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

An Efficient Saline-Linked Cautery (SLiC) Method for Robotic Liver Parenchymal Transection Using Simultaneous Activation of Saline-Linked Cautery and Robotic Suctioning: Detailed Technical Aspects and Short-Term Outcomes

Introduction While there are several advantages to utilizing robotics in liver surgery compared to traditional open and laparoscopic approaches, the most challenging part of robotic liver resection (RLR) remains the liver parenchymal transection. This is primarily due to the constraints of the existing robotic tools and the absence of a standard procedure. This study presents detailed technical aspects of our novel saline-linked cautery (SLiC) method for RLR and assesses the short-term outcomes for both non-anatomical and anatomical RLRs. Methods In this study, 82 cases that underwent RLR utilizing the SLiC method at our hospital from September 2021 to December 2023 were examined. A novel SLiC method is introduced in this study for robotically transecting the liver parenchyma utilizing bipolar cautery or monopolar scissors. The technique involves activating the SLiC and robotic suctioning simultaneously. The included patients were divided into two groups: patients undergoing robotic anatomical hepatectomy (n=39), and those receiving robotic non-anatomical hepatectomy (n=43). Short-term outcomes, including intraoperative and postoperative complications, were assessed in patients receiving both anatomical and non-anatomical hepatectomies. Results In the whole cohort, 74% of patients had performance status 1 or 2, and 24% were classified as Child-Pugh class B. RLR was performed without Pringle's maneuver in more than 80% of cases in patients receiving robotic non-anatomical hepatectomy, and more than 80% of patients undergoing robotic anatomical hepatectomy required only four or fewer 15-minute Pringle's maneuvers. There was no conversion to open hepatectomy, no cases of grade B or C post-hepatectomy liver failure, and no mortality in the entire cohort. Four postoperative complications with CDC IIIa or higher occurred (small bowel obstruction in two cases, intraabdominal hemorrhage in one, and bile leak in another), but no differences in the frequency of complications were found between those undergoing non-anatomical and anatomical hepatectomy (p=0.342). Conclusions The SLiC method, which involves simultaneously activating SLiC and robotic suctioning with either monopolar scissors or bipolar cautery, appears to be a secure and convenient technique for liver parenchymal transection in RLR. This innovative method permits precise access to the major Glissonean and venous structures within the liver, making RLR more standardized and easily applicable in routine patient care.

Laparoscopic Liver Resection Utilizing a Water Jet Scalpel for Patients With Liver Fibrosis

Introduction A variety of devices are utilized in order to resect liver parenchyma in laparoscopic liver resection. However, liver fibrosis makes hepatectomy problematic because the liver is rigid and prone to bleeding. The water jet scalpel, which dissociates the liver parenchyma with a jet stream has no thermal damage and is clinically utilized in liver resection, but its safety and efficacy during laparoscopic liver resection for patients with liver fibrosis remain unknown. Methods We analyzed patients who underwent laparoscopic liver resection utilizing the water jet scalpel with liver fibrosis at our hospital. A water jet scalpel was used for liver parenchymal transection, and a saline-linked ball-tipped electrocautery was simultaneously used for hemostasis. Results Subsectionectomy was one case, left lateral sectionectomy was two cases, and non-anatomical liver resection was three cases. The median blood loss was 70 mL (24-104 mL). There was no need for the intraoperative Pringle's maneuver. No perioperative blood transfusion was performed, and there were no postoperative complications, including posthepatectomy liver failure. Conclusion It was suggested that laparoscopic liver resection in patients with liver fibrosis can be safely performed with the water jet scalpel.

Novel Liver Parenchymal Transection Technique Using Saline-linked Monopolar Cautery Scissors (SLiC-Scissors) in Robotic Liver Resection

Introduction

Although there are a number of benefits to using robotics in liver surgery over conventional open and laparoscopic approaches, liver parenchymal transection is still the most difficult aspect of robotic liver resection (RLR) due to the limitations of the currently available robotic instruments and the lack of a standardized method.

Methods

We present a novel method for transecting the liver parenchyma during RLR employing saline-linked monopolar cautery (SLiC) scissors (SLiC-Scissors method). Between September 2021 and April 2022, 10 RLRs were performed utilizing the SLiC-Scissors method for both anatomical and non-anatomical liver resections. We assessed the short-term results, as well as the safety and practicality of our robotic liver parenchymal transection technique.

Results

Six of the 10 patients had malignant liver tumors, and four of them had liver metastases from colorectal cancer. Except for S1, the target lesions were present everywhere, and their median size was 25 mm (14-43 mm). The median amount of intraoperative bleeding was 5 mL (5-30 mL), and the median operative and console times were 223 and 134 min, respectively. There were no conversions to open liver resections. The median length of the postoperative stay was seven (4-13) days, and there were no serious postoperative complications or mortality.

Conclusions

The SLiC-Scissors method is a safe and practical procedure for liver parenchymal transection in RLR. In order to standardize and broadly implement RLR into normal patient treatment, this unique approach enables an advanced, locally controlled preparation of intrahepatic vessels and bile ducts.