Transection Devices

Abstract

The risk of massive bleeding during liver transection and postoperative biliary leaks are due to the complex biliary and vascular anatomy of the liver. Hemorrhage was once the leading cause of death in liver resection, and the now reduced hospital mortality rate of ≤5% can be attributed to better intraoperative bleeding control. Hemorrhage and perioperative blood transfusion not only increase the risk of operative morbidity and mortality but jeopardize long-term survival after resection of liver malignancies because of the associated immunosuppression, leading to a higher risk of tumor recurrence [1]. Bleeding control is the result of the evolution of different aspects of liver surgery and anesthesia. Technological advances led to the development of specific instruments for liver transection; intraoperative ultrasound allows better delineation of the transection plane; and a better understanding of physiology and anatomy improved control of inflow and outflow. Inflow occlusion and low central venous pressure (CVP) anesthesia have been widely used to reduce bleeding from inflow vessels and backflow in the transection surface. Inflow occlusion (Pringle maneuver) has been used since the early twentieth century to prevent bleeding during transection, which is performed by crushing the liver parenchyma with the fingers or forceps (Kelly-clamp crushing), and the concomitant low CVP induced by anesthesia further minimizes blood loss by preventing retrograde bleeding from the hepatic veins. Assuming that inflow occlusion and low CVP cause significant damage due to ischemia and reperfusion, there has been a growing interest in using new devices that facilitate bloodless transection, obviating the need for inflow occlusion. In the laparoscopic setting, these factors, associated with the struggle to perform an intermittent Pringle maneuver and clamp crushing, have led to a wide diffusion of a variety of transection devices, mostly derived from those routinely used in open surgery. This chapter provides a description of the main transection device features and considerations on the Pringle maneuver associated with clamp crushing in the laparoscopic setting.