and dissections of descending aorta: the endovascular approach.

BACKGROUND: Acute aortic dissection is a life-threatening medical condition. It is associated with high morbidity and mortality. Type B dissections are usually managed clinically during the acute phase. Conventional surgery carries high mortality rates due to the presence of serious complications. We herein present treatment of this condition with a less invasive endovascular approach. Other clinical situations such as penetrating ulcers, intramural hematomas, and true aneurysms of descending aorta were similarly treated. METHODS: From December 1996 to March 2002, 191 patients with type B dissections were treated with self-expandable, polyester-covered stents. There were 120 patients (62.8%) with type B dissections, 61 patients (31.9%) with true aneurysms, 6 patients (3.1%) with penetrating ulcers or intramural hematomas, and 4 patients (2.1%) with trauma. Patients with abdominal aneurysms (44) and stents introduced under direct vision through the aortic arch (70) were excluded. The stent graft was delivered in the catheterization laboratory under general anesthesia, with induced hypotension and heparinization. All stents used were made in Brazil (Braile Biomedics, Sao Jose do Rio Preto, SP). RESULTS: The procedure was performed in 191 consecutive cases. The success rate was 91.1% (174/191). Success was defined as occlusion of the thoracic intimal tear, or exclusion of the aneurysm without leaks. Hospital mortality was 10.4% (20/191 patients), due to preoperative comorbidities. Six patients required conversion to surgery. No case of paraplegia was observed. An actuarial survival curve showed 87.4% +/- 29% survival in the late follow-up period. CONCLUSIONS: Stent grafts are an important development in the treatment of descending aortic aneurysms or dissections. This novel approach may replace conventional surgical treatment of these conditions, with earlier intervention and less morbidity.

Aortic Dissection↗

PubMed2003

Routine extended graft replacement for an acute type A aortic dissection and the patency of the residual false channel.

BACKGROUND: Recent surgical progress has had an impact on the mortality of acute type A aortic dissection. Routine aortic arch replacement, irrespective of the location of the intimal tears, may improve not only the outcome of the residual dissection but the operative mortality, because complete resection of intimal tears, including those invisible through the aortotomy in the ascending aorta is achieved. METHODS: During the past 7 years, total aortic arch replacement was performed in 50 consecutive patients with acute type A aortic dissection. Cerebral protection was achieved by deep hypothermia associated with pharmacologic cerebroplegia. Computed tomography and aortic angiography were performed to examine 48 patients for the possible presence of residual false channels before discharge. RESULTS: The duration of circulatory arrest ranged from 30 to 84 minutes. The hospital mortality was 10%, and a cerebral complication was observed in 1 patient. No evidence of a persisting false channel was detected in 27 patients (54%) who were totally thrombosed. During the follow-up period (range: 2 months to 7 years), 2 patients died of hepatoma or pneumonia, respectively, and 2 patients underwent reoperation for recurrence of a dissection at the sinus of Valsalva. The Kaplan-Meier method estimated a 7-year survival of 82%, and a 7-year freedom from reoperation of 93%. CONCLUSIONS: These results suggest that our aggressive use of routine aortic arch grafting can be accomplished with an acceptable risk and that our strategy not only improved the late results but the mortality associated with repairs for acute type A aortic dissection.

Acute Disease↗

PubMed1977

Retrograde aortic dissection during cardiopulmonary bypass: "nonoperative" management.

Seven patients are reported in whom retrograde aortic dissection occurred, 2 during valve replacement and 5 during coronary artery bypass, among 770 patients perfused through the common femoral artery. Successful management included : (1) immediate cessation of cardiopulmonary bypass; (2) removal of the arterial cannula and its replacement in the ascending aorta, usually through both lumens of the dissection; (3) completion of the operation by suturing the proximal ends of saphenous vein grafts to both lumens of the dissection in the ascending aorta; and (4) no treatment of the dissection itself. One patient died of other causes 30 days postoperatively. Follow-up from 2 to 3 1/2 years in 6 long-term survivors has revealed no complications related to the dissection. Saphenous vein graft function is apparently satisfactory.

Adult↗

PubMed1997

Surgical treatment of acute type B aortic dissection using an endoprosthesis (elephant trunk).

BACKGROUND: The surgical treatment of acute complicated type B aortic dissection continues to be a challenge and is still associated with high morbidity and mortality rates. METHODS: Seventy consecutive patients with an acute type B aortic dissection underwent an elephant trunk procedure through a median sternotomy during deep hypothermic circulatory arrest. An endoprosthesis that was 22 to 24 mm in diameter was inserted through an incision in the arch and held in place with only proximal sutures. RESULTS: The mean arrest time was 31.4 +/- 8.7 minutes, and it was possible to adequately position the endoluminal graft in every patient. The procedure was done in association with other procedures in 13 patients. There were six in-hospital deaths not related to the endoprosthesis, and four late deaths. Late reoperation was necessary in 6 patients to manage leakage at the proximal suture line. CONCLUSIONS: The insertion of an endoprosthesis through the arch for the management of a complicated acute type B dissection has several advantages over the conventional thoracotomy approach. The hospital mortality rate in this series of 70 patients was 20%, and the actuarial 5-year survival rate was 62.5%. We consider the elephant trunk procedure the treatment of choice in patients with type B acute dissections, regardless of whether the dissection is complicated or not.

Adult↗

PubMed1997

Surgical delay for acute type A dissection with malperfusion.

BACKGROUND: An acute type A aortic dissection is considered a surgical emergency. Review of the risk factors for a type A dissection showed that preoperative malperfusion was associated with a 22% (2/9) intraoperative mortality and an 89% (8/9) hospital mortality. Intraoperative deaths were secondary to pulmonary failure resulting from capillary leak; the remaining patients died of multiorgan failure resulting from reperfusion injury. METHODS: The surgical delay approach was adopted for malperfused patients, and treatment in these patients included percutaneous reperfusion, with aortic fenestration and branch stenting where appropriate. Twenty patients had a type A dissection and malperfusion shown by pulsed-wave Doppler echocardiography, transesophageal echocardiography, or spiral computed tomographic scanning. Malperfusion was documented by angiography. After reperfusion, all patients' conditions were stabilized in the intensive care unit; intravenous beta-blockers were administered to decrease the maximum rate of increase of left ventricular pressure. Once patients completely recovered from the consequences of malperfusion, surgical repair was performed. Statistical comparison of the non-delay and delay groups was performed using Fisher's exact test and Student's t test. Multiple logistic regression analysis was used to establish independent predictors for mortality. RESULTS: The mean delay to repair was 20 days (2 to 67 days). Four (31%) patients were discharged home and readmitted for operation. Three patients (15%) died preoperatively, 1 of retrograde dissection and rupture and 2 of reperfusion injury. Seventeen underwent surgical repair, with two deaths (12%); 15 (75%) were discharged, with an average follow-up of 16.8 months (p < 0.003). Delay was the only independent predictor of outcome. CONCLUSIONS: Patients with an acute type A dissection and malperfusion should undergo percutaneous reperfusion, and surgical repair should be delayed until the reperfusion injury resolves.

Adult↗

PubMed1999

Extended aortic replacement in acute dissection by the separated elephant trunk technique.

BACKGROUND: Extensive aortic replacement in acute dissection is currently not a widely accepted method of treatment. METHODS: We developed a safe method for extended aortic repair including the aortic arch in type A acute dissection, and describe here its application in 5 cases. This method was based on a modification of the elephant trunk method and several other strategies. Most of the procedures were carried out under simple hypothermic circulatory arrest. RESULTS: All patients recovered within 2 days without recurrent nerve injury. One patient suffered from unilateral upper arm palsy due to severe innominate dissection. Patients were all discharged and early postoperative computed tomography (CT) showed thrombotic obliteration around the elephant trunk. Follow-up CT after 4 to 18 months confirmed that thromboexclusion proceeded down to the distal end of the elephant graft in 1 patient and to the diaphragmatic level in 3 patients. Total obliteration was observed in the remaining 1 patient. CONCLUSIONS: This technique enables extended aortic repair in acute dissection with no increase in morbidity, and effectively promotes thromboexclusion of the dissected lumen to a wider extent than conventional methods.

Aged↗

PubMed1999

Application of AdvaSeal for acute aortic dissection: experimental study.

BACKGROUND: In the surgical treatment of acute aortic dissection, intractable hemorrhage often occurs. We performed an animal study to test the hypothesis that a new sealant, AdvaSeal (Ethicon Inc, Johnson & Johnson Medical KK, Somerville, NJ), can close the false channel of aortic dissection. METHODS: Acute descending aortic dissection was created surgically in 12 mongrel dogs. In 7 of these (treated group), AdvaSeal was applied to the false cavity for reinforcing and fusing the dissected layers and also to the suture line. The other 5 dogs (control) were left untreated. Specimens were harvested 2 weeks after surgery. RESULTS: The sealant could be used in wet conditions. In the treated group, hemostasis was easily achieved during surgery. All false cavities were perfectly thrombosed, causing no deleterious effects related to the sealant. In the control group, all false lumina remained patent. CONCLUSIONS: The advantage of AdvaSeal was its effectiveness on wet tissue and its adhesiveness, allowing good hemostasis and closure of the false lumen. The sealant can be an easy and efficacious sealant in treatment for acute aortic dissection.

Acute Disease↗

PubMed1997

Proximity injury by the ultrasonically activated scalpel during dissection.

The ultrasonically activated scalpel is a high-frequency oscillating instrument that is reported to have a decreased dispersion of energy to surrounding tissues during use. To determine if this effect is beneficial and safe to surrounding tissue, it was used on anesthetized adolescent swine to dissect the portal vein from the pancreas, the renal artery and vein from the renal hilum, the ureter from the retroperitoneum, the aorta from the inferior vena cava and the common bile duct from surrounding tissue. Three-second contact to intestine and nerve roots was also performed. Wedge biopsy specimens of liver and spleen were performed. Dissection technique used was as described by the company. Structures were dissected with electrocautery using similar techniques for comparison. Tissues were harvested and placed in formalin for histological analysis. Dissection with the ultrasonically activated scalpel was simple, achieved excellent hemostasis, and did not appear to damage adjacent tissue. Microscopic analysis showed adventicial and media injury to vascular structures. The ureter and common bile duct demonstrated marked injury with regions of transmural coagulation. Nerve and small bowel did not appear to have much injury from the 3-second contact with the instrument. This study indicated that although the ultrasonically activated scalpel can ease dissection with good hemostasis, care must be taken to avoid injury to adjacent structures. Although its lateral energy dispersion may be less than that of cautery, it can still cause transmural necrosis to major structures.

Abdomen↗