Introducing a new era in robotic vessel sealing

At the recent IFSO-EC meeting in Malaga, Spain, Medtronic hosted a fascinating lunch time symposium tiled, ‘A new era in robotic vessel sealing’ featured several presentations and a panel discussion on Medtronic's Ligasure vessel sealing technology, covering its technical underpinnings, clinical applications and recent integration into the Hugo RAS robotic surgery platform.

Hugo RAS Ligasure Maryland

In the first presentation by Dr Bruce Dunne, Senior Distinguished Engineer, R&D Medtronic, explained the technology behind Ligasure vessel sealing devices. He highlighted a quote by the legendary surgeon, Dr Michael DeBakey: “’Good information is the best medicine’, and I firmly believe that if you understand the technology, you can get better results for your patients,” added Dunne. “And, and so I want to give you some good information today.” He explained that surgical energy is to give surgeons the best possible haemostasis, making the procedure easier for them and safer for the patient.

“So when I think about energy devices in bariatric surgery, these are the factors I consider to be important; good visualisation, effective dissection, obviously, you need to have good vessel sealing and the ability to create enterotomies., Jaw temperature is going to be a consideration, if you touch another structure with the jaw while you're activating, is it going to burn that tissue? How far outside of the jaws does the temperature effect go, lateral thermal spread, important if you're going to be near a critical structure? Finally, the ergonomics of the device as well, because you use these devices every day.”

The technology

He explained that the key behind the LigaSure vessel sealing system is the generator, the FT10, that includes technology called TissueFect that controls delivery of energy to tissue. This technology monitors the tissue properties 434,000 times a second, equating to 434,000 decisions per second as to how to deliver energy to the tissue, measuring the impedance of the tissue to electrical energy. The algorithm is sensitive to the volume of tissue. Energy is dosed into the tissue and this is key for the consistency of effect.”

LigaSure modifies the body's own proteins to form a seal and can seal vessels up to and including seven millimetres in diameter, as well as lymphatics and tissue bundles. It work by applying pressure and electrical energy to tissue. Its alternating current goes between the two electrodes stimulating the water molecules that generates heat, collagen melts, water is driven off and the impedance of the tissue rises until the required change is achieved. The pressure of the jaws fuses the melted collagen together to form the vessel seal. The surgeon can decide whether to transect that seal using the mechanical knife blade.”

Some of the Medtronic devices suited to bariatric surgery include; LigaSure XP Maryland, with improved performance on thick tissue, LigaSure Maryland L-hook dissector, and Hugo RAS has LigaSure as well as bipolar scissors for making enterotomies.

He repeated the considerations for the ideal vessel sealing technology for energy devices in bariatric surgery;  good visualisation, a long curved jaw with a narrow tip for blunt dissection. For vessel sealing, the burst pressure is high. Enerotomy creation laparoscopically can be achieved with  the L-hook on the LigaSure or using  bipolar scissors On Hugo. Jaw temperature on a single activation is less than 60 degrees centigrade, and lateral thermal spread is less than 2mm. with all LigaSures Ergonomically, a pistol grip for the laparoscopic devices and Hugo.

Clinical experience with LigaSure XP Maryland in bariatric surgery

In the next presentation, Professor Giuseppe M Marinari, Senior Consultant Bariatric Surgeon, Policlinico San Marco, Gruppo San Donato, Zingonia, Italy, bariatric surgery often involves complex, adipose-rich tissue and revisional anatomy, making reliable haemostasis and precise dissection essential.  LigaSure™ XP Maryland can support surgical efficiency and safety in these demanding conditions.

The LigaSure™ XP Maryland is designed to deliver consistent sealing quality in thick or fatty tissue, which is particularly relevant in bariatric and revisional procedures where fibrosis, tissue density, and limited access can complicate dissection and haemostasis.

Clinical observations comparing LigaSure™ XP Maryland with the Enseal curved jaw device suggest greater haemostatic confidence, reduced reliance on clips and knots, and faster sealing action. These factors may help improve operative workflow, particularly in high-volume bariatric settings.

According to Professor Marinari, the LigaSure™ XP Maryland -style jaw supports fine, controlled dissection, including in sensitive areas such as the gastro-oesophageal junction. Sealing at the tip of the jaws, strong grasping capability, and 360° rotation can further support access, visibility, tissue manipulation, and ease of use during laparoscopic procedures.

“When we as surgeons are talking about a device, we are concerned about three topics: performance, safety and speed. What do we know about LigaSure™ XP Maryland? We know that it is a very good sealer, a consistent sealer, that it has a high performance in thick tissue. And this is close to our activities every day because obviously we are working not on a lean patient, but on a fat patient. So, the vessels are surrounded by adipose tissue. Very often we are dealing with a revision surgery, that by definition entails thick tissues because they have been just operated on years before. Therefore, we need a device that must be very efficient on thick tissue. Finally, this type of vessel sealing device must give us a reduced bleeding risk.”

He added that safe sealing and controlled thermal spread have clinical implications, and he showed that using the Ligasure device for radical gastrectomy resulted in reduced length of stay and fewer reoperations, compared with conventional ligation.

His own comparative series of 3,000 sleeve gastrectomy procedures (unpublished data), comparing 1500 consecutive sleeve gastrectomies (SG) with the Enseal device and 1500 SGs performed with LigaSure™ XP Maryland, showed significantly fewer bleeding events (p=0.0057) with the LigaSure™ XP Maryland. This supports the potential value of advanced bipolar vessel sealing in improving procedural safety.

“The LigaSure™ XP Maryland is a highly reliable device, valued for its performance and dependability. It offers precision, confidence, and speed enabling effective outcomes in various procedures, “he concluded. “However, as with any device – regardless of its level of remote control – its ultimate safety depends on the skill and attention of the human operator, who may still be prone to error, not only from a surgical point of view, but also from total OR team consideration.”

Robotic integration with Hugo™ RAS and LigaSure™: clinical experience in bariatric surgery

In the final presentation by Dr Gabriel Díaz Del Gobbo, Head of Gastric, Bariatric and Metabolic Surgery, Althaia Foundation, presented clinical experience with the integration of LigaSure™ technology into the Hugo™ robotic-assisted surgery (RAS) platform, highlighting its impact on workflow, efficiency, and surgical performance.

The Hugo™ RAS system represents a shift towards a modular robotic architecture, where each arm is independently docked. This design allows greater flexibility in positioning and adaptation to both patient anatomy and procedural requirements. Such flexibility supports a smoother transition from laparoscopic to robotic surgery, particularly when familiar technologies such as LigaSure are maintained across both approaches.

A key component of this integration is LigaSure™ RAS Maryland, which brings advanced bipolar energy into the robotic environment. Designed to seal vessels up to 7mm, LigaSure™ RAS Maryland enables efficient haemostasis while maintaining procedural flow. In comparison, ultrasonic systems are typically limited to smaller vessels and may differ in thermal behaviour and sealing speed.

“When you go from laparoscopic to the robotic approach, it will be somehow seamless because you are already used to been using this device in your laparoscopic procedures. So, when you start with the robot, you don't face the issue of having a new technology that you have to learn and eventually have some complication or some issues related to you getting used to the new technology.”

Clinical experience at Althaia reflects a progressive transition towards fully robotic procedures within the Hugo™ ecosystem. Following the introduction of the platform in November 2025, the team expanded from a three-arm to a four-arm configuration, enabling more complex surgical setups and increasing surgeon autonomy at the console. This evolution has supported a move away from hybrid approaches towards fully robotic bariatric surgery.

Early results with LigaSure™ RAS Maryland have demonstrated its clinical utility in key procedural steps. Compared with the bedside LigaSure™ Maryland, the LigaSure™ RAS Maryland has been associated with reduced operative times during gastric dissection in sleeve gastrectomy and gastro-duodenal dissection in primary SADI procedures, with no reported intraoperative or postoperative bleeding events in this experience.

Additional applications further illustrate its versatility. The use of LigaSure™ RAS Maryland in combination with indocyanine green (ICG) imaging enables real-time assessment of tissue perfusion during gastro-jejunal anastomosis takedown and revision, supporting intraoperative decision-making.

In complex cases, such as Type III hiatal hernia repair, the device has been effectively used for mobilisation of the greater curvature and precise dissection of the hiatus.

The integration of LigaSure™ technology into Hugo™ RAS represents an important step towards fully robotic, streamlined bariatric procedures. By leveraging familiar energy platforms within an advanced robotic system, surgeons can maintain consistency in technique while benefiting from enhanced control and efficiency across a wide range of procedures - from routine cases to more complex surgical scenarios.

He acknowledged that while current LigaSure™ RAS Maryland device is not wristed, limiting degrees of freedom compared with some robotic systems, ongoing developments are expected to enhance these capabilities. Despite this, LigaSure™ RAS Maryland already fulfils key requirements of a modern energy device, combining reliable vessel sealing, controlled thermal spread, efficient workflow, and reduced instrument exchange within a fully integrated robotic platform.

Ligasure XP Maryland Jaw

“There's no secret for all surgeons the vessel sealing is fundamental to perform a precise operation, especially when it's integrated with the robotic surgery, providing the patient with all the benefits from the platform. I think everyone will start using the Ligasure RAS it will be a step forward into fully robotic and seamless integrated procedures with the Hugo platform. This tool is designed with all the key features of an advanced robotic energy device,” he concluded. “We can use the Hugo RAS in a diverse range of procedures from the most straightforward to cases that are highly complex and more demanding. And of course, the most important thing is that Ligasure delivers the same great outcomes that have been proven already in a large laparoscopic experience.”