Current techniques of liver transection

Robotic Hepatic Parenchymal Transection Techniques: A Choice Between Imperfect Tools

Regardless of approach, safe and effective parenchymal transection is critical for hepatectomies.1 In robotic surgery, this can be accomplished via several methods. The authors highlight some of the more common tools and techniques used to transect the liver. The Vessel Sealer Extend is a console-controlled device with bipolar energy, mechanical cutting, full-wristed articulation, and grasping abilities that allow it to replicate the clamp-crush technique while sealing small vessels. However, the jaw is bulky and suboptimal for firm/fibrotic livers.2,3 The Synchroseal shares many features of the Vessel Sealer Extend but has thinner jaws, making it easier to advance in firm livers, and lacks a cutting blade, relying instead on a cut electrode to divide tissue. Proteinaceous char can accumulate on the jaws, impairing its effectiveness, but intermittent irrigation can mitigate this. The robotic Harmonic Scalpel coagulates, transects, and precisely dissects parenchyma. However, it is limited in length and lacks wristed articulation.4,5 Ultrasonic surgical aspiratory devices allow for precise, atraumatic dissection around vasculobiliary structures, but no robotic-integrated versions currently exist. Therefore, application of this technology in robotic surgery requires an experienced bedside assistant operating the laparoscopic version while the console surgeon uses robotic instruments to coagulate, clip, and divide larger structures.6-9 The dual bipolar technique is useful for spot coagulation and dissection but has limited transection ability.10 It often is an adjunct to other transection techniques.11-13 Several methods exist for robotic parenchymal transection, and although none are perfect, they can be combined for safe and effective transection.

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.

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.

The impacts of corrected left ventricular ejection time combined with dobutamine on hepatocellular carcinoma patients

To evaluate the clinical effect of corrected left ventricular ejection time (LVETc) combined with dobutamine on the intraoperative management of patients undergoing hepatectomy for hepatocellular carcinoma. Sixty-eight patients with elective proposed pancreaticoduodenectomy, aged 61-78 years, body mass index 19-26 kg/m², and ASA classification II or III, were divided into two groups (n = 34) using the random number table method: the esophageal ultrasound group (S group) and the esophageal ultrasound combined with dobutamine group (D group). In both groups, an esophageal ultrasound probe was placed after induction of anesthesia, and the left ventricular ejection time (LVET) and stroke volume (SV) were measured via a long-axis section of gastric fundus to guide fluid infusion. Nitroglycerin or a combination of dobutamine and nitroglycerine were pumped intravenously from the beginning of surgery to the completion of hemostasis after partial hepatectomy, in groups S or D, respectively. Central Venous Pressure (CVP), heart rate HR, and mean arterial pressure MAP were recorded at entry (T₀), immediately after induction (T₁), at the beginning of the operation (T₂), during hilar occlusion (T₃), after partial hepatectomy (T₄), and after the operation (T₅). SV and LVETc were recorded between T₁ and T₅. At T₀ and T₅, blood samples from radial artery and central vein were taken to determine the concentration of blood lactic acid, and the oxygen supply index (DO₂I) and oxygen uptake rate (O₂ERe) were calculated by blood gas analysis. The operation time, hilar occlusion time, intraoperative urine volume, intraoperative crystalloid and colloid infusion, intraoperative blood loss and blood transfusion, and the occurrence of cardiac gas emboli during the operation were also recorded. Adverse events of cardiovascular, pulmonary, and renal function during and after operation were registered. Sixty-four patients were included in the final analysis. Compared with group S, group D had lower CVP values at T₂-T₃ and higher SV values at T₂-T₅, reduced intraoperative blood loss, significantly increased intraoperative urine output, a smaller total dose of nitroglycerin use, and lower incidences of intraoperative hypotension and cardiac gas emboli (P < 0.05). Esophageal ultrasound detection of LVETc combined with dobutamine ensures hemodynamic stability in patients undergoing partial hepatectomy while reducing the incidence of intraoperative hypotension and air embolism.

Laparoscopic liver resection with "ultrasonic scalpel mimic CUSA" technique

BACKGROUND

Liver parenchymal transection is the most critical step for laparoscopic liver resection (LLR). Ultrasonic scalpel (Harmonic) is a common used energy instrument in LLR; however, it is only recommended for superficial layer transection and the Cavitron Ultrasonic Surgical Aspirator (CUSA) is recommended for deep layer dissection. We herein introduce the "Harmonic mimic CUSA" technique for LLR.

METHODS

We retrospectively reviewed the medical records of the patients who underwent LLR using CUSA or the "Harmonic mimic CUSA" for parenchymal transection between July 2018 and October 2020 at West China Hospital of Sichuan University. Observation indicators included general demographic information, operative time, intraoperative blood loss, blood transfusion volume, complication rate, hospital stay, and the costs. Perioperative data was compared between the two groups by propensity score matching analysis (PSM).

RESULTS

A total of 298 patients, including 192 in Harmonic group and 106 in CUSA group, were enrolled in this study. After a 1:1 PSM, 99 patients using "Harmonic mimic CUSA" were matched with 99 patients via CUSA for parenchymal transection in LLRs. The Harmonic group had significantly less intraoperative blood loss (mean, 150 ml vs. 250 ml, P < 0.001), shorter operative time (mean 170 min vs. 250 min, P < 0.001) and less costs (mean 6723$ vs. 8307$, P < 0.001). The conversion to laparotomy, length of postoperative hospital stay, complications were comparable between the two groups. There perioperative mortality was nil.

CONCLUSION

The "Harmonic mimic CUSA" technique is safe, simple and feasible for LLR, which may be an alternative to CUSA for LLR.

Effective sealing of biliary and pancreatic fistulas with a novel biodegradable polyurethane-based tissue sealant patch

BACKGROUND

To date, no approved sealants for the prevention of postoperative pancreatic fistulas (POPFs) or bile leakage are available. The aim of the study is to assess the feasibility of a new synthetic and biodegradable polyurethane-based sealant patch (PBSP) for hepato-pancreato-biliary (HPB) surgery.

METHODS

Benchmarking of the PBSP with commercially available products with a historical use in HPB surgery (Tachosil®, Hemopatch®, Surgicel® and Veriset®) was followed by performance testing in randomized controlled porcine animal studies. These studies focused on haemostasis as well as the prevention of POPFs and bile leakage.

RESULTS

The newly designed PBSP demonstrated the strongest adherence to liver tissue compared to Tachosil®, Hemopatch® and Veriset®. The new patch was the only patch with complete intra- and postoperative hemostasis (72 h after application) compared to Tachosil and Veriset in a porcine liver abrasion study on 12 animals. In addition, the new patch demonstrably prevents the development of POPFs. The rate of postoperative pancreatitis and clinically relevant POPFs was significantly lower compared to the control groups in a porcine pancreatic fistula model based on 14 animals (14-day follow-up). Furthermore, the incidence of biloma after 7 days, considered as significant bile leakage, was significantly lower in the new PBSP compared to the Veriset® group. The PBSP was as effective as suturing in a porcine bile leakage model (7-day follow-up).

CONCLUSION

The PBSP induces constant hemostasis in the context of liver resection and prevents pancreatic fistulas and bile leakage. The promising preclinical data implicate clinical trials for further evaluation of this newly developed patch.

Liver Resection Using Saline-Linked Radiofrequency Technology in an Infant with Congenital Hepatoblastoma

We herein report a case of giant congenital hepatoblastoma in a 3-month-old male treated with neoadjuvant chemotherapy and hepatic resection. After considerable reduction of the tumor with chemotherapy, a right bloodless hemihepatectomy using saline-linked radiofrequency technology (SLRT) and without clamping of the hepatic pedicle was performed. Intraoperative blood loss was minimal, and consequently, no blood transfusions were required. The surgery lasted 140 min, and SLRT was used for a total of 60 min. No complications were observed during or after the surgery. In conclusion, congenital hepatoblastoma is a very rare cancer for which surgery is an essential therapeutic step, and in our presented case, we showed that SLRT allowed for a safe and effective bloodless liver resection.

Tranexamic acid versus placebo to reduce perioperative blood transfusion in patients undergoing liver resection: protocol for the haemorrhage during liver resection tranexamic acid (HeLiX) randomised controlled trial

INTRODUCTION

Despite use of operative and non-operative interventions to reduce blood loss during liver resection, 20%-40% of patients receive a perioperative blood transfusion. Extensive intraoperative blood loss is a major risk factor for postoperative morbidity and mortality and receipt of blood transfusion is associated with serious risks including an association with long-term cancer recurrence and overall survival. In addition, blood products are scarce and associated with appreciable expense; decreasing blood transfusion requirements would therefore have health system benefits. Tranexamic acid (TXA), an antifibrinolytic, has been shown to reduce the probability of receiving a blood transfusion by one-third for patients undergoing cardiac or orthopaedic surgery. However, its applicability in liver resection has not been widely researched.

METHODS AND ANALYSIS

This protocol describes a prospective, blinded, randomised controlled trial being conducted at 10 sites in Canada and 1 in the USA. 1230 eligible and consenting participants will be randomised to one of two parallel groups: experimental (2 g of intravenous TXA) or placebo (saline) administered intraoperatively. The primary endpoint is receipt of blood transfusion within 7 days of surgery. Secondary outcomes include blood loss, postoperative complications, quality of life and 5-year disease-free and overall survival.

ETHICS AND DISSEMINATION

This trial has been approved by the research ethics boards at participating centres and Health Canada (parent control number 177992) and is currently enrolling participants. All participants will provide written informed consent. Results will be distributed widely through local and international meetings, presentation, publication and ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT02261415.

Restrictive Pulmonary Dysfunction May Increase Blood Loss During Liver Resection

BACKGROUND

Restrictive pulmonary dysfunction (RPD) is a risk factor for perioperative complications during gastrointestinal surgery. We hypothesized that high airway pressure due to RPD results in increased intraoperative blood loss during liver surgery. Thus, we investigated the effects of RPD on perioperative outcomes for liver resection.

METHODS

This study included 496 patients who underwent curative liver resection at our hospital between April 2009 and April 2020. Perioperative outcomes for the RPD and control groups were compared. Restrictive pulmonary dysfunction was defined as % vital capacity <80%.

RESULTS

Forty-one patients (8.3%) had RPD. No significant differences were observed in intraoperative blood losses (440 mL vs 320 mL, P = .340), overall complication rates (29.3% vs 31.2%, P = .797), or pulmonary complication rates (4.9% vs 9.0%, P = .286) between the RPD and control groups. In the 256 patients who underwent anatomical liver resection, 18 patients (7.0%) had RPD. The intraoperative blood loss was significantly higher in the RPD group (925 mL vs 456 mL, P = .013), but no differences in the overall complication rates (44.4% vs 37.3%, P = .528) or pulmonary complication rates (11.1% vs 10.5%, P = .589) between the two groups were detected. A multivariate analysis showed that RPD was an independent risk factor for intraoperative blood loss ≥500 mL during anatomical liver resection (odds ratio 4.132; 95% confidence interval 1.135-15.045; P = .031).

DISCUSSION

Restrictive pulmonary dysfunction may be a risk factor for intraoperative blood loss during anatomical liver resection, which requires exposure of the main hepatic vein.

Linear radiofrequency ablation using dual switching-control mode achieves rapid and bloodless liver resection, an experimental research

BACKGROUND

Radiofrequency (RF)-assisted devices are widely used for hemostasis during liver resection. This study compared the use of dual switching (DS) versus single switching (SS) control modes for RF-based liver resections in a pig model.

METHODS

The RF-based system comprised a 200-W generator and three electrodes with 4-cm tips arranged in a linear configuration using an adaptor. Eight Lanyu pigs were used to assess ablation outcomes with electrode spacing of 2 or 3 cm, and ablation durations of 1.5, 2 or 3 min. All combinations were tested in DS and SS modes. Procedures were performed on left lateral, caudal and right anterior liver lobes, and after which transections were performed using a scalpel. Blood loss, complete ablation rate and ablation speed were compared.

RESULTS

DS mode was shown to induce significantly less blood loss than SS mode when the electrode spacing was set at 2 cm and the ablation duration was 2 min or 3 min (p=.010 and .012, respectively). Extended ablation duration and narrow electrode spacing tended to induce less blood loss, regardless of operating mode. Bloodless resection was achieved using DS mode with electrode spacing of 2 cm and ablation duration of 2-3 min. The highest rate of complete ablation (11.3 cm²/min) was achieved using DS mode with electrode spacing of 2 cm and ablation duration of 1.5 min.

CONCLUSION

RF-based hepatic resection using DS mode is safe and feasible, resulting in less blood loss than SS mode with a higher rate of complete ablation (i.e., superior ablation efficiency).

Feasibility of Microwave-Based Scissors and Tweezers in Partial Hepatectomy: An Initial Assessment on Canine Model

Purpose: This study aimed to assess the feasibility of partial hepatectomy (PH) simplified by using microwave-based devices in animal experiments.

Methods: PH was performed on 16 beagles using either Acrosurg Scissors (AS) or Acrosurg Tweezers (AT) without hepatic pedicle (HP) control. Parenchymal transection time, Glissonean pedicle (GP) seal time, bleeding volume, bile leak, and burst pressure were recorded. Probable complications were investigated after 4 weeks.

Results: Transection time (6.5 [6.0–7.6] vs. 11.8 [10.5–20.2] min, p < 0.001) with AT were significantly shorter than with AS. GP sealing times (60 [55–60] vs. 57 [46–91] s, p = 0.859) by both devices were nearly similar. Bleeding volume in the AT group was approximately one-fourth of that in the AS group (6.7 [1.4–22] vs. 28.8 [5.8–48] mL, p = 0.247). AT created higher burst pressure on the bile duct stumps (p = 0.0161). The two devices did not differ significantly in morbidity and mortality after four-week follow-up.

Conclusion: Acrosurg devices achieved a safe PH without HP control owing to microwave-based sealing. AS could be used alone in PH, whereas the clamp-crushing function of AT seemed more advantageous in reducing the transection time and blood loss.

Novel Techniques to Improve Precise Cell Injection

We noted recently that the injection of cells with a needle through a cystoscope in the urethral sphincter muscle of pigs failed to deposit them nearby or at the intended target position in about 50% of all animals investigated (n > 100). Increasing the chance for precise cell injection by shotgun approaches employing several circumferential injections into the sphincter muscle bears the risk of tissue injury. In this study, we developed and tested a novel needle-free technique to precisely inject cells in the urethral sphincter tissue, or other tissues, using a water-jet system. This system was designed to fit in the working channels of endoscopes and cystoscopes, allowing a wide range of minimally invasive applications. We analyze key features, including the physical parameters of the injector design, pressure ranges applicable for tissue penetration and cell injections and biochemical parameters, such as different compositions of injection media. Our results present settings that enable the high viability of cells post-injection. Lastly, the method is suitable to inject cells in the superficial tissue layer and in deeper layers, required when the submucosa or the sphincter muscle of the urethra is targeted.

The Effect of Mechanical Ventilation With Low Tidal Volume on Blood Loss During Laparoscopic Liver Resection: A Randomized Controlled Trial

BACKGROUND

Control of bleeding during laparoscopic liver resection (LLR) is important for patient safety. It remains unknown what the effects of mechanical ventilation with varying tidal volumes on bleeding during LLR. Thus, this study aims to investigate whether mechanical ventilation with low tidal volume (LTV) reduces surgical bleeding during LLR.

METHODS

In this prospective, randomized, and controlled clinical study, 82 patients who underwent scheduled LLR were enrolled and randomly received either mechanical ventilation with LTV group (6-8 mL/kg) along with recruitment maneuver (once/30 min) without positive end-expiratory pressure (PEEP) or conventional tidal volume (CTV; 10-12 mL/kg) during parenchymal resection. The estimated volume of blood loss during parenchymal resection and the incidence of postoperative respiratory complications were compared between 2 groups.

RESULT

The estimated volume of blood loss (median [interquartile range {IQR}]) was decreased in the LTV group compared to the CTV group (301 [148, 402] vs 394 [244, 672] mL, P = .009); blood loss per cm2 of transected surface of liver (5.5 [4.1, 7.7] vs 12.2 [9.8, 14.4] mL/cm2, P < .001) and the risk of clinically significant estimated blood loss (>800 mL) were reduced in the LTV group compared to the CTV group (0/40 vs 8/40, P = .003). Blood transfusion was decreased in the LTV group compared to the CTV group (5% vs 20% of patients, P = .043). No patient in the LTV group but 2 patients in the CTV group were switched from LLR to open hepatectomy. Airway plateau pressure was lower in the LTV group compared to the CTV group (mean ± standard deviation [SD]) (12.7 ± 2.4 vs 17.5 ± 3.5 cm H2O, P = .002).

CONCLUSIONS

Mechanical ventilation with LTV may reduce bleeding during laparoscopic liver surgery.

Rationality and necessity of vascular stapler application during liver resection (Review)

Liver resection (LR) is the primary treatment method for patients with hepatocellular carcinoma (HCC). Improving surgical safety and reducing surgical morbidity and mortality is important for patients receiving LR. Various devices have been developed to facilitate vascular transection to reduce intraoperative blood loss, which is considered to be a predictor of poor surgical outcomes in patients undergoing LR. Vascular staplers have been widely applied for the division of major vascular and biliary structures in the process of LR; however, when and how to use these tools remains controversial. This review aims to report the rationality and necessity of using vascular staplers in vessel transection during liver surgery. Due to the risk of intraoperative and postoperative hemorrhage and biliary fistula, the process of transection of the portal pedicle and hepatic vein is a crucial step during LR. Stapling represents a vascular dissection technique that is widely used in laparoscopic LR and has then been popularized in open LR. Advocates argue that stapler transection methods provide several advantages, including diminished blood loss, fewer transfusion requirements and shorter operative times. However, other studies have failed to demonstrate those benefits when using these tools compared with the simple clamp-crushing technique. Using the stapler vascular transection method resulted in smaller surgical margins and similar surgical outcomes compared with those of the clamp-crushing vascular transection method. However, the intraoperative use of vascular staplers may significantly increase the financial burden of liver resection for patients with HCC, while not improving short- and long-term outcomes. Therefore, it has been suggested that vascular staplers should not be routinely used in LR. The current review discussed the above points and recommended that the stapling transection of the portal pedicle and hepatic vein should be applied during laparoscopic LR in a rational manner. However, the suturing ligation method should be routinely used in open LR.

Laparoscopic Versus Open Left Lateral Segmentectomy for Large Hepatocellular Carcinoma: A Propensity Score-Matched Analysis

BACKGROUND

With the advancement of endoscopic technology, laparoscopic liver resection has become the standard procedure for left lateral segmentectomy. The aim of this study was to compare perioperative and oncological outcomes between laparoscopic and open left lateral segmentectomy for hepatocellular carcinoma (HCC) >5 cm.

PATIENTS AND METHODS

A total of 66 patients underwent left lateral segmentectomy for HCC (>5 cm) during the period spanning between 2013 and 2015. To overcome selection bias, 1:3 match using propensity score-matched analysis was performed between laparoscopic and open liver resection.

RESULTS

Relatively smaller tumor size (6.0 vs. 7.0 cm; P=0.030) and more frequent incidence of complete tumor capsule (93.3% vs. 58.8%; P=0.013) were observed in the laparoscopic group compared with the open group before matching. Although the longer operation time (195 vs. 150 min; P=0.022) was consumed in the laparoscopic procedure after matching, the laparoscopic group had shorter postoperative hospital stay (6 vs. 7 d; P=0.002) and less blood loss volume (50 vs. 100 mL; P=0.022). The Pringle maneuver for hepatic inflow occlusion was more likely to be applied in patients who underwent open surgery. The incidence of postoperative complication seemed to be lower in the laparoscopic group (6.7%) compared with that in the open group (11.8%) before matching. On the basis of propensity score-matched analysis, the complication rates were comparable between the 2 groups (7.1% vs. 6.7%, P=0.953). No difference in the 1-year and 3-year overall and recurrence-free survival rates was found between the laparoscopic and open groups.

CONCLUSION

Laparoscopic left lateral segmentectomy for large HCC patients showed better perioperative outcomes and equivalent oncologic outcomes as the open procedure, providing evidence for considering as a standard laparoscopic practice through careful selection.

Minimally invasive donor hepatectomy, systemic review

Liver transplantation is a life-saving therapy for patients with end-stage liver disease. Living donation is a critical source of organs throughout the world. Reducing donor morbidity and mortality is of utmost importance while maintaining access to liver transplantation for recipients. While laparoscopy was more rapidly utilized in donor nephrectomy, laparoscopy has been slower to develop for living donor hepatectomies due to the concerns about hemostasis, safety of the donor and quality of the graft. Pure minimal invasive approach has become a standard of care for left lateral sectionectomy (LLS) for pediatric recipients. In the past few years, a number of centers with significant laparoscopic and living donor experience have reported fully minimally invasive approach to hemi-hepatectomies. In this manuscript we discuss the experiences, lessons learned and path forward for laparoscopic and minimal invasive surgery(MIS) in donor hepatectomies (DH).

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.

A novel model for predicting posthepatectomy liver failure in patients with hepatocellular carcinoma

Posthepatectomy liver failure (PHLF) is the most leading cause of mortality following hepatectomy in patients with hepatocellular carcinoma (HCC). Platelet count was reported to be a simple but useful indicator of liver cirrhosis and function of spleen. Spleen stiffness (SS) was used to evaluate the morphological change of spleen and was reported to be related to liver cirrhosis and portal hypertension. However, the predictive value of platelet to spleen stiffness ratio (PSR) on PHLF remains unknown. A retrospective study was performed to analyze 158 patients with HCC following hepatectomy from August 2015 to February 2016. Univariate and multivariate analyses were performed to evaluate the value of each risk factor for predicting PHLF. The predictive efficiency of the risk factors was evaluated by receiver operating characteristic (ROC) curve. PHLF occured in 23 (14.6%) patients. PSR (P<0.001, odds ratio (OR) = 0.622, 95% confidence interval (CI) 0.493~0.784), hepatic inflow occlusion (HIO) (P = 0.003, OR = 1.044, 95% CI 1.015~1.075) and major hepatectomy (P = 0.019, OR = 5.967, 95% CI 1.346~26.443) were demonstrated to be the independent predictive factors for development of PHLF in a multivariate analysis. Results of the present study suggested PSR is a novel and non-invasive model for predicting PHLF in patients with HCC.

A Systematic Review and Meta-Analysis Comparing Liver Resection with the Rf-Based Device Habib™-4X with the Clamp-Crush Technique

Liver cancer is the sixth most common cancer and third most common cause of cancer-related mortality. Presently, indications for liver resections for liver cancers are widening, but the response is varied owing to the multitude of factors including excess intraoperative bleeding, increased blood transfusion requirement, post-hepatectomy liver failure and morbidity. The advent of the radiofrequency energy-based bipolar device Habib™-4X has made bloodless hepatic resection possible. The radiofrequency-generated coagulative necrosis on normal liver parenchyma provides a firm underpinning for the bloodless liver resection. This meta-analysis was undertaken to analyse the available data on the clinical effectiveness or outcomes of liver resection with Habib™-4X in comparison to the clamp-crush technique. The RF-assisted device Habib™-4X is considered a safe and feasible modality for liver resection compared to the clamp-crush technique owing to the multitude of benefits and mounting clinical evidence supporting its role as a superior liver resection device. The most intriguing advantage of the RF-device is its ability to induce systemic and local immunomodulatory changes that further expand the boundaries of survival outcomes following liver resection.

Primary hepatocellular carcinoma in a patient with history of treated breast cancer: a case report with challenging diagnosis and treatment

Introduction

Breast cancer is the most common malignancy in women worldwide. Long-term survivors among patients treated for breast cancer are at a high risk for developing a second primary malignancy. Hepatocellular carcinoma is the most frequent primary hepatic malignancy and should be ruled out in breast cancer patients who are diagnosed with solitary hepatic lesions. False diagnosis may lead to inappropriate oncologic staging and treatment of the disease.

Case presentation

We present the case of a 73-year-old female patient who had been treated for invasive ductal breast cancer 7 years ago and was diagnosed with a solid hepatic lesion at segments VI and VII and a small, calcified lesion at the tail of the pancreas on follow-up with an abdominal computed tomography. Oncology council decided that both lesions could be resected after determining whether they were metastatic or second primary malignancies. The patient underwent laparotomy and rapid biopsy which showed primary hepatocellular carcinoma and fibrosis of the pancreas. We performed hepatic segmentectomy (VI–VII) and cholecystectomy, while the pancreatic lesion was left intact. The postoperative course of the patient was uncomplicated and she remains disease free 2 years after the operation without any adjuvant therapy.

Conclusion

All hepatic lesions detected in breast cancer patients should be evaluated with open mind and liver biopsy should be performed to get a definitive diagnosis and implement the proper treatment strategy.

Evaluation of THUNDERBEAT® in open liver resection- a single-center experience

Background

THUNDERBEAT® (TB) (Olympus Medical Systems Corp., Tokyo, Japan) is a dynamic energy system device that simultaneously delivers ultrasonically generated frictional heat energy and electrically generated bipolar energy. TB is being routinely used in various operative procedures, however, less is known about its utility in liver resection. We, herein, report our early experience of using TB in open liver resection particularly in patients with normal or near-normal liver parenchyma.

Methods

We retrospectively reviewed the clinical characteristics, and evaluated the perioperative outcome of twenty-eight patients who underwent liver resection with TB, and twenty-four patients who underwent liver resection with basic procedure in our institution. The resection type was stratified into: major hepatectomy; resection of 3 or more than 3 Couinauds segments, and minor hepatectomy; resection of less than 3 Couinauds segments.

Results

Liver resection time (mean ± SD) in TB group with major hepatectomy was significantly shorter: 16.7 ± 8.8 compared to 62.8 ± 39.4 min in basic procedure group (P < 0.0001). Accordingly, the liver resection time (mean ± SD) in TB group with minor hepatectomy was also significantly shorter, 8.3 ± 2.9 min compared to 45.2 ± 23.9 min in liver resection with basic procedure (P < 0.001). No significant difference was observed between the groups in terms of intraoperative blood transfusion ratio, postoperative complication and postoperative liver dysfunction.

Conclusion

TB as a new energy device can offer a safe, reliable and substantially rapid liver resection particularly in patients with normal or near-normal liver parenchyma.

A new technique for hepatic parenchymal transection using an articulating bipolar 5 cm radiofrequency device: results from the first 100 procedures

BACKGROUND

Parenchymal transection(PT) still remains a challenge in liver resection. The outcomes of the first experience of a novel vessel-sealer for hepatic transection were assessed.

METHODS

A bipolar articulating vessel-sealer (Caiman^®, Aesculap Inc., Center Valley, PA) was used in 100 liver resections through both open (OLR) and laparoscopic (LLR) approaches. All data were prospectively collected into an IRB-approved department database, and clinical, surgical and perioperative parameters were analyzed.

RESULTS

Fifty patients underwent OLR and 50 patients underwent LLR. Eighty hepatectomies were performed for malignancy. Median number of tumors was 1, with the largest focus measuring an average of 5.1 cm. Forty-nine of the procedures were major liver resections. Parenchymal transection time was 29.9 ± 3.1 min in OLR and 29.9 ± 3.6 min in LLR. Median estimated blood loss was 300 cc (Inter-quartile range (IQR) 100-575 cc). Median hospital stay was 6 days for open and 3 days for laparoscopic procedures. Ninety-day complication rate was 8% without any mortality. Bile leak rate was 4%. Staplers were used for parenchymal transection in 16 cases.

CONCLUSION

This study introduces a new multifunctional device into the armamentarium of the liver surgeon. In our experience, this device facilitated the parenchymal transection by adding speed and consolidating the amount of instrumentation used in liver resection without increasing complications.

Radiofrequency-assisted liver resection: Technique and results

BACKGROUND

Radiofrequency (RF)-assisted liver resection allows non-anatomical liver resection with reduced blood loss and offers the opportunity for a combination of resection and ablation. However, there are still concerns with regard to postoperative complications related to this technique. In the present study, we discuss the technical aspects of RF-assisted liver resections and analyse the rate of perioperative complications, focusing on post-hepatectomy liver failure (PLF), bile leak and abscess, and mortality.

METHODS

Between 2001 and 2015, 857 consecutive open and laparoscopic elective RF-assisted liver resections for benign and malignant liver tumours were reviewed retrospectively to assess perioperative outcomes.

RESULTS

Median intraoperative blood loss was 130 mL, with 9.8% of patients requiring blood transfusion. Intra-abdominal collections requiring percutaneous drainage developed in 8.7% of all patients, while bile leak at resection margin developed in 2.8% of the cases. Major liver resection was performed in 34% of patients and the incidence of PLF was 1.5% with one directly related mortality (0.1%).

CONCLUSION

RF-assisted liver resection has evolved into a feasible and safe technique of liver resection with an acceptable incidence of perioperative morbidity and a low incidence of PLF and related mortality.

Impact of cavitron ultrasonic surgical aspirator (CUSA) and bipolar radiofrequency device (Habib-4X) based hepatectomy for hepatocellular carcinoma on tumour recurrence and disease-free survival

Background

The aim of this study was to evaluate the oncological outcomes of hepatocellular carcinoma patients undergoing liver resection using cavitron ultrasonic surgical aspirator (CUSA) or radiofrequency (RF) based device Habib-4X.


Study Design

We prospectively analyzed the data of 280 patients who underwent liver resection for hepatocellular carcinoma at our institution from 2010–2012 with follow up till August 2016. The CUSA was used in the 163 patients whilst Habib-4X in 117 patients. The end points of analysis were oncological outcomes as disease recurrence, disease-free survival (DFS) and overall survival (OS) were estimated by the Kaplan–Meier method, which has been compared with all other existing literature on the survival study.

Results

Compared with CUSA the reported incidence of recurrence was significantly lower, in Habib-4X group; p < 0.01. The median DFS was significantly better in Habib-4X group than CUSA group (50.80 vs 45.87 months, p = 0.03). The median OS was better in Habib-4X group than CUSA group (60.57 vs 57.17 months, p = 0.12) though the lesser difference in OS between the groups might be explained by the use of palliative therapies as TACE, percutaneous RFA, etc. in case of recurrence.

Conclusions

RF based device Habib-4X, is safe and effective device for resection of hepatocellular carcinoma, in comparison to CUSA with better oncological outcomes, i.e., significantly lesser tumour recurrence and better DFS. This could be explained on the basis of systemic and local immunomodulatory effect involving induction of kupffer cells and effector CD-8 T cells that help in minimizing postoperative complications and bring more advantageous oncological outcomes.

Comparative Study With Propensity Score Matching Analysis of Two Different Methods of Transection During Hemi-Right Hepatectomy: Ultracision Harmonic Scalpel Versus Cavitron Ultrasonic Surgical Aspirator

BACKGROUND

Several devices are available for liver parenchyma transection (LPT). The aim of this study was to compare the Ultracision Harmonic scalpel (UHS) with the Cavitron Ultrasonic Surgical Aspirator (CUSA) among patients who underwent hemi-right hepatectomies (RH) to homogenize transection areas.

METHODS

From September 2012 to June 2015, 24 patients who underwent the UHS surgery approach were matched with 24 patients who underwent the CUSA transection procedure for RH using propensity score matching.

RESULTS

Total operative time (TOT) was shorter in the UHS group, 240 minutes (range 172.5-298.8) versus 330 minutes (range 270-400) in the CUSA group ( P = .0002). The occurrence of hepatopathy (odds ratio = 17; 95% confidence interval = 1.02-230) and the use of the CUSA device (odds ratio = 8; 95% confidence interval = 0.98-77) were associated with a TOT exceeding 300 minutes in multivariate analysis ( P = .05).

CONCLUSIONS

The UHS is a safe and effective method of LPT as compared to the use of the CUSA system. TOT is statistically decreased.

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.

Anesthetic and operative considerations for laparoscopic liver resection

We enumerate the broad range of anesthetic considerations that affect the outcome of patients undergoing laparoscopic liver resection. Key elements for excellent outcomes after laparoscopic liver resection are careful patient selection and risk stratification, appropriate monitoring, techniques to reduce blood loss and transfusion, and active recovery management. Although some of these key elements are the same for open liver operation, there are specific anesthetic considerations of which both the surgical and anesthesia teams must be aware to achieve optimal patient outcomes after laparoscopic liver resection. While unique advantages of laparoscopic liver resection typically include decreased intraoperative bleeding, transfusion requirements, and a lower incidence of postoperative ascites, specific challenges include management of the complicated interplay between low-volume anesthesia and increased intraabdominal pressure due to pneumoperitoneum, with additional considerations regarding circulatory support to treat acute blood loss with need for emergent conversion in some cases. This article will address in detail the preoperative, intraoperative, and postoperative anesthetic considerations for patients undergoing laparoscopic liver resection that both the surgical and anesthesia team should be aware of to optimize outcomes.

Radiofrequency Energy in Hepatic Bed during Partial Cystectomy for Hydatid Liver Disease: Standing Out from the Usual Conservative Surgical Management

Background. Surgical treatment of hydatid liver disease (HLD) is divided into conservative and radical procedures. While conservative techniques are easier and faster to perform, there is an emerging need to reduce their morbidity and recurrence rates. Our aim was to present and evaluate the efficiency and safety of the application of radiofrequency energy (TissueLink® and Aquamantys® systems) in hepatic bed during partial cystectomy. Materials and Methods. Eighteen consecutive patients with hydatid liver cysts were referred to our department between April 2006 and June 2014. Data about demographics, mortality, morbidity, and recurrence rate were obtained and analyzed retrospectively. Results. The mean follow-up was 38 months (range: 4–84 months). The postoperative course of most patients was uneventful. One case of recurrence was found in our series in a patient with 4 cysts in the right lobe, 3 years after initial treatment. He was reoperated on with the same method. Conclusions. Saline-linked RF energy seems to be an effective means to be employed in conservative surgical procedures of HLD, with satisfactory postoperative morbidity. Recurrence rates appear to be low, but further follow-up is needed in order to draw safer conclusions.

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.

The Cavitron ultrasonic surgical aspirator with a low amplitude is a useful dissection device for surgical procedures: application to vascular detachment and lymph node dissection

In surgical procedures, although resection and hemostasis maneuvers have become more efficient through the use of dedicated devices, no dedicated device for the dissecting (detaching) maneuver exists at present. The Cavitron ultrasonic surgical aspirator (CUSA: Integra lifesciences Corporation, NJ, USA) is a device originally used mainly for hepatic parenchyma resection in the gastrointestinal surgical field. Tissue is selectively fragmented by an ultrasonically vibrating chip at the tip of the device. Furthermore, physiologic saline is ejected from the tip and aspirated with the fragmented tissue by the device. By reducing the amplitude of the CUSA to 10-20 %, we have been using the device not only for hepatic parenchyma resection but also for dissection in gastrointestinal surgical procedures in general. Here, we explain the details of the techniques that we routinely use, such as dissection of vessels and lymph nodes in radical operations for gastrointestinal cancer. With the CUSA set at a greatly reduced amplitude, dissection can be performed in consideration of layers, surfaces, and membranes while tissue damage and bleeding are minimized. The device is useful for performing higher quality operations.

Metabolic profile in right lobe living donor hepatectomy: Comparison of lactated Ringer's solution and normal saline versus acetate based balanced salt solution - a pilot study

BACKGROUND AND AIMS

Lactate levels predict outcomes after hepatectomy. We compared metabolic effects of lactated versus lactate free solutions in living donor hepatectomy.

METHODS

Consecutive right lobe donors (n = 53) were alternatively allotted to lactated Ringer's solution and normal saline (Group L-control) or acetated crystalloid (Sterofundin B Braun^® Group S -study group) in an observational prospective randomised study. The primary outcome measure was lactate level, and secondary outcomes were base excess, bicarbonate, glucose and chloride intra- and post-operatively. Mann-Whitney and Chi-square tests were used for analysis.

RESULTS

The intraoperative, post-operative lactate levels and the time for normalisation were comparable. Group L had significantly lower intraoperative bicarbonate levels (mmol/L) at 6 and 8 h (20.0 ± 2.14 vs. 21.3 ± 1.6, P = 0.0471; 18.68 ± 2.04 vs. 20.39 ± 17, P = 0.002), base excess at 4 and 6 h (mmol/L) (-3.64 ± 2.73 vs. -3.0 ± 1.52, P = 0.031; -6.64 ± 2.76 vs. -4.35 ± 1.7 P = 0.006). The intraoperative chloride levels (mmol/L) were higher in group L at 4 and 8 h (108 ± 5.9 vs. 105.99 ± 2.76, P = 0.0471; 109.51 ± 3.86 vs. 106.93 ± 3.09, P = 0.002). Intraoperative glucose (mg/dL) at 6 h was higher in group L, 160.55 ± 31.52 vs. 145.5 ± 24.29, P = 0.043. The highest post-operative chloride (mmol/L) was higher in Group L (112.3 ± 3.86 vs. 109.81 ± 3.72, P = 0.034). Post-operative base excess and bicarbonate showed an improved profile in Group S (-7.37 ± 2.99 vs. -5.06 ± 1.71 P = 0.001 and 17.79 ± 2.23 vs. 19.68 ± 1.51 P = 0.005).

CONCLUSION

Acetated fluids were associated with higher levels of bicarbonate, lesser base deficit, glucose and chloride but no difference in lactate levels in comparison with Ringer's lactate and normal saline in living donor hepatectomy.

Pre-resectional inflow vascular control: extrafascial dissection of Glissonean pedicle in liver resections

BACKGROUND/AIMS

We are evaluated technique of anatomic major and minor hepatic resections using suprahilar-extrafascial dissection of Glissonean pedicle with vascular stapling device for transection of hepatic vessels intending to minimize operative time, and blood loss.

METHODOLOGY

We prospectively analyzed the clinical records of 170 patients who underwent hepatic resection by suprahilar-extrafascial pedicle isolation and stapling technique in our clinic for emergency surgery in Belgrade. Patients who underwent hilar extrahepatic intrafascial dissection were excluded from the study.

RESULTS

We performed 102 minor liver resections and 68 major hepatectomies. The minor liver resections were associated with significantly shorter surgery duration (95.1±31.1 vs. 186.6±56.5) and transection time (35.9±14.5 vs. 65.3±17.2) than major hepatectomies (P<0.001 for all). The mean blood loss was 255.6±129.9 mL in minor resection and 385.7±200.1 mL in major resection (P=0.003). The mean blood transfusion requirement was 300.8±99.5 mL for the patients with minor hepatectomy and 450.9±89.6 mL for those with major liver resection (P=0.067). There was no significant difference in morbidity and mortality between the groups (P=0.989; P=0.920). Major as well as minor liver resection were a superior oncologic operation with no significant difference in the 3-year overall survival rates.

CONCLUSIONS

Extrafascial dissection of Glissonean pedicle with vascular stapling represents both an effective and safe surgical technique of anatomical liver resection. Presented approach allows early and easy ischemic delineation of appropriate anatomical liver territory to be removed (hemiliver, section, segment) with selective inflow vascular control. Also, it is not time consuming and it is very useful in re-resection, as well as oncologically reasonable.

Consensus and controversy in hepatic surgery: a survey of Canadian surgeons

BACKGROUND

Heterogeneity in practice provides an opportunity for further study, as it may [IRT Rev 1] reflect deficiencies in knowledge translation or knowledge gaps. This survey aimed to assess practice patterns for the surgical treatment of malignancies of the liverwith the goal of identifying areas of variability.

METHODS

We created a web-based survey focusing on scope of surgical practice, pre-and post-operative measures and practice patterns for liver and biliary surgery. We piloted the survey for clarity and made changes as needed. All members of the Canadian Hepato-Pancreatico-Biliary Association (CHPBA) were invited to participate. Descriptive statistics were used to analyze the results.

RESULTS

The survey was sent to sixty-nine surgeons and thirty-six (52%) completed the survey in its entirety. Areas of agreement include defining the resectability of a tumourand in imaging modalities used to determine resectability. Variability surrounded utlilization of blood conservation strategies, withlow CVP anesthesia frequently used and all other strategies (autologous blood donation, acute normovolemic hemodilution, cell-saver, and tranexamic acid) rarely used. Post-operative analgesic technique was variable with epidural analgesia (50%) and IV-PCA (35.3%) nearly equally preferred.

CONCLUSIONS

There is variability in some techniques and approaches used by hepatobiliary surgeons. Future research focusing on areas of uncertainty including techniques of blood conservation and post-operative analgesia are needed.

Hemostatic efficacy of latest-generation fibrin sealant after hepatic resection: a randomized controlled clinical study

PURPOSE

This randomized, controlled, single-blinded multicenter study evaluated the efficacy of latest-generation fibrin sealant containing synthetic aprotinin as fibrinolysis inhibitor as supportive treatment for hemostasis after elective partial hepatectomy.

METHODS

Adult subjects undergoing resection of at least one liver segment were assigned to treatment with fibrin sealant or manual compression with a surgical gauze swab if persistent oozing necessitated additional hemostatic measures after primary control of arterial and venous bleeding. The primary outcome measure was the proportion of subjects with intraoperative hemostasis at 4 min after start of randomized treatment application. Secondary efficacy outcome measures included intraoperative hemostasis at 6, 8, and 10 min, intra- and postoperative rebleedings, transfusion requirements, and drainage volume.

RESULTS

Seventy subjects were randomized. Hemostasis at 4 min was achieved in 29/35 (82.9 %) fibrin sealant subjects compared with 13/35 (37.1 %) control subjects (p < 0.001). Significantly more fibrin sealant subjects achieved hemostasis at 6 (p < 0.001), 8 (p = 0.028), and 10 min (p = 0.017). The number of rebleedings was low in both study arms. Transfusion requirements and 48-h drainage volumes were similar between the study arms. No adverse events related to study treatment were reported.

CONCLUSIONS

Fibrin sealant was shown to be safe and superior to manual compression in the control of parenchymal bleeding after hepatic resection. The use of synthetic aprotinin as fibrinolysis inhibitor further improves the safety margin of fibrin sealant by eliminating the risk of transmission of bovine spongiform encephalopathy and other bovine pathogens.

The Nd:YAG LIMAX® 120 high-output laser: local effects and resection capacity on liver parenchyma

Various technical options are available for the resection of liver metastases, including CUSA, Ultracision, water-jet, and stapler devices. It has been shown that new generation high-output lasers are suitable for the resection of lung metastases. The goal of the present study was to evaluate the local effects of laser application on liver parenchyma. Livers of freshly slaughtered pigs (N = 6) were analyzed. The handheld laser was vertically held in the clamp of a hydraulic machine and sharply focused on the liver surface. The diode pumped Nd:YAG laser LIMAX® 120 (Gebrüder Martin GmbH & Co. KG, Tuttlingen, Germany) moved evenly over the liver surface at speeds of 5, 10, and 20 mm/s. Laser outputs of 60 and 120 W were applied at every speed. Histological sections (hematoxylin and eosin (HE) staining) of the extension area of vaporization and coagulation were analyzed by the use of the ImageJ software. In addition, the area of the liver parenchyma cut by the laser within 1 min was measured. The vaporized zone appeared wedge-shaped after histological section, whereas the area of coagulation appeared radiated outward. At 10 mm/s and 60 W, the mean vaporization of the measured zone was 356.6 ± 3.9 μm in length. Superficial coagulation was observed at 20 mm/s laser speed, without effective resection. At 120 W and 5 mm/s working speed, the mean vaporization zone and the average width of coagulation were largest with 664.6 ± 5.9 and 375.6 ± 2.3 μm, respectively. The laser output power of 120 W allowed resection of an area of 6 ± 0.4 cm(2) of liver parenchyma within 1 min. The Nd:YAG Laser LIMAX® 120 might be an effective tool for liver parenchyma dissection when it is applied at maximum output (120 W) and at a constant working speed of 5 mm/s.

Morbidity and mortality in 1,174 patients undergoing hepatic parenchymal transection using a stapler device

BACKGROUND

Transection of liver parenchyma using staplers is now commonly performed. Large studies are needed to assess the usefulness of the technique as well as perioperative outcomes.

METHODS

This is a retrospective study of a prospectively maintained database. A total of 1,174 patients undergoing liver resections in routine surgical practice, using a stapler device at MD Anderson Cancer Center between January 1, 1994 and November 10, 2011 were evaluated.

RESULTS

There were 900 major resections (3 segments or more) (77 %) and 274 minor resections (<3 segments or wedge resections) (23 %). A vast majority, 1,133 (96.5 %), were indicated for an underlying malignancy (24 % primary liver or gall bladder and 72.5 % metastatic) compared with benign disease, 41 (3.5 %), with the most common indication being metastatic colorectal cancer 584 (49.7 %). Of the total 1,174 patients 128 (10.9 %) had a prior liver resection. Median OR time and blood loss was 206 min and 300 mL, respectively, with 11 % of patients requiring transfusion in the perioperative or postoperative period. Overall morbidity and mortality rate was 14 and 3.2 %, respectively, with a median hospital stay of 7 days (interquartile range [IQR], 4 days). Multivariate logistic regression demonstrated blood loss and extent of liver resection to be independent predictors of adverse outcome. A total of 13 instances (1.1 %) of misfired staplers were noted and were associated with higher blood loss (p < 0.001) and mortality (15 vs. 3.1 %, p = 0.013).

CONCLUSIONS

Use of stapler device for hepatic resection is safe and effective, but rare instances of a misfired stapler device are associated with an adverse outcome.

Liver resection using cavitron ultrasonic surgical aspirator (CUSA) versus harmonic scalpel: a retrospective cohort study

BACKGROUND

The aim of this study was to evaluate the safety and efficacy of two device combinations used in parenchymal division during hepatic resections in non-cirrhotic patients and without inflow vascular occlusion.

METHODS

We retrospectively analyzed 47 patients who underwent liver resection at our Institution from 2004 to 2010 using the TissueLink with either the Cavitron Ultrasonic Surgical Aspirator (CUSA) or the Harmonic Scalpel. The TissueLink was used with the CUSA in 27 patients and with the Harmonic Scalpel in 20 patients.

RESULTS

Median estimated blood loss (EBL) in the Harmonic Scalpel and CUSA groups was 250 and 1035 mL respectively (p < 0.05). Three patients were transfused banked blood perioperatively in the Harmonic Scalpel group and 11 in the CUSA group (p < 0.05). Median operative time in the Harmonic Scalpel and CUSA groups was 185 and 290 min respectively. Length of stay (LOS) was shorter in the Harmonic Scalpel group at 6 days compared to 7 days in the CUSA group (p < 0.05). Perioperative complications were documented in 20% and 26% in the Harmonic Scalpel and CUSA groups, respectively.

CONCLUSIONS

Our results show the Harmonic Scalpel with TissueLink to be a safe, effective method of parenchymal division with significantly less EBL and LOS when compared to CUSA with TissueLink.

Randomized clinical trial of stapler versus clamp-crushing transection in elective liver resection

BACKGROUND

Various devices have been developed to facilitate liver transection and reduce blood loss in liver resections. None of these has proven superiority compared with the classical clamp-crushing technique. This randomized clinical trial compared the effectiveness and safety of stapler transection with that of clamp-crushing during open liver resection.

METHODS

Patients admitted for elective open liver resection between January 2010 and October 2011 were assigned randomly to stapler transection or the clamp-crushing technique. The primary endpoint was the total amount of intraoperative blood loss. Secondary endpoints included transection time, duration of operation, complication rates and resection margins.

RESULTS

A total of 130 patients were enrolled, 65 to clamp-crushing and 65 to stapler transection. There was no difference between groups in total intraoperative blood loss: median (i.q.r.) 1050 (525-1650) versus 925 (450-1425) ml respectively (P = 0·279). The difference in total intraoperative blood loss normalized to the transection surface area was not statistically significant (P = 0·092). Blood loss during parenchymal transection was significantly lower in the stapler transection group (P = 0·002), as were the parenchymal transection time (mean(s.d.) 30(21) versus 9(7) min for clamp-crushing and stapler transection groups respectively; P < 0·001) and total duration of operation (mean(s.d.) 221(86) versus 190(85) min; P = 0·047). There were no significant differences in postoperative morbidity (P = 0·863) or mortality (P = 0·684) between groups.

CONCLUSION

Stapler transection is a safe technique but does not reduce intraoperative blood loss in elective liver resection compared with the clamp-crushing technique.

REGISTRATION NUMBER

NCT01049607 (http://www.clinicaltrials.gov).

A novel liver parenchyma transection technique using locking straight rigid ties. An experimental study in pigs

INTRODUCTION

Technological advances have led to the development of many devices used in liver resections. However, no single transection tool is uniformly considered to be better than the others. This study aimed to develop an effective, fast, and cost-efficient technique for hepatic parenchymal transection.

MATERIALS AND METHODS

A liver parenchyma compression device in the form of a locking straight rigid tie (LoStRiT) was newly developed. Twelve pigs were distributed into two groups. The control group ( n = 6) comprised animals that underwent hepatectomy using the standard Kelly-clysis technique. The study group (n = 6) comprised animals that underwent hepatectomy using sequential LoStRiT mechanisms. The transection speed, blood loss, and biloma formation were recorded.

RESULTS

The mean parenchymal transection speed was 1.27 ± 0.27 cm(2)/min for the control group and 2.39 ± 0.56 cm(2)/min for the LoStRiT group ( p = .003). The mean blood loss per kilogram of body weight was 9.8 ± 5.2 ml/kg for the control group and 3.9 ± 0.9 ml/kg for the LoStRiT group ( p = .040). No bilomas were identified.

CONCLUSION

LoStRiT hepatectomy appears to be effective, fast, and reproducible in a porcine model of liver resection. Further development of this novel and potentially cost-efficient technique includes construction of the device using absorbable materials.

Usefulness of vessel-sealing devices combined with crush clamping method for hepatectomy: a retrospective cohort study

BACKGROUND

Blood loss during resection of the hepatic parenchyma in hepatectomy can be minimized using vessel-sealing (VS) devices. Some sealing devices were retrospectively compared to evaluate the efficacy of each device for controlling blood loss, transection time and postoperative complications in hepatectomy as a cohort study.

METHODS

Between 2005 and September 2012, hepatectomy was underwent in 150 patients using one of three types of LigaSure™ (Dolphin Tip Laparoscopic Instrument, Precise or Small Jaw) or the Harmonic Focus or Ace ultrasonic dissecting sealer. Results were compared to crush-clamping alone as the control method by the historical study (n = 81).

RESULTS

Irrespective of the vessel-sealing device used for underlying chronic hepatitis, blood loss, blood transfusion rate, operating time and transection time were significantly reduced in the VS group compared with controls (p < 0.05). Rates of postoperative bile leakage and intra-abdominal abscess formation were significantly lower in the VS group than in controls (p < 0.05). Comparing devices, LigaSure Small Jaw and Harmonic Focus showed lower blood loss, shorter transection time and reduced rates of post-hepatectomy complications, in turn resulting in shorter hospital stays (p < 0.05). Tendencies toward uncontrolled ascites and bile leakage were only concern with the use of Harmonic Focus. Satisfactory surgical results were achieved using the sealing device for laparoscopic hepatectomy.

CONCLUSIONS

The use of energy sealing devices improves surgical results and avoids hepatectomy-related complications. Adequate use of vessel sealers is necessary for safe and rapid completion of hepatic resection.

Technology-Assisted Versus Clamp-Crush Liver Resection

Objective. To review the published evidence on technology-assisted liver resection regarding operative time, intraoperative bleeding, mortality, hospital stay, postoperative bile leak, and other outcomes. Method. A systematic review of clinical studies comparing liver resection using vessel sealing systems (VSSs—LigaSure), Cavitron Ultrasonic Surgical Aspirator (CUSA), or radiofrequency dissecting sealer (RFDS) with the conventional clamp-crushing technique (CC) was performed. Data for each modality were synthesized and individually compared with CC with the methodology of meta-analysis. Result. In all, 8 randomized controlled trials (RCTs) and 7 nonrandomized studies evaluating 1539 patients were included. Compared with CC, the VSS group (3 RCTs and 3 nonrandomized studies) had significantly lower blood loss by a mean of 109 mL (weighted mean difference [WMD] = −109; 95% confidence interval [CI] = −192, −26; data on 494 patients), lower risk for postoperative bile leak by 63% (odds ratio [OR] = 0.37; CI = 0.17, 0.78; 559 patients), and shorter total hospital stay by 2 days (WMD = −2.04; CI = −3.08, −1; 340 patients); no difference was noted for liver parenchyma transection time and mortality. No difference was noted between CUSA (4 RCTs and 1 nonrandomized study) or RFDS (3 RCTs and 3 nonrandomized studies) versus CC for any of the studied outcomes. Conclusion. Of the 3 modalities used in liver resection (VSS, CUSA, and RFDS), only VSS appeared to offer significant benefit over standard CC. However, the generalization of our findings is limited by the scarcity and clinical heterogeneity of the published studies. Large, well-designed and implemented RCTs are warranted to further investigate the usefulness of novel modalities used in liver resection.

Comparison of two different transection techniques in liver surgery-an experimental study in a porcine model

AIMS

Postoperative morbidity and mortality after liver resection is closely related to the degree of intraoperative blood loss; the majority of which occurs during transection of the liver parenchyma. Many approaches and devices have therefore been developed to limit bleeding, but none has yet achieved perfect results up to now. The aim of this standardized chronic animal study was to compare the safety and efficacy of the LigaSure™ Vessel Sealing System (LVSS) with the stapler technique, which is one of the modern techniques for transecting the parenchyma in liver surgery.

METHODS

Sixteen pigs underwent a left liver resection (LLR). Eight pigs received a LLR by means of an Endo GIA, whereas the other eight pigs underwent liver parenchymal transection followed by simultaneous sealing by the LVSS. The operating time, transection time, blood loss during transection, and time of hemostasis were measured on the day of LLR (postoperative day 0/POD 0). Animals were re-explored on postoperative day 7 (POD 7) and the transection surface of remnant liver was observed for fluid collection (hematoma, biloma, and abscess), necrosis, and other pathologies. A biopsy was taken from the area of transection for histopathological examination.

RESULTS

All animals survived until POD 7. Operating time and transection time of the liver parenchyma on POD 0 was significantly shorter in the stapler group. There was no significant difference between the two groups in terms of blood loss during transection, time of hemostasis and number of sutures for hemostasis on POD 0, morbidity rate, as well as the histopathological examination on POD 7. Furthermore, the material costs were significantly higher in the stapler group than in the LVSS group.

CONCLUSION

In this standardized chronic animal study concerning transection of the parenchyma in liver surgery, LVSS seems not only to be safe, but also comparable with the stapler technique in terms of morbidity and mortality. Additionally, LVSS significantly reduces material costs. However, the transection time is significantly longer for LVSS than for the stapler resection technique.

Radiofrequency on the liver remnant after liver resection to reach the haemostasis not otherwise achievable with conventional techniques

INTRODUCTION

During liver resection, in same case of inflamed, steatotic or neo-vascularized liver parenchyma, reaching of haemostasis on the liver resection surface could be very difficult for the surgeon because of the presence of fragile tissue that does not allows the proper placement of stitches, and the conventional method fail.

PRESENTATION OF CASE

The authors describe a novel technique in which, after a formal liver resection, liver haemostasis is achieved using radiofrequency energy on the resected surface. A patient affected by a hystiocytic sarcoma localized on the VI-V and IVa segments was scheduled for liver resection. During the resection a diffuse bleeding from the resected surface started with little success obtained with conventional method. So we decided to use the coagulative necrosis generated by the radiofrequency, using a cool type cluster needle, hand-piece with 3 needle, bending 2 needles in a way resembling a "fork", to reach a complete and definitive haemostasis.

DISCUSSION

Haemostasis remains a critical issue in liver surgery not only for the catastrophic effect of haemorrhage but also because it is correlated to complications rate and to survival. The coagulative necrosis generated by the radiofrequency could be used to facilitate the creation of a necrotic plane to be transacted.

CONCLUSION

The use of the radiofrequency energy, delivered through needles, is suggested when the conventional techniques fail to reach a proper haemostasis after a liver resection or, to consider its use, prior to resect the liver in presence of fragile parenchyma.