[Technical aspects of laparoscopic liver surgery : Transfer from open to laparoscopic liver surgery]

The CUSA Clarity Soft Tissue Removal Study: Clinical Performance Investigation of the CUSA Clarity Ultrasonic Surgical Aspirator System for Soft Tissue Removal During Liver Surgery

Background: Intraoperative blood loss has an unfavorable impact on the outcome of patients undergoing liver surgery. Today, the use of devices capable of minimizing this risk with high technical performance becomes mandatory. Into this scenario fits the CUSA® Clarity Ultrasonic Surgical Aspirator System. This prospective survey involving five liver surgery centers had the objective of investigating whether this innovative ultrasonic surgical aspirator is safe and effective in the transection of the liver parenchyma. Materials and Methods: This clinical study was a prospective, multicenter, single-arm Post-Market Clinical Follow-up study investigating 100 subjects who underwent liver surgery using the CUSA Clarity Ultrasonic Surgical Aspirator System at five centers during a period of 1 year and 8 months. After collecting all the patient's clinical information and instrument usage details, surgeons completed a brief survey giving their opinions on the performance of CUSA. Therefore, safety and efficacy outcomes were evaluated. Results: Surgeons had a 95% success rate in complete removal of the mass with an average overall operative time of 4 hours and 34 minutes. Overall, there were no complications or device deficiencies. Conclusion: The CUSA Clarity Ultrasonic Surgical Aspirator System performs well during liver surgery with a low complication rate. ClinicalTrials.gov Identifier: NCT04298268.

[Robotics in Liver Surgery - Tips and Tricks]

Since minimally invasive liver surgery has proven benefits over open surgery, this technique should also be implemented more broadly in Germany. With the dramatic development in minimally invasive and robotic liver surgery, this approach has been established in recent years. Most recent analyses suggest lower complication rates, blood loss and hospital stay compared to open and laparoscopic liver surgery. In contrast to laparoscopic surgery, the technical setting of robotic liver surgery is widely independent of the type of resection. The laparoscopic and robotic technologies should be considered to be equal at the moment, although most recent analyses even suggest additional advantages of robotic over laparoscopic liver surgery. Moreover, robotics has a greater potential for technical refinements, including the inclusion of artificial intelligence and machine learning. Most steps can be transferred from open and laparoscopic liver surgery, but a dissection device such as the CUSA has not yet been developed. Consequently, different techniques have been reported for parenchymal transsection. Due to the special technical features of robotic surgery, intensive training programs should be used prior to the establishment of a robotic liver surgery program.

The Optimal Fluid Strategy Matters in Liver Surgery: A Retrospective Single Centre Analysis of 666 Consecutive Liver Resections

As optimal intraoperative fluid management in liver surgery has not been established, we retrospectively analyzed our fluid strategy in a high-volume liver surgery center in 666 liver resections. Intraoperative fluid management was divided into very restrictive (<10 m kg^-1 h^-1) and normal (≥10 mL kg^-1 h^-1) groups for study group characterization. The primary endpoint was morbidity as assessed by the Clavien-Dindo (CD) score and the comprehensive complication index (CCI). Logistic regression models identified factors most predictive of postoperative morbidity. No association was found between postoperative morbidity and fluid management in the overall study population (p = 0.89). However, the normal fluid management group had shorter postoperative hospital stays (p = <0.001), shorter ICU stays (p = 0.035), and lower in-hospital mortality (p = 0.02). Elevated lactate levels (p < 0.001), duration (p < 0.001), and extent of surgery (p < 0.001) were the most predictive factors for postoperative morbidity. In the subgroup of major/extreme liver resection, very low total (p = 0.028) and normalized fluid balance (p = 0.025) (NFB) were associated with morbidity. Moreover, fluid management was not associated with morbidity in patients with normal lactate levels (<2.5 mmol/L). In conclusion, fluid management in liver surgery is multifaceted and must be applied judiciously as a therapeutic measure. While a restrictive strategy appears attractive, hypovolemia should be avoided.

[Advantages and future perspectives of laparoscopic liver surgery]

BACKGROUND

Laparoscopic liver surgery (LLS) is increasingly utilized worldwide due to several potential advantages over open liver surgery.

OBJECTIVE

Analysis and presentation of the advantages and disadvantages of LLS in comparison to open surgery.

MATERIAL AND METHODS

Analysis of clinically relevant factors of minimally invasive liver surgery in comparison to open liver surgery in the current literature.

RESULTS

In addition to obvious cosmetic advantages, the current literature shows advantages regarding length of hospital stay and quality of life after LLC. In contrast to major liver resections, parenchyma-preserving resections often appear cost-neutral due a shorter postoperative hospital stay compared to conventional liver resections. In addition to particular personnel requirements, LLS also has technical prerequisites, such as a dedicated intraoperative ultrasound system. Furthermore, contrast-enhanced laparoscopic examinations are possible and ultrasound information can be fused with preoperative imaging. Virtual reality technology and 3‑dimensional printing are currently under investigation to improve the intraoperative anatomical orientation of LLS.

CONCLUSION

The current literature reveals significant advantages for LLS so that this procedure should be further developed in Germany in order to offer this technique to as many patients as possible.

[Minimally invasive liver surgery]

Minimally invasive liver surgery is safe and can be performed with results practically equal to those in open surgery. There are different techniques of parenchyma dissection and hemostasis available for the safe performance of minor and major resections, both laparoscopically and robotics based. Due to its technical options robotics-based surgery is a further development of laparoscopy. Expertise in minimally invasive and in liver surgery are essential prerequisites.

[Evidence of minimally invasive oncological surgery of the liver]

BACKGROUND

The evidence for minimally invasive surgery (MIS) of the liver has significantly increased with the increasing number of publications on this topic in recent years; however, this technique has not yet gained broad acceptance among surgeons.

OBJECTIVE

Analysis and presentation of the current literature on MIS of the liver.

MATERIAL UND METHODS

Structured PubMed literature search and analysis.

RESULTS

According to the literature, MIS and open liver surgery are equivalent regarding the oncological quality. In addition to parenchyma-preserving resections, major hepatectomies (e.g. hemihepatectomy and sectorectomy), two-stage concepts and re-resections have increasingly been reported. The MIS of the liver is associated with less blood loss and other immunological advantages in addition to a shorter hospital stay. The highest level of evidence has been achieved for colorectal liver metastases for which a systematic review even revealed a survival benefit for patients undergoing MIS surgery. From an oncological perspective, laparoscopic and robotic liver surgery are considered to be equivalent.

CONCLUSION

According to the current literature MIS of the liver is recommended for the resection of colorectal liver metastases and hepatocellular carcinoma.