Easier hepatic resections with a straight needle

Clinical Value of Trans-parenchymal Compressing Suture to Decrease the Cutting Surface Related Complications after Non-anatomical Liver Resection

Non-anatomical liver resection with appropriate resection margin is regarded as a potential curative treatment for selected major hepatic carcinoma due to preserving maximal normal liver, especially in cirrhotic patients. But occurrence of cutting surface related complications becomes a main challenge. From June 2010 to June 2016, 448 patients with major hepatic carcinoma received non-anatomical liver resection in our liver surgery center. After excluding 66 cases that were incongruent with the purpose of study, 235 patients undergoing transparenchymal compressing suture (TCS) to "not good" cutting surface were allocated as study group; 147 patients with exposed surface (ES) were matched as control group. The characteristics of postoperative drainage, postoperative hepatic and renal functions, hospital days, and outcomes were collected retrospectively. We further compared cutting surface related complications under different levels of liver cirrhosis between the two groups. Compared with ES group, patients in TCS group had a decreased incidence of cutting surface related complications (14.3% vs. 6.8%, P=0.011) and a decreased probability of interventions for cutting surface related complications (8.2% vs. 3.4%, P=0.042). TCS application was much more effective to prevent cutting surface related complications in patients with moderate and severe cirrhosis (5.4% vs. 15.8%, P=0.003). Postoperative hepatic and renal function, hospital days and mortality did not differ between the two groups. In conclusion, TCS decreases the probability of cutting surface related complications and postoperative interventions for related complications, especially in patients with moderate and severe cirrhosis.

Pringle's Maneuver With a Releasable Insulok Band

BACKGROUND

Currently, there are many conventional instruments being applied to perform hepatic inflow control, the Pringle's maneuver, distal to the hepatic hilum during hepatic resections. We wondered if a commonly used Insulok band can be added.

MATERIALS AND METHODS

Insulok band is a plastic tying device molded in one piece with an excellent cam-lock mechanism. We have applied releasable Insulok band to the Pringle's maneuver in 10 partial hepatectomy cases, which are not suitable for application of Chang's needle. After opening the lesser omentum, the band was passed through the Winslow foramen to the lesser sac, and the portal triad was occluded by locking the band. During the intermittent reperfusion period, this Insulok band allowed easy and fast control of hepatic inflow with its simple releasable locking device.

RESULTS

Single inflow block was used on 6 cases while repeated block on 4 cases for partial hepatectomy. The average ischemic time was 15.2 ± 8.2 minutes with an interval of 5 minutes. There was neither procedure-related morbidity nor mortality. No patient had developed postoperative hepatic failure or prolonged liver dysfunction. The efficacy of bleeding control was excellent and the average blood loss during Pringle's maneuver was 6 ± 12.6 mL. Furthermore, locking and unlocking of the Insulok band each took only 5 seconds.

CONCLUSION

Releasable Insulok band is a simpler, faster, cheaper, and safe alternative to the conventional methods for blocking hepatic inflow in Pringle's maneuver, especially in those cases not suitable for using the Chang's needle.

The past and present of liver suture

Since the first attempts at resecting parts of diseased livers in the late nineteenth century, hemorrhage has been the main obstacle for surgeons. One of the first hemostasis techniques in liver resection was liver suture. The idea of suturing the liver in order to perform resection was proposed by a team of Russian and Polish surgeons from Kharkiv University in today's Ukraine. The liver suture became widely popular and has been used in various forms throughout the surgical world. Further into the twentieth century, it has lost much of its popularity; however, over more than 100 years of existence it has seen several peaks in interest. Currently, it is still being used by some liver surgeons as it is one of the cheapest ways of obtaining a bloodless liver parenchyma transection.

Bleeding in Hepatic Surgery: Sorting through Methods to Prevent It

Liver resections are demanding operations which can have life threatening complications although they are performed by experienced liver surgeons. The parameter “Blood Loss” has a central role in liver surgery, and different strategies to minimize it are a key to improve results. Moreover, recently, new technologies are applied in the field of liver surgery, having one goal: safer and easier liver operations. The aim of this paper is to review the different principal solutions to the problem of blood loss in hepatic surgery, focusing on technical aspects of new devices.

Blocking intrahepatic inflow and backflow using Chang's needle during hepatic resection: Chang's maneuver

BACKGROUND

Chang's needle is a straight, 18-gauge stainless steel needle with a hook near its top to catch the thread and can be used for various hepatic resections. Since its introduction in 1996, accumulated experience has shown that using Chang's needle is simple and safe. We recently explored a new application for the needle with an intrahepatic vascular block during hepatic resections.

METHODS

Using Chang's needle makes whole-thickness interlocking sutures of the liver possible. One or two rows of multiple sutures secure the inflow and backflow while allowing a hepatic parenchymal division with less blood loss. Under ultrasound guidance, single temporary sutures can be made in the respective branches of the Glisson sheath to block inflow, and, on the right or left hepatic vein, to block backflow as well.

RESULTS

We did 89 hepatic resections without specifically aimed inflow or backflow blocks, including 12 right lobectomies, three trisegmentectomies, 21 bisegmentectomies, and 15 segmentectomies. Twenty-seven patients had mild to severe liver cirrhosis. Specifically aimed inflow blocks for partial hepatic resections were done on the Glisson sheath (G) of segment 8 (two patients), segment 6 (one patient), and segment 3 (one patient). One patient with a G8 block had a concomitant backflow block of the right hepatic vein. Overall, there was no procedure-related mortality or hepatic failure. Ischemia and reperfusion induced liver function deterioration was minimal in the group with this kind of temporary vascular blocks.

CONCLUSION

In addition to hepatic resections, Chang's maneuver can be used for intrahepatic individual inflow or backflow blocks, or both, to minimize ischemic and reperfusion injuries.

Silkclasy: a simple way for liver transection during anatomic hepatectomies

BACKGROUND

Parenchymal transection is the most important step of liver resection, and during this phase, blood loss may lead to morbidity and mortality. Liver parenchyma can be transected by different ways such as finger fracture, clamp crushing, or instrument-based techniques.

METHODS

A simple and cost-efficient method has been developed for liver transection using a technique based on silk crushing of the liver substance.

RESULTS

We have successfully employed this technique in 278 consecutive liver resections from July 2001 to March 2006. The average duration of hepatic transection varied according to the type of liver resection: 22 min (range 15-42), 19 min (range 11-37), and 12 min (range 7-21) for right hepatectomy, left hepatectomy, and bisegmentectomy 2-3, respectively. The mean transection speed was 6.9 +/- 2.3 cm(2)/min. Blood transfusions were necessary in 42 patients (15.1%), and there were three operative deaths (1.1%). Morbidity rate was 20.9% (58 patients).

CONCLUSIONS

This technique allows a safe and quick liver transection without the use of expensive hemostatic devices, and also precludes the use of inflow occlusion maneuvers. We recommend the use of this technique in centers with low economic resources.

Simplified hepatic resections with the use of a Chang's needle

OBJECTIVE

To demonstrate the use of Chang's needle for hepatic resections.

SUMMARY BACKGROUND DATA

Specialized instruments, fine surgical skills, and good control of hepatic inflow and backflow are essential for hepatic resections. This needle was specifically designed to simplify these requirements.

METHODS

Whole-thickness interlocking sutures of the liver can first be made along the designed resection line with a Chang's needle; then parenchyma transection can follow without inflow or backflow control. This was consecutively performed on 69 patients with primary (41), metastatic (10), and benign (18) diseases since 1997.

RESULTS

Blood loss during parenchyma transection was reduced in 11 right lobectomies (652 mL), 1 3-segmentectomy (300 mL), 14 bisegmentectomies (252 mL), 7 segmentectomies (104 mL), 12 subsegmentectomies (19 mL), 5 wedge resections (7 mL), 18 left lateral segmentectomies (110 mL), and 1 hepatorrhaphy (minimal). There was no procedure-related mortality. A mild bile leakage occurred in 1 case (1.5%) but healed spontaneously.

CONCLUSIONS

The preliminary results demonstrate that this maneuver is a simple, easy, and safe method for performing hepatic resections.