Surgical Techniques for Liver Resection

Abstract

Major goals during liver resection are the reduction of intraoperative blood loss and avoidance of parenchymal trauma. Despite refinements in many techniques of liver resection over the past 20 years, intraoperative hemorrhage has remained an important issue. For many years, liver transections have been done using finger-fracture or other crushing techniques using a Kelly (or similar) clamp. Over the past two decades, several novel devices have been developed aiming at more bloodless and accurate parenchymal transection, including the bipolar forceps, ultrasonically activated scissors, argon beam coagulator, monopolar floating ball, and dissecting sealer (TissueLink Medical, Inc.; Dover, NH). However, these techniques may cause deep tissue damage and do not have the ability to discriminate vascular or biliary structures from the surrounding parenchyma. Other devices, which do not generate heat and thereby do not cause thermal damage to the surrounding healthy liver tissue, have been proposed, including the cavitron ultrasonic surgical aspirator (CUSA; Tyco Healthcare, Mansfield, MA) and the Hydrojet (Hydro-Jet; Erbe, Tubingen, Germany). Inflow occlusion (Pringle maneuver) has been used for many years to prevent bleeding during parenchyma transection. The concomitant use of low central venous pressure (CVP) anesthesia further minimizes blood loss by preventing retrograde bleeding from the hepatic veins. Assuming that inflow occlusion and low CVP anesthesia cause significant damage through ischemia and reperfusion, there has been a growing interest in using new devices that facilitate bloodless transection, obviating the need for inflow occlusion. However, none of these devices or techniques have gained unanimous acceptance among liver surgeons. It is also unknown how to adapt these techniques for specific diseases or underlying liver diseases. For example, we recently reported some advantages to the use of the Hydrojet for the radical treatment of hydatid disease in patients with bilobar diseases. However, no consensus exists regarding the best surgical techniques or devices to be used in patients