Two-surgeon technique using saline-linked electric cautery and ultrasonic surgical aspirator in living donor hepatectomy: its safety and efficacy

Simultaneous Co-surgeon Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstructions: Feasibility and Clinical Outcomes

BACKGROUND

A co-surgeon model is known to be favorable in microvascular breast reconstruction, but simultaneous co-surgeon deep inferior epigastric perforator (DIEP) flap cases have not been well-studied. The authors hypothesize that performing two simultaneous co-surgeon bilateral DIEP flap reconstructions results in non-inferior clinical outcomes and may improve patient access to care.

METHODS

A single-institution, retrospective cohort study was performed utilizing record review to identify all cases of co-surgeon free-flap breast reconstructions over a 38-month period. Patients who underwent simultaneous bilateral DIEP flap breast reconstructions with the same two co-surgeons were identified. The control group consisted of subjects who underwent non-simultaneous reconstruction by the same co-surgeons within the same, preceding, or following month of those in the study group. Primary outcome variables were 90-day postoperative complications, while secondary outcomes were operating time, ischemia time, and length of stay. Descriptive statistics, univariate and multivariable regression analyses were performed.

RESULTS

Overall, 137 subjects were identified and 64 met the inclusion criteria (n = 28 study, n = 36 control). There were no statistically significant differences between groups in body mass index, radiation, trainee experience, flap perforator number, immediate/delayed reconstruction, or length of stay. There were also no statistically significant differences in complications, including flap loss, anastomosis revision, take-back to the operating room, or re-admission. Operative time was longer in the simultaneous DIEP group (540.5 vs. 443.5 min, p < 0.01), but ischemia time was shorter in the simultaneous group (64.0 vs. 80.5 min, p < 0.01).

CONCLUSIONS

A simultaneous co-surgeon approach to bilateral DIEP flap reconstruction may improve access to care and does not result in a higher complication rate compared with non-simultaneous bilateral DIEP flaps.

Co-surgery in head and neck microvascular reconstruction

PURPOSE

Co-surgery with two attending reconstructive surgeons is becoming increasingly common in breast microvascular reconstruction due to case complexity and the potential for improved outcomes and operative efficiency. The impact of co-surgery on outcomes in head and neck microvascular reconstruction has not been studied.

METHODS

Our multidisciplinary head and neck reconstruction team (Otolaryngology, Plastic Surgery) at the University of Pittsburgh transitioned to a practice of co-surgery on head and neck free flaps. In this study, we compare outcomes of two surgeon head and neck reconstruction to single surgeon reconstruction in a prospectively maintained database.

RESULTS

384 patients met our inclusion criteria from 2020 to 2022. Cases were performed by a single surgeon in 77.8 % of cases (299/384) and two surgeons in 22.1 % (85/384). The mean age was 62.5 years. There was no difference between the single surgeon cohort and the co-surgery cohort in terms of flap survival, procedure time, ischemia time, hospital length of stay, recipient site complications, or rates of return to the operating room. Donor site complications were less common in the co-surgery cohort (0 % vs 4.7 %, p = 0.021). For our reconstructive team, the transition to co-surgery has increased total surgeon fee collection per free flap by 28 % and increased surgeon flap related RVU production by 35 %.

CONCLUSION

Co-surgery is feasible and safe in head and neck microvascular reconstruction. Benefits may include reduced complications, increased reimbursement, and improved interdisciplinary collaboration.

A Multicenter, Open-Label, Single-Arm Phase I Trial of Dual-Wield Parenchymal Transection: A New Technique of Liver Resection Using the Cavitron Ultrasonic Surgical Aspirator and Water-Jet Scalpel Simultaneously (HiSCO-14 Trial)

PURPOSE

This study evaluated the safety and feasibility of a technique of liver resection named dual-wield parenchymal transection technique (DWT), using cavitron ultrasonic surgical aspirator (CUSA) and water-jet scalpel simultaneously.

METHODS

This multicenter, prospective, open-label, and single-arm phase I trial included patients aged 20 years or older with hepatic tumors indicated for surgical resection and scheduled for open radical resection. This study was conducted at two institutions affiliated with the Hiroshima Surgical Study Group of Clinical Oncology (HiSCO). The primary endpoint was the proportion of massive intraoperative blood loss (≥ 1000 mL). The secondary endpoints were the amount of blood loss, operative time, parenchymal transection speed, postoperative complications, and mortality. The safety endpoints were device failure and adverse events associated with devices.

RESULTS

From June 2022 to May 2023, 20 patients were enrolled; one was excluded and 19 were included in the full analysis set (FAS). In the FAS, segmentectomy was performed in nine cases, sectionectomy in four cases, and hemihepatectomy in six cases. Radical resection was achieved in all patients. Intraoperative blood loss greater than 1000 mL was observed in five patients (26.3%). The median amount of blood loss was 545 mL (range, 180-4413), and blood transfusions were performed on two patients (10.5%). The median operative time was 346 minutes (range, 238-543) and the median parenchymal transection speed was 1.2 cm2/minute (range, 0.5-5.1). Postoperative complications of Clavien-Dindo classification ≥ Grade 3 occurred in four patients (21.1%). No mortalities occurred in this study. In the safety analysis, there were no device failures or adverse events associated with devices.

CONCLUSIONS

This study demonstrated the safety and feasibility of DWT for liver resection. The efficacy of the DWT will be evaluated in future clinical trials.

Novel Hemostatic Technique During Laparoscopic Liver Parenchymal Transection: Saline-Linked Electrocautery Combined With Wet Oxidized Cellulose (SLiC-WOC) Method

Introduction: Although laparoscopic hepatectomy has the potential advantage of reducing intraoperative blood loss, it is more difficult to control bleeding laparoscopically compared to an open approach. We introduced a novel hemostatic technique, the saline-linked electrocautery combined with wet oxidized cellulose (SLiC-WOC) method, during laparoscopic hepatectomy where a combination of saline-linked electrocautery (SLiC) and wet oxidized cellulose (WOC) is used. This study aimed to investigate the feasibility of employing the SLiC-WOC method for laparoscopic hepatectomy.

Methods: Thirteen patients who underwent laparoscopic liver resection with the SLiC-WOC method between 2019 and 2020 were included in this study. The number of bleeding episodes in which the SLiC-WOC method was applied was counted, and the time required to achieve complete hemostasis was measured.

Results: Among the bleeding events that were difficult to achieve hemostasis by SLiC alone, 94% were safely and efficiently controlled. Additionally, 69% of hemostasis was achieved within 60 seconds and 91% within 120 seconds. Postoperatively, most patients experienced no complications and no operative mortality was observed.

Conclusions: The SLiC-WOC method can provide safe and time-efficient hemostasis during laparoscopic hepatectomy. This is especially crucial for bleeding, which is difficult to control using electrocautery alone.

Microvascular Breast Reconstruction in the Era of Value-Based Care: Use of a Cosurgeon Is Associated with Reduced Costs, Improved Outcomes, and Added Value

BACKGROUND

Reducing complications while controlling costs is a central tenet of value-based health care. Bilateral microvascular breast reconstruction is a long operation with a relatively high complication rate. Using a two-surgeon team has been shown to improve safety in bilateral microvascular breast reconstruction; however, its impact on cost and efficiency has not been robustly studied. The authors hypothesized that a cosurgeon for bilateral microvascular breast reconstruction is safe, effective, and associated with reduced costs.

METHODS

The authors retrospectively reviewed all patients who underwent bilateral microvascular breast reconstruction with either a single surgeon or surgeon/cosurgeon team over an 18-month period. Charges were converted to costs using the authors' institutional cost-to-charge ratio. Surgeon opportunity costs were estimated using time-driven activity-based costing. Propensity scoring controlled for baseline characteristics between the two groups. A locally weighted logistic regression model analyzed the cosurgeon's impact on outcomes and costs.

RESULTS

The authors included 150 bilateral microvascular breast reconstructions (60 single-surgeon and 90 surgeon/cosurgeon reconstructions) with a median follow-up of 15 months. After matching, the presence of a cosurgeon was associated with a significantly reduced mean operative duration (change in operative duration, -107 minutes; p < 0.001) and cost (change in total cost, -$1101.50; p < 0.001), which was even more pronounced when surgeon/cosurgeon teams worked together frequently (change in operative duration, -132 minutes; change in total cost, -$1389; p = 0.007). The weighted logistic regression models identified that a cosurgeon was protective against breast-site complications and trended toward reduced overall and major complication rates.

CONCLUSION

The practice of using a of cosurgeon appears to be associated with reduced costs and improved outcomes, thereby potentially adding value to bilateral microvascular breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Safety and effectiveness evaluation of a two-handed technique combining harmonic scalpel and laparoscopic Peng's multifunction operative dissector in laparoscopic hemihepatectomy

OBJECTIVES

This study was designed to evaluate the safety and effectiveness of a two-hand technique combining harmonic scalpel (HS) and laparoscopic Peng's multifunction operative dissector (LPMOD) in patients who underwent laparoscopic hemihepatectomy (LHH).

METHODS

We designed and conducted a case-control study nested in a prospectively collected laparoscopic liver surgery database. Patients who underwent LHH for liver parenchyma transection using HS + LPMOD were defined as cases (n = 98) and LPMOD only as controls (n = 47) from January 2016 to May 2018. Propensity score matching (1:1) between the case and control groups was used in the analyses.

RESULTS

The case group had significantly less intraoperative blood loss in milliliters (169.4 ± 133.5 vs. 221.5 ± 176.3, P = 0.03) and shorter operative time in minutes (210.5 ± 56.1 vs. 265.7 ± 67.1, P = 0.02) comparing to the control group. The conversion to laparotomy, postoperative hospital stay, resection margin, the mean peak level of postoperative liver function parameters, bile leakage rate, and others were comparable between the two groups. There was no perioperative mortality.

CONCLUSIONS

We demonstrated that the two-handed technique combing HS and LPMOD in LHH is safe and effective which is associated with shorter operative time and less intraoperative blood loss compared with LPMOD alone. The technique facilitates laparoscopic liver resection and is recommended for use.

Robotic hepatic parenchymal transection: a two-surgeon technique using ultrasonic dissection and irrigated bipolar coagulation

Liver transection is the most challenging part of hepatectomy due to the risk of hemorrhage which is associated with postoperative morbidity and mortality and reduced long-term survival. Parenchymal ultrasonic dissection (UD) with bipolar coagulation (BPC) has been widely recognized as a safe, effective, and standard technique during open and laparoscopic hepatectomy. We here introduce our technique of robotic liver transection using UD with BPC and report on short-term perioperative outcomes. From a single-institution prospective liver surgery database, we identified patients who underwent robotic liver resection. Demographic, anesthetic, perioperative, and oncologic data were analyzed. Fifty patients underwent robotic liver resection using UD and BPC for liver malignancies (n = 42) and benign lesions (n = 8). The median age of the patients was 67 years and 28 were male. According to the difficulty scoring system, 60% (n = 30) of liver resection were considered difficult. Three cases (6%) were converted to open surgery. The median operative time was 240 min, and the median estimated blood loss was 200 ml; 2 patients required operative transfusions. The overall complication rate was 38% (grade I, 29; grade II, 15; grade III, 3; grade IV, 1). Seven patients (14%) experienced biliary leakage. The median length of hospital stay post-surgery was 7 (range 3-20) days. The R0 resection rate was 92%. Robotic parenchymal transection using UD and irrigated BPC appears a simple, safe, and effective technique. However, our results must be confirmed in larger series or in randomized controlled trials.

Clamp-Crush Technique Versus Harmonic Scalpel for Hepatic Parenchymal Transection in Living Donor Hepatectomy: a Randomized Controlled Trial

BACKGROUND

Hepatic parenchymal transection is the most invasive step in donor operation. During this step, blood loss and unintended injuries to the intrahepatic structures and hepatic remnant may occur. There is no evidence to prove the ideal techniques for hepatic parenchymal transection. The aim of this study is to compare the safety, efficacy, and outcome of clamp-crush technique versus harmonic scalpel as a method of parenchymal transection in living-donor hepatectomy.

METHODS

Consecutive living liver donors, undergoing right hemi-hepatectomy, during the period between May 2015 and April 2016, were included in this prospective randomized study. Cases were randomized into two groups; group (A) harmonic scalpel group and group (B) Clamp-crush group.

RESULTS

During the study period, 72 cases underwent right hemi-hepatectomy for adult living donor liver transplantation and were randomized into two groups. There were no statistically significant differences between the two groups regarding preoperative demographic and radiological data. Longer operation time and hepatectomy duration were found in group B. There were no significant differences between the two groups regarding blood loss, blood loss during hepatectomy, and blood transfusion. More unexpected bleeding events occurred in group A. Higher necrosis at the cut margin of the liver parenchyma was noted in group A. There were no statistically significant differences between the two groups regarding postoperative ICU stay, hospital stay, postoperative morbidities, and readmission rates.

CONCLUSION

Clamp-crush technique is advocated as a simple, easy, safe, and cheaper method for hepatic parenchymal transection in living donors.

Bilateral mastectomies: can a co-surgeon technique offer improvements over the single-surgeon method?

PURPOSE

Bilateral mastectomy (BM) is traditionally performed using a single-surgeon (SS) technique (SST); a co-surgeon (CS) technique (CST), where each attending surgeon concurrently performs a unilateral mastectomy, offers an alternative approach. We sought to compare the CST and SST for BM with respect to operative times and complications.

METHODS

Patients undergoing BM without reconstruction at our institution between 2005 and 2015 were identified using operative caselogs and stratified into CS- and SS-cohorts. Operative time (OT; incision to closure) was calculated. Patient age, cancer presence/stage, hormone receptor/BRCA status, breast weight, axillary procedure, and 30-day complications were extracted. Differences in OT, complications, and demographics between cohorts were assessed with t tests and Chi-square tests. A multivariate linear regression model was fit to identify factors independently associated with OT.

RESULTS

Overall, 109 BM cases were identified (CS, n = 58 [53.2%]; SS, n = 51 [46.8%]). Average duration was significantly shorter for the CST by 33 min (21.6% reduction; CS: 120 min vs. SS: 153 min, p < 0.001), with no difference in complication rates (p = 0.65). Demographic characteristics did not differ between cohorts except for total breast weight (TBW) (CS: 1878 g vs. SS: 1452 g, p < 0.05). Adjusting for TBW, CST resulted in a 27.8% reduction in OT (44-min savings, p < 0.001) compared to SST.

CONCLUSIONS

The CST significantly reduces OT for BM procedures compared to the SST without increasing complication rates. While time-savings was < 50% and may not be ideal for every patient, the CST offers an alternative BM approach potentially best-suited for large TBW patients and those undergoing axillary procedures.

Spray Diathermy Versus Harmonic Scalpel Technique for Hepatic Parenchymal Transection of Living Donor

BACKGROUND

Liver parenchymal transection is the most invasive and challenging part in the living donor operation. The study was planned to compare the safety, efficacy, and outcome of harmonic scalpel versus spray diathermy as a method of parenchymal liver transection in donor hepatectomy.

PATIENT AND METHOD

Eighty consecutive patients, who were treated by living donor liver transplantation (LDLT), were included in the study. The study population was divided into two groups according to the method of liver transection: group A by harmonic scalpel (HS) and group B by spray diathermy (SD). The primary outcome was the volume of blood loss during transection. Secondary outcomes were time of transection, number of ligatures needed during transection, pathological changes at cut surface, postoperative morbidities, cost, and hospital stay RESULTS: Blood loss during overall liver transection and in each zone was significantly less in the SD than in the HS group (P = 0.015). The number of ligatures was significantly less in the SD than in the HS group (P = 0.0001). The SD group had significantly higher level of serum bilirubin, serum glutamic pyruvic transaminase (SGPT), and international normalized ratio (INR) levels on postoperative day 3 than the HS group. Lateral tissue coagulation and hepatic necrosis are significantly less in HS group. The overall incidence of postoperative morbidities was the same in both groups. The cost was higher in HS group than SD group (US$760 vs. US$40 P = 0.0001).

CONCLUSION

Spray diathermy is an effective method of parenchymal transection with significantly lower blood loss and lower cost compared to HS with no increase in morbidity. HS is associated with earlier recovery of liver functions.

Expert opinion on advanced techniques for hemostasis in liver surgery

BACKGROUND

Reduction of perioperative blood loss and intraoperative transfusion are two major factors associated with improving outcomes in liver surgery. There is currently no consensus as to the best technique to achieve this.

METHODS

An international Panel of Experts (EP), made up of hepatobiliary surgeons from well-known high-volume centres was assembled to share their experience with regard to the management of blood loss during liver resection surgery. The process included: a review of the current literature by the panel, a face-to-face meeting and an on-line survey completed by the EP prior to and following the face-to-face meeting, based on predetermined case scenarios. During the meeting the most frequently researched surgical techniques were appraised by the EP in terms of intraoperative blood loss.

RESULTS

All EP members agreed that high quality research on the subject was lacking. Following an agreed risk stratification algorithm, the EP concurred with the existing research that a haemostatic device should always be used along with any user preferred surgical instrumentation in both open and laparoscopic liver resection procedures, independently from stratification of bleeding risk. The combined use of Ultrasonic Dissector (UD) and saline-coupled bipolar sealing device (Aquamantys(®)) was the EP preferred technique for both open and laparoscopic surgery.

CONCLUSIONS

This EP propose the use of a bipolar sealer and UD for the best resection technique and essential equipment to minimise blood loss during liver surgery, stratified according to transfusion risk, in both open and laparoscopic liver resection.

Advances in hepatectomy technique: Toward zero transfusions in the modern era of liver surgery

BACKGROUND

Perioperative blood transfusions suppress immunity and increase hospital costs. Despite multiple improvements in perioperative care, rates of transfusion during/after hepatectomy are reported to range from 25 to 50%. The purpose of this study was to determine the current risk factors for perihepatectomy transfusion by assessing the impact of recent technical advances in liver surgery on transfusion rates.

METHODS

Using our prospectively maintained hepatobiliary tumor database from a high-volume center, a modern cohort of 2,249 hepatectomies (2004-2013) were identified. Patient and operative characteristics were compared between 2 time periods, 2004-2008 (n = 1,139) and 2009-2013 (n = 1,110). Throughout the study interval, transfusions were given based on clinical assessment and not triggered by laboratory thresholds.

RESULTS

Compared with the early cohort, the recent cohort had more patients with an American Society of Anesthesiologists score of ≥ 3 (79 vs 74%), preoperative chemotherapy (73 vs 68%), and a lesser median preoperative hemoglobin (12.9 vs 13.1 mg/dL) and platelet (215,000 vs 243,000) values (all P < .001). Despite these adverse risk factors, with an increasing use of the 2-surgeon resection technique (63 vs 50%), estimated blood loss (309 vs 394 mL), transfusion rates (6 vs 15%), and duration of stay (7.0 vs 8.4 days) were decreased (all P < .001) with no change in overall morbidity or mortality. Multivariate analysis of the recent cohort determined that the independent risk factors associated with transfusion were preoperative anemia and >350 mL of blood loss. The only independent factor associated with less transfusion was use of the 2-surgeon technique for hepatic parenchymal transection.

CONCLUSION

With the exception of patients with moderate to severe preoperative anemia requiring major hepatectomy, recent technical advances have decreased significantly the need for transfusion in liver surgery.

Prospective study of the safety and efficacy of intermittent inflow occlusion (Pringle maneuver) in living donor left hepatectomy

AIM

The impact of intermittent inflow occlusion (Pringle maneuver) in living donor hepatectomy on the outcome of both the donor and the recipient is unknown. The aim of this study is to elucidate the safety and efficacy of Pringle maneuver in living donor hepatectomy.

METHODS

Twenty consecutive cases of living donors who underwent left hepatectomy were prospectively divided into two groups, with (Group A, n = 10) or without (Group B, n = 10) the Pringle maneuver during hepatectomy. Intraoperative blood loss, postoperative liver functions in the donors and recipient outcome were reviewed.

RESULTS

Median blood loss was significantly less in group A than in group B. Median alanine aminotransferase was significantly higher on postoperative day 1 in group A than in group B, but the difference was not significant at 7 days after surgery. Eight of 10 recipients in each group survived with good graft function with a median follow-up period of 20 months in group A and 19 months in group B.

CONCLUSION

The Pringle maneuver was safely applied in living donor hepatectomy, but the only benefit was the reduction of blood loss during the donor surgery, and no positive impact on the recipient outcome.

Radiofrequency bipolar hemostatic sealer reduces blood loss, transfusion requirements, and cost for patients undergoing multilevel spinal fusion surgery: a case control study

Background

A relatively new method of electrocautery, the radiofrequency bipolar hemostatic sealer (RBHS), uses saline-cooled delivery of energy, which seals blood vessels rather than burning them. We assessed the benefits of RBHS as a blood conservation strategy in adult patients undergoing multilevel spinal fusion surgery.

Methods

In a retrospective cohort study, we compared blood utilization in 36 patients undergoing multilevel spinal fusion surgery with RBHS (Aquamantys®, Medtronic, Minneapolis, MN, USA) to that of a historical control group (n = 38) matched for variables related to blood loss. Transfusion-related costs were calculated by two methods.

Results

Patient characteristics in the two groups were similar. Intraoperatively, blood loss was 55% less in the RBHS group than in the control group (810 ± 530 vs. 1,800 ± 1,600 mL; p = 0.002), and over the entire hospital stay, red cell utilization was 51% less (2.4 ± 3.4 vs. 4.9 ± 4.5 units/patient; p = 0.01) and plasma use was 56% less (1.1 ± 2.4 vs. 2.5 ± 3.4 units/patient; p = 0.03) in the RBHS group. Platelet use was 0.1 ± 0.5 and 0.3 ± 0.6 units/patient in the RBHS and control groups, respectively (p = 0.07). The perioperative decrease in hemoglobin was less in the RBHS group than in the control group (−2.0 ± 2.2 vs. –3.2 ± 2.1 g/dL; p = 0.04), and hemoglobin at discharge was higher in the RBHS group (10.5 ± 1.4 vs. 9.7 ± 0.9 g/dL; p = 0.01). The estimated transfusion-related cost savings were $745/case by acquisition cost and approximately 3- to 5-fold this amount by activity-based cost.

Conclusions

The use of RBHS in patients undergoing multilevel spine fusion surgery can conserve blood, promote higher hemoglobin levels, and reduce transfusion-related costs.

Management of post-hepatectomy complications

Hepatic resection had an impressive growth over time. It has been widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses. Management of hepatic resection is challenging. Despite technical advances and high experience of liver resection of specialized centers, it is still burdened by relatively high rates of postoperative morbidity and mortality. Especially, complex resections are being increasingly performed in high risk and older patient population. Operation on the liver is especially challenging because of its unique anatomic architecture and because of its vital functions. Common post-hepatectomy complications include venous catheter-related infection, pleural effusion, incisional infection, pulmonary atelectasis or infection, ascites, subphrenic infection, urinary tract infection, intraperitoneal hemorrhage, gastrointestinal tract bleeding, biliary tract hemorrhage, coagulation disorders, bile leakage, and liver failure. These problems are closely related to surgical manipulations, anesthesia, preoperative evaluation and preparation, and postoperative observation and management. The safety profile of hepatectomy probably can be improved if the surgeons and medical staff involved have comprehensive knowledge of the expected complications and expertise in their management. This review article focuses on the major postoperative issues after hepatic resection and presents the current management.

A prospective randomized controlled trial of hemostasis with a bipolar sealer during hepatic transection for liver resection

BACKGROUND

Excessive intraoperative blood loss and the possible requirement for blood transfusion are major problems in hepatic resection for liver tumors. The decrease of blood loss is a goal in liver surgery, and several technical developments have been introduced for this purpose. The aim of this prospective randomized study was to compare the use of the Cavitron Ultrasonic Surgical Aspirator (CUSA) with a radiofrequency-based bipolar hemostatic sealer versus CUSA with standard bipolar cautery (BC) in patients undergoing hepatic resection.

METHODS

One hundred nine patients with liver tumors were randomized to undergo hepatic transection via CUSA with a bipolar sealer (Aquamantys 2.3 Bipolar Sealer; n = 55) or BC (n = 54). Blood loss during parenchymal transection and speed of transection were the primary end points, whereas the degree of postoperative liver injury and morbidity were secondary end points.

RESULTS

Compared with the BC group, the bipolar sealer showed lesser blood loss during transection and blood loss divided by resection area (P = .0079 and .0008, respectively), shorter transection time (P = .0025), faster speed of transection (P < .0001), and fewer ties and ties divided by resection area required during transection (P < .0001).

CONCLUSION

CUSA with a bipolar sealer is superior to CUSA with standard BC for various hepatectomy in terms of less blood loss and faster speed of transection, with no increase in morbidity.

A hybrid method of laparoscopic-assisted open liver resection through a short upper midline laparotomy can be applied for all types of hepatectomies

BACKGROUND

Although hepatectomy procedures should be designed to provide both curability and safety, minimal invasiveness also should be pursued.

METHODS

We analyzed the data related to our method for laparoscopy-assisted open resections (hybrid method) through a short upper midline incision for various types of hepatectomies. Of 215 hepatectomies performed at Nagasaki University Hospital between November 2009 and June 2012, 102 hepatectomies were performed using hybrid methods.

RESULTS

A hybrid method was applicable for right trisectionectomy in 1, right hemihepatectomy in 32, left hemihepatectomy in 29, right posterior sectionectomy in 7, right anterior sectionectomy in 1, left lateral sectionectomy in 2, and segmentectomy in 7 patients, and for a minor liver resection in 35 patients (12 combined resections). The median duration of surgery was 366.5 min (range 149-709) min, and the median duration of the laparoscopic procedure was 32 min (range 18-77) min. The median blood loss was 645 g (range 50-5,370) g. Twelve patients (12 %) developed postoperative complications, including bile leakage in three patients, wound infections in two patients, ileus in two patients, and portal venous thrombus, persistent hyperbilirubinemia, incisional hernia, local liver infarction each in one patient. There were no perioperative deaths.

CONCLUSIONS

Our method of hybrid hepatectomy through a short upper midline incision is considered to be applicable for all types of hepatectomy and is a reasonable approach with no abdominal muscle disruption, which provides safe management of the hepatic vein and parenchymal resection even for patients with bilobular disease.

Standardized less invasive living donor hemihepatectomy using the hybrid method through a short upper midline incision

BACKGROUND

Recently, applications of less invasive liver surgery in living donor hepatectomy (LDH) have been reported. The objective of this study was to evaluate the safety and efficacy of a hybrid method with a midline incision for LDH.

METHODS

Hemihepatectomy using the hybrid method was performed in the fifteen most recent among 150 living donors who underwent surgery between 1997 and August 2011. Six donors underwent right hemihepatectomy and 9 underwent left hemihepatectomy. An 8-cm subxiphoid midline incision was created for hand assistance during liver mobilization and graft extraction. After sufficient mobilization of the liver, the hand-assist/extraction incision was extended to 12 cm for the right hemihepatectomy and 10 cm for a left hemihepatectomy. Encircling the hepatic veins and hilar dissection were performed under direct vision. Parenchymal transection was performed with the liver hanging maneuver. Bile duct division was performed after visualizing the planned transection point by encircling the bile duct using a radiopaque marker filament under real-time C-arm cholangiography.

RESULTS

All procedures were completed without any extra subcostal incision. All grafts were safely extracted through the 10-12-cm upper midline incision without mechanical injury. No donors required an allogeneic transfusion; all of them have returned to their preoperative activity levels.

CONCLUSION

LDH by the hybrid method with a short upper midline incision is a safe procedure.

A Microwave Surface Applicator for Tissue Coagulation: Technical Characteristics and Performances

This work describes the mechanical and the electromagnetic design of a microwave surface applicator used to coagulate liver tissue in the treatment of hepatic tumors. A good prediction of the ratio between reflected and forward microwave power (return loss) is obtained with a finite element model using commercial software. Laboratory testing of the applicator performed in polyacrylamide gel (PAG) and in ex vivo bovine liver show a hemispherical heat distribution pattern and hemispherical ablations up to 20 mm in diameter and 15 mm in depth in a controlled manner in 1 min. The applicator can also be used to coagulate larger areas of tissue with 2–5 mm depth by moving the applicator on the surface of the tissue. Experimental results indicate that the coagulated volume of tissue is approximately proportional to the energy delivered into ex vivo bovine liver, hemispherical in shape, obtained in short time duration with a volumetric rate of coagulated tissue of about 50 mm3/s.

Saline conducted electric coagulation (SCEC): original experience in experimental hepatectomy

OBJECTIVE

To evaluate the feasibility and superiority of a new coagulating and hemostatic method named "saline conducted electric coagulation (SCEC)".

METHODS

The Peng's multifunction operative dissector (PMOD) was modified to enable saline to effuse persistently out of its nib at a constant speed. In a group of six New Zealand rabbits, two hepatic lobes of each rabbits were resected respectively by SCEC and conventional electric coagulation (EC). The features of SCEC were recorded by photo and compared with conventional EC. After 7 d, the coagulating depth was measured in each residual hepatic lobe. Hepatic tissue was dyed by hematoxylin and eosin (HE) and studied under a microscope.

RESULTS

The coagulating depth increased with the continuation of SCEC time. Hepatectomies were performed successfully, no rabbit died in the perioperative period. The incisal surface of SCEC was gray-white with no red bleeding point. There was a thick solidified layer at the margin and a thin red-white intermittent layer between the solidified layer and normal hepatic tissue at the vertical section of SCEC. The mean coagulating depth of SCEC was 1.8 cm vs. 0.3 cm of conventional EC. Pathological examination showed a mild inflammatory reaction by SCEC.

CONCLUSIONS

SCEC is a feasible and safe method for surgical hemostasis. As a new technique for liver resection, SCEC shows better coagulating effect and milder inflammatory reaction than conventional EC. Our study shows bloodless liver resection can also be performed by SCEC, especially for liver malignant tumor.

Clinical effects of anatomic hepatectomy with Cavitron ultrasonic surgical aspirator using optimized parameter settings

AIM: To evaluate the clinical effects of anatomic hepatectomy with Cavitron ultrasonic surgical aspirator (CUSA) using optimized parameter settings.

METHODS: Thirty-one patients with space-occupying lesions of the liver who underwent hepatectomy with CUSA were divided into two groups: patients using recommended parameters for CUSA (control group, n = 10) and those using optimized parameters (optimization group, n = 21). Total blood loss, blood transfusion, operative time, and recovery of liver function after operation were compared between the two groups.

RESULTS: All the patients recovered in 4 weeks after operation. Radical treatment was achieved in 90% of patients using recommended parameters and in 87.5% of those using optimized ones, with no significant different between the two groups. Total blood loss, blood transfusion, operative time, and recovery of liver function after operation were better in the optimization group than in the control group (3.8 h ± 0.8 h vs 6.2 h ± 1.9 h; 1 150 mL ± 460 mL vs 2 900 mL ± 510 mL; 530 mL ± 300 mL vs 1 760 mL ± 1 700 mL, all P < 0.05). The mean amount of abdominal drainage in 24 h after operation was not remarkably different between the two groups.

CONCLUSION: Using optimized parameters for CUSA can improve the clinical effects and efficiency of anatomic hepatectomy for patients with space-occupying lesions of the liver.

Hemi-hepatectomy in pediatric patients using two-surgeon technique and a liver hanging maneuver

AIM: To evaluate the efficacy of the two-surgeon technique with the liver hanging maneuver (LHM) for hepatectomies in pediatric patients with hepatoblastoma.

METHODS: Three pediatric patients with hepatoblastoma were enrolled in this study. Two underwent right hemi-hepatectomies and one underwent a left hemi-hepatectomy using the two-surgeon technique by means of saline-linked electric cautery (SLC) and the Cavitron Ultrasonic Surgical Aspirator (CUSA; Valleylab, Boulder, CO) and the LHM.

RESULTS: The mean operative time during the parenchymal transections was 50 min and the mean blood loss was 235 g. There was no bile leakage from the cut surface after surgery. No macroscopic or microscopic-positive margins were observed in the hepatic transections.

CONCLUSION: The two-surgeon technique using SLC and CUSA with the LHM is applicable to even pediatric patients with hepatoblastoma.

Multiple cerebral infarction and paradoxical air embolism during hepatectomy using the Cavitron Ultrasonic Surgical Aspirator -A case report-

A venous air embolism and paradoxical air embolism (PAE) are serious complications in patients undergoing a hepatectomy. We report a case of PAE and cerebral infarctions in a patient undergoing a hepatic resection using a Cavitron Ultrasonic Surgical Aspirator (CUSA®). A 65-year-old woman underwent a left lobe hepatectomy. During the middle phase of the liver resection with CUSA®, there was a sudden decrease in arterial blood pressure, end-tidal carbon dioxide and SpO₂. With resuscitation, intraoperative ultrasonography revealed massive air emboli in both her left and right heart, which lasted for 40 min. The hepatectomy was completed after the disappearance of the air emboli from her heart. After surgery, her mental status was stuporous. The brain CT and MRI revealed multiple acute cerebral infarctions. Finally, she died from septic shock. This case highlights the need for anesthetists and surgeons to be aware of the potential for CUSA®-related massive PAE.

Two-surgeon technique of parenchymal transection contributes to reduced transfusion rate in patients undergoing major hepatectomy: analysis of 1,557 consecutive liver resections

BACKGROUND

Blood transfusions are an independent risk factor for adverse outcomes after hepatectomy. In-hospital transfusions are still reported in one third of patients in major series. Data on factors affecting blood transfusions in large series of liver resection are limited. The aim of this study was to evaluate factors predictive of blood transfusion in hepatectomies performed at a tertiary referral center.

METHODS

Records of 1,477 patients who underwent 1,557 liver resections between 1998 and 2007 were reviewed. Multivariate analysis of risk factors for red cell transfusion was performed.

RESULTS

Median intra-operative blood loss was 250 cc, and 30-day peri-operative red cell transfusion rate was 27%. On multivariate analysis, factors that significantly predicted increased red cell transfusion rates were female sex, pre-operative hematocrit<30%, platelet count<100,000/mm3, simultaneous resection of other organs, major hepatic resection, use of the Pringle maneuver, and tumors>10 cm. Parenchymal transection technique was an independent risk factor for perioperative red cell transfusion; the usage of the 2-surgeon technique (combined saline-linked cautery and ultrasonic dissection) was associated with a lower transfusion rate than other techniques, including ultrasonic dissection alone, finger fracture, and stapling (P<.001).

CONCLUSION

Although most factors that affect the red cell transfusion rate for liver resection are patient- or tumor-related, the parenchymal transection technique is under the surgeon's control. The decrease in transfusion rate associated with the use of the 2-surgeon technique emphasizes the important role of the hepatobiliary surgeon in determining outcomes after liver resection.