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Ultrasonic Bone Removal With the Sonopet Omni

Ultrasonic Bone Removal With the Sonopet Omni We used a new instrument that ultrasonically removes bone (Sonopet Omni, model UST-2001 Ultrasonic Surgical Aspirator) in 13 orbital decompressions and 6 dacryocystorhinostomies. We noted no surgical complications of ocular or soft tissue damage, infection, inflammation, or visual loss. Visualization, manipulation, ease of use, and speed were far superior with the Sonopet ultrasonic bone curette compared with drills or rongeurs. The Sonopet Omni is an outstanding innovation in technology for bone removal in surgery.Orbital bone removal is accomplished by grinding with a burr drill and piecemeal fracturing with a rongeur. The drill is bulky, can compromise visualization in tight orbital spaces, catch and tear soft tissue including vascular structures and dura, and creates bone dust that obscures the operative field and takes time to clear. Heat generation, although minimized with high-speed drilling, and physical vibration can lead to optic nerve damage and visual loss.Rongeurs require a bony edge and, therefore, do not work well on smooth surfaces, do not allow fine control, and are difficult to use on thick bone. We describe our bone removal experience with an ultrasonic (US) instrument new to orbital and lacrimal surgery, the Sonopet Omni, model UST-2001, Ultrasonic Surgical Aspirator (Synergetic, Inc, O’Fallon, Mo).METHODSHISTORICAL BACKGROUND AND ULTRASOUND PRINCIPLESCharles Kelman revolutionized modern cataract surgery by using US energy to fragment the intraocular lens. Modern phacoemulsification machines and the Sonopet Omni use alternating current to cause expansion and contraction of a piezoelectric element. This resultant low US frequency vibration is transmitted to a cutting tip that fragments tissue with minimal displacement or energy deliverance to surrounding structures.Since 1967, many instruments have been developed using this principle, covering a wide spectrum of surgical specialties.The Sonopet Omni was developed and introduced in 1993. During the last 10 years many new handpieces have been developed. At present there are 4 handpieces that can be used for US bone removal.INSTRUMENT DESCRIPTIONWe used the Sonopet Omni model UST-2001 Ultrasonic Surgical Aspirator, designed by Miwatec Co, Kawasaki, Japan, and distributed in North America by Synergetics, Inc. This instrument consists of a console, surgical handpiece, and foot switch (Figure 1). Like a phacoemulsification unit, irrigation and aspiration occur at the handpiece tip.Figure 1.Sonopet Omni model UST-2001, Ultrasonic Surgical Aspirator (Synergetics Inc, O’Fallon, Mo) console (A), foot pedal (B), and assembled handpiece (C). A, On the console the solid arrow indicates vibration amplitude control; open arrow, aspiration pressure control; arrowhead, irrigation rate control; and oval, alarm indicators. B, The 2 foot pedals regulate the levels of the ultrasonic (US) power switch and irrigation (IRR). C, View of the handheld assembled instrument.The console requires a 110-V alternating current, 50- to 60-Hz, 3-A outlet. It regulates the amplitude of tip vibration, rate of irrigation, and aspiration pressure (Figure 1A). The surgeon can adjust the amplitude of tip vibration by adjusting the US power switch on the console. The irrigation rate is between 3 and 40 mL/min. The maximum aspiration pressure is 500 mm Hg with linear pressure control. We used 75% to 100% US power, an irrigation rate from 35 to 40 mL/min, and 80% to 90% suction (400 mm Hg; Figure 1A).Eleven handpieces are available for use with this console. Four of these transmit 25 kHz of vibration, which is specific for bone removal. A disposable tip with sleeve is attached to each handpiece. We used the HB-15S Hyper LT Angled Bone Curette Handpiece with the 25-kHZ Spetzler disposable tip (N6071315) (Figure 1C and Figure 2). Setting the US power between 75% and 100% yields a vibration amplitude of 240 to 320 &mgr;m with this handpiece. This handpiece is 210 mm long, 21 mm wide, and weighs 120 g.The tip and sleeve extend 55 mm from the handpiece. The protective sleeve tapers from 12 to 4 mm. The tip is 2.5 mm in diameter; the cutting head of the tip is 3.5 × 2 mm (Figure 2and Figure 3).Figure 2.Close-up view of the bone curette tip.Figure 3.View of the ultrasonic bone tip next to a 5-mm burr drill bit.The footswitch has 2 pedals, US power switch and IRR (irrigation) (Figure 1B). Depression of the US power switch pedal causes US fragmentation with simultaneous irrigation and aspiration. Depression of the IRR pedal gives a fast flush of irrigation to clear the operative field as needed.There are 3 alarm indicators—the frequency alarm indicator for damaged or incorrectly attached tips and excessive heat generation, the overload alarm indicator for excessive pressure on the handpiece, and the abnormal oscillation indicator for malfunction of US vibration circuit. If any of these are activated, US energy will not be produced (Figure 1A).RESULTSThirteen orbital decompressions (8 patients) and 6 dacryocystorhinostomies (DCRs) (5 patients) were performed by 2 oculoplastic surgeons (J.A.S.-C. and J.V.L.). In the decompression group, the Sonopet Omni was used on 13 lateral walls, 4 orbital floors, and 1 medial wall. Follow-up ranged from 1 week to 12 months. No patient experienced visual loss, infection, or unanticipated inflammation (Table). Complications included mild scarring after external DCR (n = 1) and orbital hemorrhage that occurred at extubation after fat removal during decompression (n = 1). Neither complication was thought to be secondary to Sonopet Omni use.Table. Sonopet Omni Ultrasonic Surgical Aspirator: Surgical Experience and Outcome for Bone Removal*Patient/Sex/Age, yDiagnosisOperative ProcedureLength of Follow-up1/F/72R NLDOR ext DCR6 wk2/F/82B NLDOB DCR8 wk3/F/81L NLDOL ext DCR8 wk4/F/72R NLDOR ext DCR6 wk5/F/81L NLDOL ext DCR6 wk6/F/50Thyroid orbitopathyR DecL Dec (lateral and  inferior walls)3 wk1 wk7/F/56Thyroid orbitopathyR DecL Dec (lateral and  inferior walls)3 wk1 wk8/F/49Thyroid orbitopathyR DecL Dec (lateral wall)4 mo9/F/48Thyroid orbitopathyR DecL Dec (lateral wall)3 mo Abbreviations: B, bilateral; DCR, dacryocystorhinostomy; Dec, orbital decompression; ext, external; L, left; NLDO, nasal lacrimal duct obstruction with irrigation; R, right. *No ocular complications, adjacent tissue damage, postoperative infection, or inflammation was noted for any patient. With the exception of patient 1 who had a mild skin scar, there were not other complications.During surgery we observed closely for significant bleeding, heat generation, underlying or surrounding tissue damage, and ease of use. There was no significant heat generation and no excessive bleeding, especially from the posterolateral orbital wall. The dura underlying the posterolateral wall and the mucosa underlying the lacrimal sac fossa and the medial wall were not damaged in any patient, even when exposed by bone removal. Bone was removed effortlessly with precise control by dragging the serrated tip across any bone surface while activating US energy with the foot pedal. This was effective regardless of bone thickness. Constant irrigation and suction allowed continuous work. The handpiece was light and easy to manipulate, and its angled shape enabled good visualization in a tight orbital space. The tip did not have to be changed in any procedure. In our estimation, surgical time was shorter than with a standard burr drill because it was possible to continuously remove bone without pausing to remove debris or blood.COMMENTOrbital bone removal is accomplished with drills and rongeurs. Especially in the deep orbit, visualization, soft tissue damage (including blood vessels, dura, and mucosa), heat generation, mechanical chatter, and lack of fine control are limitations with these methods. These limitations are minimized with the Sonopet Omni US Surgical Aspirator.Visualization is improved by the constant irrigation and aspiration, eliminating the need to stop and clear the operative field. The handpiece is angled, making it easy to maintain visualization in tight orbital spaces (Figure 1C). The tip is small (Figures 2and 3) and cuts only on 1 side. It does not rotate and, therefore, does not catch cottonoids or orbital soft tissues like the rotating burr drill does. Neurosurgical experience has shown that dural damage was less with US bone removal than with burr drilling.The handpiece is light, allows fine control, and can be used on smooth or rough, or thick or thin surfaces. The Sonopet Omni was effective for bone removal from the orbital floor, lateral wall, medial wall, and lacrimal sac fossa. Although we did not formally measure heat production or chatter, we noted no significant heat generation or mechanical vibration. We had no intraoperative or postoperative complications that we could attribute to this instrument. Hadeishi et alreported 8 cases of anterior clinoidectomy using the Sonopet Omni, and none of their patients experienced visual or ocular complications.In medicine today, the cost of new technology is important. The Sonopet Omni disposable tip is $150 vs $90 for a burr drill. We believe that improved safety, efficiency, and control with the Sonopet Omni justify the cost difference.While the number of cases is small and 2 surgeons were involved, this first-generation instrument is promising for effective bone removal in orbital and lacrimal surgery. Just as phacoemulsification has evolved over the years into a magnificent tool for cataract surgeons, time, more surgical experience, and research will likely lead to further development of this outstanding technical innovation for bone removal.Correspondence:Jennifer Sivak-Callcott, MD, Department of Ophthalmology, West Virginia University Eye Institute, 1 Stadium Dr, Morgantown, WV 26506.Submitted for Publication:October 1, 2004; final revision received December 7, 2004; accepted December 22, 2004.Financial Disclosure:The authors have no financial interest in this equipment.REFERENCESHHadeishiASuzukiNYasuiYSatouAnterior clinoidectomy and opening of the internal auditory canal using an ultrasonic bone curette.Neurosurgery20035286787112657183CDKelmanPhysics of ultrasound in cataract removal.Int Ophthalmol Clin196997397445396780TInoueKIkezakiYSatoUltrasonic surgical system (SONOPET) for microsurgical removal of brain tumors.Neurol Res20002249049410935222Miwatec Co, Ltd.Sonopet Omni Model UST-2001 Ultrasonic Surgical System Owner’s Manual.Version A-1.Kawasaki, Japan: Sonopet Omni; 2001 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Ophthalmology American Medical Association

Ultrasonic Bone Removal With the Sonopet Omni

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American Medical Association
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Copyright 2005 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
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2168-6165
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2168-6173
DOI
10.1001/archopht.123.11.1595
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16286624
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Abstract

We used a new instrument that ultrasonically removes bone (Sonopet Omni, model UST-2001 Ultrasonic Surgical Aspirator) in 13 orbital decompressions and 6 dacryocystorhinostomies. We noted no surgical complications of ocular or soft tissue damage, infection, inflammation, or visual loss. Visualization, manipulation, ease of use, and speed were far superior with the Sonopet ultrasonic bone curette compared with drills or rongeurs. The Sonopet Omni is an outstanding innovation in technology for bone removal in surgery.Orbital bone removal is accomplished by grinding with a burr drill and piecemeal fracturing with a rongeur. The drill is bulky, can compromise visualization in tight orbital spaces, catch and tear soft tissue including vascular structures and dura, and creates bone dust that obscures the operative field and takes time to clear. Heat generation, although minimized with high-speed drilling, and physical vibration can lead to optic nerve damage and visual loss.Rongeurs require a bony edge and, therefore, do not work well on smooth surfaces, do not allow fine control, and are difficult to use on thick bone. We describe our bone removal experience with an ultrasonic (US) instrument new to orbital and lacrimal surgery, the Sonopet Omni, model UST-2001, Ultrasonic Surgical Aspirator (Synergetic, Inc, O’Fallon, Mo).METHODSHISTORICAL BACKGROUND AND ULTRASOUND PRINCIPLESCharles Kelman revolutionized modern cataract surgery by using US energy to fragment the intraocular lens. Modern phacoemulsification machines and the Sonopet Omni use alternating current to cause expansion and contraction of a piezoelectric element. This resultant low US frequency vibration is transmitted to a cutting tip that fragments tissue with minimal displacement or energy deliverance to surrounding structures.Since 1967, many instruments have been developed using this principle, covering a wide spectrum of surgical specialties.The Sonopet Omni was developed and introduced in 1993. During the last 10 years many new handpieces have been developed. At present there are 4 handpieces that can be used for US bone removal.INSTRUMENT DESCRIPTIONWe used the Sonopet Omni model UST-2001 Ultrasonic Surgical Aspirator, designed by Miwatec Co, Kawasaki, Japan, and distributed in North America by Synergetics, Inc. This instrument consists of a console, surgical handpiece, and foot switch (Figure 1). Like a phacoemulsification unit, irrigation and aspiration occur at the handpiece tip.Figure 1.Sonopet Omni model UST-2001, Ultrasonic Surgical Aspirator (Synergetics Inc, O’Fallon, Mo) console (A), foot pedal (B), and assembled handpiece (C). A, On the console the solid arrow indicates vibration amplitude control; open arrow, aspiration pressure control; arrowhead, irrigation rate control; and oval, alarm indicators. B, The 2 foot pedals regulate the levels of the ultrasonic (US) power switch and irrigation (IRR). C, View of the handheld assembled instrument.The console requires a 110-V alternating current, 50- to 60-Hz, 3-A outlet. It regulates the amplitude of tip vibration, rate of irrigation, and aspiration pressure (Figure 1A). The surgeon can adjust the amplitude of tip vibration by adjusting the US power switch on the console. The irrigation rate is between 3 and 40 mL/min. The maximum aspiration pressure is 500 mm Hg with linear pressure control. We used 75% to 100% US power, an irrigation rate from 35 to 40 mL/min, and 80% to 90% suction (400 mm Hg; Figure 1A).Eleven handpieces are available for use with this console. Four of these transmit 25 kHz of vibration, which is specific for bone removal. A disposable tip with sleeve is attached to each handpiece. We used the HB-15S Hyper LT Angled Bone Curette Handpiece with the 25-kHZ Spetzler disposable tip (N6071315) (Figure 1C and Figure 2). Setting the US power between 75% and 100% yields a vibration amplitude of 240 to 320 &mgr;m with this handpiece. This handpiece is 210 mm long, 21 mm wide, and weighs 120 g.The tip and sleeve extend 55 mm from the handpiece. The protective sleeve tapers from 12 to 4 mm. The tip is 2.5 mm in diameter; the cutting head of the tip is 3.5 × 2 mm (Figure 2and Figure 3).Figure 2.Close-up view of the bone curette tip.Figure 3.View of the ultrasonic bone tip next to a 5-mm burr drill bit.The footswitch has 2 pedals, US power switch and IRR (irrigation) (Figure 1B). Depression of the US power switch pedal causes US fragmentation with simultaneous irrigation and aspiration. Depression of the IRR pedal gives a fast flush of irrigation to clear the operative field as needed.There are 3 alarm indicators—the frequency alarm indicator for damaged or incorrectly attached tips and excessive heat generation, the overload alarm indicator for excessive pressure on the handpiece, and the abnormal oscillation indicator for malfunction of US vibration circuit. If any of these are activated, US energy will not be produced (Figure 1A).RESULTSThirteen orbital decompressions (8 patients) and 6 dacryocystorhinostomies (DCRs) (5 patients) were performed by 2 oculoplastic surgeons (J.A.S.-C. and J.V.L.). In the decompression group, the Sonopet Omni was used on 13 lateral walls, 4 orbital floors, and 1 medial wall. Follow-up ranged from 1 week to 12 months. No patient experienced visual loss, infection, or unanticipated inflammation (Table). Complications included mild scarring after external DCR (n = 1) and orbital hemorrhage that occurred at extubation after fat removal during decompression (n = 1). Neither complication was thought to be secondary to Sonopet Omni use.Table. Sonopet Omni Ultrasonic Surgical Aspirator: Surgical Experience and Outcome for Bone Removal*Patient/Sex/Age, yDiagnosisOperative ProcedureLength of Follow-up1/F/72R NLDOR ext DCR6 wk2/F/82B NLDOB DCR8 wk3/F/81L NLDOL ext DCR8 wk4/F/72R NLDOR ext DCR6 wk5/F/81L NLDOL ext DCR6 wk6/F/50Thyroid orbitopathyR DecL Dec (lateral and  inferior walls)3 wk1 wk7/F/56Thyroid orbitopathyR DecL Dec (lateral and  inferior walls)3 wk1 wk8/F/49Thyroid orbitopathyR DecL Dec (lateral wall)4 mo9/F/48Thyroid orbitopathyR DecL Dec (lateral wall)3 mo Abbreviations: B, bilateral; DCR, dacryocystorhinostomy; Dec, orbital decompression; ext, external; L, left; NLDO, nasal lacrimal duct obstruction with irrigation; R, right. *No ocular complications, adjacent tissue damage, postoperative infection, or inflammation was noted for any patient. With the exception of patient 1 who had a mild skin scar, there were not other complications.During surgery we observed closely for significant bleeding, heat generation, underlying or surrounding tissue damage, and ease of use. There was no significant heat generation and no excessive bleeding, especially from the posterolateral orbital wall. The dura underlying the posterolateral wall and the mucosa underlying the lacrimal sac fossa and the medial wall were not damaged in any patient, even when exposed by bone removal. Bone was removed effortlessly with precise control by dragging the serrated tip across any bone surface while activating US energy with the foot pedal. This was effective regardless of bone thickness. Constant irrigation and suction allowed continuous work. The handpiece was light and easy to manipulate, and its angled shape enabled good visualization in a tight orbital space. The tip did not have to be changed in any procedure. In our estimation, surgical time was shorter than with a standard burr drill because it was possible to continuously remove bone without pausing to remove debris or blood.COMMENTOrbital bone removal is accomplished with drills and rongeurs. Especially in the deep orbit, visualization, soft tissue damage (including blood vessels, dura, and mucosa), heat generation, mechanical chatter, and lack of fine control are limitations with these methods. These limitations are minimized with the Sonopet Omni US Surgical Aspirator.Visualization is improved by the constant irrigation and aspiration, eliminating the need to stop and clear the operative field. The handpiece is angled, making it easy to maintain visualization in tight orbital spaces (Figure 1C). The tip is small (Figures 2and 3) and cuts only on 1 side. It does not rotate and, therefore, does not catch cottonoids or orbital soft tissues like the rotating burr drill does. Neurosurgical experience has shown that dural damage was less with US bone removal than with burr drilling.The handpiece is light, allows fine control, and can be used on smooth or rough, or thick or thin surfaces. The Sonopet Omni was effective for bone removal from the orbital floor, lateral wall, medial wall, and lacrimal sac fossa. Although we did not formally measure heat production or chatter, we noted no significant heat generation or mechanical vibration. We had no intraoperative or postoperative complications that we could attribute to this instrument. Hadeishi et alreported 8 cases of anterior clinoidectomy using the Sonopet Omni, and none of their patients experienced visual or ocular complications.In medicine today, the cost of new technology is important. The Sonopet Omni disposable tip is $150 vs $90 for a burr drill. We believe that improved safety, efficiency, and control with the Sonopet Omni justify the cost difference.While the number of cases is small and 2 surgeons were involved, this first-generation instrument is promising for effective bone removal in orbital and lacrimal surgery. Just as phacoemulsification has evolved over the years into a magnificent tool for cataract surgeons, time, more surgical experience, and research will likely lead to further development of this outstanding technical innovation for bone removal.Correspondence:Jennifer Sivak-Callcott, MD, Department of Ophthalmology, West Virginia University Eye Institute, 1 Stadium Dr, Morgantown, WV 26506.Submitted for Publication:October 1, 2004; final revision received December 7, 2004; accepted December 22, 2004.Financial Disclosure:The authors have no financial interest in this equipment.REFERENCESHHadeishiASuzukiNYasuiYSatouAnterior clinoidectomy and opening of the internal auditory canal using an ultrasonic bone curette.Neurosurgery20035286787112657183CDKelmanPhysics of ultrasound in cataract removal.Int Ophthalmol Clin196997397445396780TInoueKIkezakiYSatoUltrasonic surgical system (SONOPET) for microsurgical removal of brain tumors.Neurol Res20002249049410935222Miwatec Co, Ltd.Sonopet Omni Model UST-2001 Ultrasonic Surgical System Owner’s Manual.Version A-1.Kawasaki, Japan: Sonopet Omni; 2001

Journal

JAMA OphthalmologyAmerican Medical Association

Published: Nov 1, 2005

References