Complex major hepatectomy by thunderbeat with the pringle maneuver and infra-hepatic inferior vena cava clamping

Abstract

Introduction: Complex major hepatectomy (CMH) equivalent to major liver resection with high complexity classification is a demanding operation. Parenchymal transection represents a crucial step during liver resection and the use of energy devices has gained popularity for faster and safer hepatectomy. Thunderbeat (TB) is a novel device that uses both ultrasonic and advanced bipolar energies. We report the CMH with TB assisted by the Pringle maneuver and infra-hepatic inferior vena cava (IVC) clamping. Method: During parenchymal transection, only the pedicles equal or larger than 3rd branches of Glissonian pedicles or main branches of major hepatic veins were ligated, the other vessels were sealed with TB. Parenchymal transection time was defined as the duration recorded from the beginning of the parenchymal resection to the removal of the en-bloc specimen of the liver. Clavien-Dindo (CD) classification ≥3a was applied to define postoperative complication. The postoperative liver dysfunction was assessed on the basis of Balzan 50-50 criteria. Result: Four patients underwent CMH with TB assisted by the Pringle maneuver and infra-hepatic IVC clamping, including extended right hepatectomy with caudate resection and hepaticojejunostomy for perihilar chalangiocarcinoma (n=2) and colon cancer liver metastasis with central biliary invasion (n=1), and anatomic middle hepatectomy for hepatocellular carcinoma (n=1). The median parenchymal transection time, operation time, and estimated blood loss was 16.5 (range: 13-45) min, 415 (range: 260-596) min, and 1,928 (range: 1,380-2,730) mL, respectively Postoperative complications were hepaticojejunostomy failure in one (CD 3a) and heparin-induced postoperative bleeding (CD 3b) in one. There were no postoperative liver dysfunction, pulmonary embolism, and hospital mortality. Conclusion: TB assisted by the Pringle maneuver and infra-hepatic IVC clamping can be feasible and offer the combination of simplicity and rapidity during CMH.