Advanced application of a vessel sealing system for major hepatic resections

Abstract

To the editors: We read with great interest the recent article by Campagnacci et al, regarding the use of a vessel sealing system (VSS) in hepatic resection [1]. They proposed the usefulness of a LigaSure V (Valleylab Inc., Boulder, CO) during hepatic parenchymal dissection and showed the significant superiority of the VSS in hemostatic efficacy in such a surgery, comparing it with the use of ultrasonic shears (harmonic scalpel). We totally agree with their concept. However, we advocate the application of VSS (LigaSure Atlas, Valleylab Inc., Boulder, CO) not only for parenchymal resection, but also for dividing major hilar Glisson pedicles and major hepatic veins, as we have done. The hilar Glisson pedicles to which we applied the VSS were second-degree branches: right anterior and posterior pedicles. The major hepatic veins included the roots of the right, middle, and left hepatic veins. Our techniques using the VSS in right hepatic lobectomy are as follows. After the main right, the anterior, and the posterior Glisson pedicles are controlled using tapes [2, 3], the VSS is applied to each of them for sealing and transection under total hilar inflow control (Fig. 1). We believe that inflow occlusion is important to remedy the blood flow into the corresponding sealing parts. Parenchymal dissection is performed using CUSA (Valleylab Inc., Boulder, CO) and electrocautery as well as the VSS [3]. The techniques we use for application of VSS during parenchymal resection are similar to those of Campagnacci et al [1]. All the vessels over 5 mm are divided using the VSS during parenchymal transection without applying so-called ties. The right hepatic vein is taped and divided by the same device (Fig. 2). We applied this technique in four cases that underwent right hepatic lobectomy for hepatocellular carcinomas (n = 2) or cholangiocellular carcinomas (n = 2). All surgeries were undertaken by junior attending surgeons. The mean operating time was 350 min (range: 291–401 min) and the mean intraoperative blood loss was 247 g (range: 130–390 g); all of these values are similar to those reported by Campagnacci et al [1]. No postoperative bleeding or bile leakage was observed. The VSS provides us with a major technical advance for hepatobiliary surgery. Moreover, our experience is that it is feasible to apply a VSS for dividing hilar Glisson bundles and major hepatic veins. The safe and constant sealing effect of a VSS enables us to perform major hepatectomies more quickly and more safely. S. Imura (&) T. Ikegami Y. Morine H. Kanemura M. Shimada Department of Surgery, University of Tokushima, Tokushima, Tokushima 770-8503, Japan e-mail: s-imura@clin.med.tokushima-u.ac.jp