A Practical Guide to Inflow Control, Retraction, and Exposure for Robotic Hepatectomy

Establishment of inflow control and gentle effective retraction of the liver for optimal exposure are critical to safe hepatectomy. Multiple methods have been previously reported for inflow control in minimally invasive (MIS) hepatectomy including Huang's Loop.1-3 We describe here the assembly and use of our modified version of Huang's loop that permits adjustable, atraumatic, and totally intracorporeal inflow control. We use a soft 16-French urinary catheter with a single premade opening near the blunt tip, across which a small slit is created. A beveled cut is made to the catheter 12-15 cm from the blunt tip and a suture sewn there that can be grasped to pull this beveled tail through the slit and window around the porta hepatis; this loop can be tightened or loosened with ease. For liver retraction, current techniques can be traumatic, especially when instruments apply traction directly onto the liver.4 Our preferred approach utilizes a liver sling made from a soft, rolled surgical sponge with 15-cm silk ties secured at each end; the length of the sling can be adjusted on the basis of thickness of the liver. The sling applies gentle, atraumatic "pulling" traction and is especially useful for exposure of the right posterior sector. We also use external band retraction to align the transection plane with the camera.5 Both also provide countertraction when advancing instruments into a firm or fibrotic liver. These techniques are commonly used in our MIS practice, and we have found them to be cost-efficient, easily reproducible, and effective.

Inflow control can be safely used in laparoscopic subsegmentectomy of the liver: a single-center 10-year experience

BACKGROUND

Several techniques have been developed to reduce blood loss in liver resection. The half-Pringle and Pringle maneuvers are commonly used for inflow control. This study compared the outcomes of different inflow control techniques in laparoscopic subsegmentectomy.

METHODS

From October 2010 to December 2020, a total of 362 laparoscopic liver resections were performed by a single surgeon (C.C. Yong) in our institute. We retrospectively enrolled 133 patients who underwent laparoscopic subsegmentectomy during the same period. Perioperative and long-term outcomes were analyzed.

RESULTS

The 133 patients were divided into 3 groups: no inflow control (n = 49), half-Pringle maneuver (n = 46), and Pringle maneuver (n = 38). A lower proportion of patients with cirrhosis were included in the half-Pringle maneuver group (P = .02). Fewer patients in the half-Pringle maneuver group had undergone previous abdominal (P = .01) or liver (P = .02) surgery. The no inflow control group had more patients with tumors located in the anterolateral segments (P = .001). The no inflow control group had a shorter operation time (P < .001) and less blood loss (P = .03). The need for blood transfusion, morbidity, and hospital days did not differ among the 3 groups. The overall survival did not significantly differ among the 3 groups (P = .89).

CONCLUSIONS

The half-Pringle and Pringle maneuvers did not affect perioperative or long-term outcomes during laparoscopic subsegmentectomy. The inflow control maneuvers could be safely performed in laparoscopic subsegmentectomy.

Social distancing in public transport: mobilising new technologies for demand management under the Covid-19 crisis

Dense urban areas are especially hardly hit by the Covid-19 crisis due to the limited availability of public transport, one of the most efficient means of mass mobility. In light of the Covid-19 pandemic, public transport operators are experiencing steep declines in demand and fare revenues due to the perceived risk of infection within vehicles and other facilities. The purpose of this paper is to explore the possibilities of implementing social distancing in public transport in line with epidemiological advice. Social distancing requires effective demand management to keep vehicle occupancy rates under a predefined threshold, both spatially and temporally. We review the literature of five demand management methods enabled by new information and ticketing technologies: (i) inflow control with queueing, (ii) time and space dependent pricing, (iii) capacity reservation with advance booking, (iv) slot auctioning, and (v) tradeable travel permit schemes. Thus the paper collects the relevant literature into a single point of reference, and provides interpretation from the viewpoint of practical applicability during and after the pandemic.

Social distancing in public transport: mobilising new technologies for demand management under the Covid-19 crisis

Dense urban areas are especially hardly hit by the Covid-19 crisis due to the limited availability of public transport, one of the most efficient means of mass mobility. In light of the Covid-19 pandemic, public transport operators are experiencing steep declines in demand and fare revenues due to the perceived risk of infection within vehicles and other facilities. The purpose of this paper is to explore the possibilities of implementing social distancing in public transport in line with epidemiological advice. Social distancing requires effective demand management to keep vehicle occupancy rates under a predefined threshold, both spatially and temporally. We review the literature of five demand management methods enabled by new information and ticketing technologies: (i) inflow control with queueing, (ii) time and space dependent pricing, (iii) capacity reservation with advance booking, (iv) slot auctioning, and (v) tradeable travel permit schemes. Thus the paper collects the relevant literature into a single point of reference, and provides interpretation from the viewpoint of practical applicability during and after the pandemic.

Social distancing in public transport: mobilising new technologies for demand management under the Covid-19 crisis

Dense urban areas are especially hardly hit by the Covid-19 crisis due to the limited availability of public transport, one of the most efficient means of mass mobility. In light of the Covid-19 pandemic, public transport operators are experiencing steep declines in demand and fare revenues due to the perceived risk of infection within vehicles and other facilities. The purpose of this paper is to explore the possibilities of implementing social distancing in public transport in line with epidemiological advice. Social distancing requires effective demand management to keep vehicle occupancy rates under a predefined threshold, both spatially and temporally. We review the literature of five demand management methods enabled by new information and ticketing technologies: (i) inflow control with queueing, (ii) time and space dependent pricing, (iii) capacity reservation with advance booking, (iv) slot auctioning, and (v) tradeable travel permit schemes. Thus the paper collects the relevant literature into a single point of reference, and provides interpretation from the viewpoint of practical applicability during and after the pandemic.

Feasible laparoscopic repeat hepatectomy using double intercostal ports and laparoscopic vascular clamp (with video)

BACKGROUND

Laparoscopic repeat hepatectomy is a technically challenging procedure owing to adhesions around the liver, causing difficulties in performing hepatic inflow control by conventional tourniquet method [1], and failure in hepatic mobilization [2].

METHOD

Thus, we introduce our technique using double intercostal ports to manipulate the fixed liver under the rib cage and using the laparoscopic Satinsky vascular clamp to perform hepatic inflow control to overcome the aforementioned concerns in ipsilateral laparoscopic repeat hepatectomy after previous open hepatectomy.

VIDEO

The patient, with histories of abdominal aortic aneurysm repair and open Segment 7 subsegmentectomy, had recurrent hepatocellular carcinoma in the dorsal region of Segment 8. After establishing pneumoperitoneum with five abdominal ports, adhesiolysis around the liver was then performed, followed by identification of the caudal part of Spiegel's lobe as the landmark for the space between the left-side of the hepatoduodenal ligament and the vena cava. Although the space between the right side of the hepatoduodenal ligament and the vena cava was obstructed, the laparoscopic blunt-tip Satinsky vascular clamp successfully was applied on the stiff hepatoduodenal ligament due to previous hepatectomy and made inflow control. Because the liver could not be mobilized at all, double intercostal ports with balloons were introduced [3] for parenchymal resection for exposing the parenchymal resection plane and also to apply the vessel sealing device. A 12-Fr chest tube (Aspiration Kit. Argyle™, Tokyo, Japan) was introduced in the right thoracic cavity as our routine.

RESULTS

The operative time was 243 minutes and the blood loss was 50g. The postoperative course was uneventful and the patient was discharged on the day 8.

CONCLUSIONS

The combination of intercostal ports and laparoscopic Satinsky vascular clamp could be significant aids for performing safe ipsilateral laparoscopic repeat hepatectomy, even after previous open hepatectomy.