Hepatic Parenchymal Transection Research Articles

Optimal central venous pressure during partial hepatectomy for hepatocellular carcinoma

Low central venous pressure (CVP) affects hemodynamic stability and tissue perfusion. This prospective study aimed to evaluate the optimal CVP during partial hepatectomy for hepatocellular carcinoma (HCC). Ninety-seven patients who underwent partial hepatectomy for HCC had their CVP controlled at a level of 0 to 5 mmHg during hepatic parenchymal transection. The systolic blood pressure (SBP) was maintained, if possible, at 90 mmHg or higher. Hepatitis B surface antigen was positive in 90 patients (92.8%) and cirrhosis in 84 patients (86.6%). Pringle maneuver was used routinely in these patients with clamp/unclamp cycles of 15/5 minutes. The average clamp time was 21.4+/-8.0 minutes. These patients were divided into 5 groups based on the CVP: group A: 0-1 mmHg; B: 1.1-2 mmHg; C: 2.1-3 mmHg; D: 3.1-4 mmHg and E: 4.1-5 mmHg. The blood loss per transection area during hepatic parenchymal transection and the arterial blood gas before and after liver transection were analyzed. With active fluid load, a constant SBP ≥90 mmHg which was considered as optimal was maintained in 18.6% in group A (95% CI: 10.8%-26.3%); 39.2% in group B (95% CI: 29.5%-48.9%); 72.2% in group C (95% CI: 63.2%-81.1%); 89.7% in group D (95% CI: 83.6%-95.7%); and 100% in group E (95% CI: 100%-100%). The blood loss per transection area during hepatic parenchymal transection decreased with a decrease in CVP. Compared to groups D and E, blood loss in groups A, B and C was significantly less (analysis of variance test, P<0.05). Compared with the baseline, the blood oxygenation decreased significantly when the CVP was reduced. Base excess and HCO3- in groups A and B were significantly decreased compared with those in groups C, D and E (P<0.05). In consideration of blood loss, SBP, base excess and HCO3-, a CVP of 2.1-3 mmHg was optimal in patients undergoing partial hepatectomy for HCC.

A Novel Liver Parenchyma Transection Technique Using Locking Straight Rigid Ties. An Experimental Study in Pigs

ABSTRACTIntroduction: Technological advances have led to the development of many devices used in liver resections. However, no single transection tool is uniformly considered to be better than the others. This study aimed to develop an effective, fast, and cost-efficient technique for hepatic parenchymal transection. Materials and Methods: A liver parenchyma compression device in the form of a locking straight rigid tie (LoStRiT) was newly developed. Twelve pigs were distributed into two groups. The control group ( n = 6) comprised animals that underwent hepatectomy using the standard Kelly-clysis technique. The study group (n = 6) comprised animals that underwent hepatectomy using sequential LoStRiT mechanisms. The transection speed, blood loss, and biloma formation were recorded. Results: The mean parenchymal transection speed was 1.27 ± 0.27 cm2/min for the control group and 2.39 ± 0.56 cm2/min for the LoStRiT group ( p = .003). The mean blood loss per kilogram of body weight was 9.8 ± 5.2 ml/kg for the control group and 3.9 ± 0.9 ml/kg for the LoStRiT group ( p = .040). No bilomas were identified. Conclusion: LoStRiT hepatectomy appears to be effective, fast, and reproducible in a porcine model of liver resection. Further development of this novel and potentially cost-efficient technique includes construction of the device using absorbable materials.

Use of innovative technology for liver resection

Background. Intraoperative blood loss has been shown to be an important factor correlating to morbidity and mortality in liver surgery. In spite of the technological advances in hepatic parenchymal transection devices, bleeding remains the single most important complication of liver surgery. The role of radiofrequency (RF) in liver surgery has been expanded from tumour ablation to major hepatic resections in the last decade. The Surtron, a new bipolar RF device designed specifically for liver resection is reported in this video.

Continuous ultrasound navigation for safe and precise anatomic resection of the liver.

Anatomic resection of the liver is one of the essential techniques in liver surgery. However, parenchymal transection precisely along intersegmental planes is still a technically demanding procedure, and an optimal navigation method is required. Real-time ultrasound monitoring with a probe applied from behind the liver was tried as a means of locating the site where resection was proceeding in the liver and confirming the direction of hepatic parenchymal transection to facilitate anatomic resection of the liver. The ultrasound navigation technique was performed during 11 hepatectomies in 10 patients in whom adequate retrohepatic space could be obtained to position the ultrasound probe. Continuous monitoring of the site in the liver where the resection was being performed was feasible, and the optimal direction of parenchymal transection was easily determined on the basis of the ultrasound images without interrupting the surgical maneuvers. The mean speed of parenchymal transection was faster (2.4cm2/min vs. 1.2cm2/min, p=0.009) and the amount of blood loss per transected area was smaller (4.4mL/cm2 vs. 7.2mL/cm2, p=0.05) in patients treated with the current technique. Continuous ultrasound monitoring of the liver facilitates the safe and precise parenchymal transection during anatomic resections of the liver.

Choosing the optimal tools and techniques for parenchymal liver transection.

The modern era of safe liver resection is based on notable advances in non-invasive solid organ imaging, improved anaesthetic management, enhanced knowledge of segmental liver anatomy as described by Couinaud, better surgical technique, an appreciation of the functional reserve of the liver remnant, and the remarkable capacity of normal liver to regenerate. The evolution and development of the surgical techniques utilised during liver resection are largely an account of the efforts to minimise bleeding during hepatic parenchymal transection. Three decades ago, major liver resection was associated with mortality rates of up to 20%, and excessive bleeding was an important and common cause of operative mortality. Liver resection can now be accomplished with mortality rates of less than 3% in most specialised hepatopancreato-bilary (HPB) centres. While better patient selection and improved assessment of intrinsic liver reserve are important factors, reduced blood loss and the diminishing need for blood transfusion have been additional reasons for improved perioperative outcome. Other advances in operative technique, including improved delineation of the optimal transection plane with intra-operative ultrasound and the benefit of intermittent inflow occlusion, have also contributed to a reduction in blood loss during major liver resections.

Comparison of liver parenchymal ablation and tissue necrosis in a cadaveric bovine model using the Harmonic Scalpel™, the LigaSure™, the Cavitron Ultrasonic Surgical Aspirator® and the Aquamantys® devices

ObjectivesThe amount of tissue that is ablated or necrosed at the line of parenchymal transection is of clinical significance in the interpretation of resection margin status following hepatic resection. The aim of this study was to define the extent of parenchymal ablation and necrosis in liver tissue using the Harmonic Scalpel™, the LigaSure™, the Cavitron Ultrasonic Surgical Aspirator® (CUSA®) and the Aquamantys® dissector ex vivo. MethodsMounted blocks of non‐perfused bovine liver were transected using the Harmonic Scalpel™, LigaSure™, CUSA® and Aquamantys® devices. Outcome measures included parenchymal ablation (ablation band widths and weights) and tissue necrosis band widths along the line of transection. Each experiment was replicated five times. ResultsAll devices were associated with parenchymal ablation (Harmonic Scalpel™, 4.73 ± 1.62 mm; LigaSure™, 4.55 ± 2.02 mm; CUSA®, 7.16 ± 2.87 mm; Aquamantys®, 4.75 ± 1.43 mm) and tissue necrosis (Harmonic Scalpel™, 1.07 ± 0.46 mm; LigaSure™, 1.36 ± 0.36 mm; CUSA®, 0.81 ± 0.21 mm; Aquamantys®, 0.81 ± 0.36 mm). ConclusionsThe Harmonic Scalpel™, LigaSure™, CUSA® and Aquamantys® devices were associated with bands of tissue loss along the hepatic parenchymal transection line in this benchtop cadaveric model. This should be taken into account in the interpretation of resection margin status following liver resection.

An improved technique for liver transection using a new device for soft coagulation in living donor hepatectomy.

In LDLT, parechymal resection is the most invasive process in the donor procedure. The control of bleeding is crucial for donor safety without the occlusion of hepatic inflow. Therefore, a reliable coagulation device is necessary for the transection of the hepatic parenchyma. This study evaluated a newly developed monopolar applicator, SOFT COAG (ERBE Elektromedizin, Tübingen) for rapid soft coagulation with regulated power output. Our objective was to assess an improved hepatic resection technique using a the SOFT COAG device for LDLT. Between July 1999 and May 2008, 195 consecutive donors underwent a hepatic resection for LDLT. For graft extraction, 50 patients had a left lateral sectionectomy (LLS), 65 had a left hemihepatectomy (LHH), and 80 had a right hemihepatectomy (RHH). In 125 donors, the control of parenchymal bleeding was performed by coagulation with bipolar forceps and in 70 donors it was controlled by soft coagulation with a monopolar electrode. The intraoperative blood loss was 763.9±494.4 mL and 435.2±424.7mL in RHH with bipolar and soft coagulation, respectively, with a statistically significant difference. Regarding postoperative liver function, most of the laboratory data showed no significant difference according to coagulation device. There was no significant difference in the incidence of postoperative complications. It is evident that the new soft coagulation device represents a safe and feasible technique for donor hepatic parenchymal transection without inflow occlusion.

Radiofrequency assisted liver resection: Analysis of 604 consecutive cases

BackgroundIntraoperative blood loss is an important factor contributing to morbidity and mortality in liver surgery. To address this we developed a bipolar radiofrequency (RF) device, the Habib 4X, used specifically for hepatic parenchymal transection. The aim of this study was to prospectively assess the peri-operative data using this technique. MethodsBetween 2001 and 2010, 604 consecutive patients underwent liver resections with the RF assisted technique. Clinico-pathological and outcome data were collected and analysed. ResultsThere were 206 major and 398 minor hepatectomies. Median intraoperative blood loss was 155 (range 0–4300)ml, with a 12.6% rate of transfusion. There were 142 patients (23.5%) with postoperative complications; none had bleeding from the resection margin. Only one patient developed liver failure and the mortality rate was 1.8%. ConclusionsRF assisted liver resection allows major and minor hepatectomies to be performed with minimal blood loss, low blood transfusion requirements, and reduced mortality and morbidity rates.

Hand-assisted laparoscopic liver resection using Habib's technique: early experience.

IntroductionHand-assisted laparoscopic liver surgery, a newly developed technique based on an innovative concept, has proved useful and safe for a variety of less invasive hepatectomies. Radiofrequency-assisted hepatic resection has been reported to be safe, associated with minimal morbidity and mortality and decreased intraoperative blood loss and transfusion requirements.AimWe describe how we perform hand-assisted laparoscopic radiofrequency-assisted hepatic resection using a bipolar radiofrequency device.ResultsThe use of the hand port has allowed the surgeon to use his hand in direct liver manipulation, mobilization, and retraction. It was also useful for tactile tumour localization. Radiofrequency-assisted hepatic parenchymal transection was performed on 15 patients using a bipolar device (Habib 4X) with minimal blood loss (74 ml), and very decent operative and resection times (92 min, 33 min respectively).ConclusionsThis combined procedure offers a safe, effective and rapid liver resection technique. This might encourage surgeons to perform a minimally invasive approach for liver resection more frequently.

Randomized clinical trial of ischaemic preconditioning in major liver resection with intermittent Pringle manoeuvre

Vascular inflow occlusion is effective in avoiding excessive blood loss during hepatic parenchymal transection but may cause ischaemic damage to the remnant liver. Intermittent portal triad clamping (IPTC) is superior to continuous hepatic pedicle clamping as it avoids severe ischaemia-reperfusion (IR) injury in the liver remnant. Ischaemic preconditioning (IPC) before continuous Pringle manoeuvre may protect against IR during major liver resection. This RCT assessed the impact of IPC in major liver resection with intermittent vascular inflow occlusion. Patients undergoing major liver resection with intermittent vascular inflow occlusion were randomized, during surgery, to receive IPC (10 min inflow occlusion followed by 10 min reperfusion) or no IPC (control group). Data analysis was on an intention-to-treat basis. The primary endpoint was serum alanine aminotransferase (ALT) level on the day after surgery. Eighty four patients were enrolled and randomized to IPC (n = 41) and no IPC (n = 43). The groups were comparable in terms of demographic data, preoperative American Society of Anesthesiologists grade and extent of liver resection. Intraoperative morbidity and postoperative outcomes were also similar. ALT levels on the day after operation were not decreased by IPC (mean(s.d.) 537·6(358·5) versus 525·0(400·6) units/ml in IPC and control group respectively; P = 0·881). Liver biochemistry tests in the week after operation showed the same pattern in both groups. IPC did not reduce liver damage in patients undergoing major liver resection with IPTC. NCT00908245 (http://www.clinicaltrials.gov).

Laparoscopic Left Hepatectomy for Liver Metastases at a National Cancer Center

This video describes the techniques necessary to perform left hepatectomy (including removal of hepatic segments I-IV) for secondary cancers using totally laparoscopic techniques. Extra-parenchymal control of hepatic inflow will be emphasized. Methods of hepatic parenchymal transection using the ultrasonic shears and laparoscopic bipolar device will be shown. Short-term oncologic outcomes regarding margin status and lymph node retrieval will be discussed. These procedures should currently be performed in high-volume cancer centers with expertise in minimally invasive techniques.

Modified liver-hanging maneuver designed to minimize blood loss during hepatic parenchymal transection in hemihepatectomy

We evaluated the efficiency of a modified liver-hanging technique for minimizing intraoperative blood loss during right and left hemihepatectomy. The lower end of the hanging tape was repositioned between the parenchyma of the left paramedian sector and the hilar plate. The upper end of the tape was positioned between the right hepatic vein and middle hepatic vein for right hepatectomy (Belghiti), and between the middle hepatic vein and left hepatic vein for left hepatectomy. The tape was positioned prior to the parenchymal transection. We compared the results of this operative technique, performed in 15 recent patients, with those of conventional hemihepatectomy performed in 14 earlier patients. There were no intergroup differences in baseline characteristics or postoperative outcomes. Intraoperative blood loss (P = 0.02), especially blood loss during the parenchymal transection (P = 0.005), was significantly less in patients undergoing the modified technique. Multivariate analysis revealed that this modified liver-hanging technique offered a significant advantage in blood-loss reduction during parenchymal transection over the conventional techniques (P = 0.005). Using the liver-hanging technique during hemihepatectomy could be crucial for liver surgeons.

Gyrus PlasmaKinetic bipolar coagulation device for liver resection

Liver parenchymal transection can be associated with significant blood loss and morbidity. We present our initial experience with the Gyrus PlasmaKinetic coagulation device in liver parenchymal resection in both cirrhotic and non-cirrhotic patients. Liver resections were performed in 51 consecutive patients, from 20 July 2005 to 31 August 2007, using the Gyrus PlasmaKinetic coagulator. Requirement for blood transfusions, operating time, duration of hospital stay and major complications were evaluated initially for the group as a whole. Subsequently, the 11 patients with histologically confirmed cirrhosis (nine men, two women, median age 54 years, range 24-74 years) were compared with 40 patients without cirrhosis (25 men, 15 women, median age 57 years, range 24-87 years). There were 34 men and 17 women. The median age was 56 (range 24-87 years). There were 48 open procedures and 3 laparoscopic procedures. There were 30 major resections (>2 segments) and 21 minor resections (one to two segments). The overall median operating time was 260 min (range 90-690). Length of stay had a median of 9 days, range 4-50 days. Twenty-one patients (41%) required a blood transfusion. Two biliary leaks were observed in non-cirrhotic patients initially before the settings of the Gyrus device were optimized. The Gyrus PlasmaKinetic coagulation device is a novel instrument for hepatic parenchymal transection in liver resection, which can be safely used in cirrhotic and non-cirrhotic patients.

Utility of the Gyrus open forceps in hepatic parenchymal transection

ObjectiveThis study aimed to evaluate if the Gyrus open forceps is a safe and efficient tool for hepatic parenchymal transection. BackgroundBlood loss during hepatic transection remains a significant risk factor for morbidity and mortality associated with liver surgery. Various electrosurgical devices have been engineered to reduce blood loss. The Gyrus open forceps is a bipolar cautery device which has recently been introduced into hepatic surgery. MethodsWe conducted a single-institution, retrospective review of all liver resections performed from November 2005 through November 2007. Patients undergoing resection of at least two liver segments where the Gyrus was the primary method of transection were included. Patient charts were reviewed; clinicopathological data were collected. ResultsOf the 215 open liver resections performed during the study period, 47 patients met the inclusion criteria. Mean patient age was 61 years; 34% were female. The majority required resection for malignant disease (94%); frequent indications included colorectal metastasis (66%), hepatocellular carcinoma (6%) and cholangiocarcinoma (4%). Right hemihepatectomy (49%), left hemihepatectomy (13%) and right trisectionectomy (13%) were the most frequently performed procedures. A total of 26 patients (55%) underwent a major ancillary procedure concurrently. There were no operative mortalities. Median operative time was 220min (range 97–398min). Inflow occlusion was required in nine patients (19%) for a median time of 12min (range 3–30min). Median total estimated blood loss was 400ml (range 10–2000ml) and 10 patients (21%) required perioperative transfusion. All patients had macroscopically negative margins. Median length of stay was 8 days. Two patients (4%) had clinically significant bile leak. The 30-day postoperative mortality was zero. ConclusionsUse of the Gyrus open forceps appears to be a safe and efficient manner of hepatic parenchymal transection which allows rapid transection with acceptable blood loss, a low rate of perioperative transfusion, and minimal postoperative bile leak.

Evaluation of a bipolar radiofrequency device for laparoscopic hepatic resection: technique and clinical experience in 18 patients

BackgroundThe increased frequency of laparoscopic hepatic resection as a principal or adjunct component of patient care has driven the need for and development of efficient and safe hepatic parenchymal transection technologies. At present, various devices are available for pre-coagulation transection (PCT) of hepatic parenchyma with the intent of minimizing procedure-associated postoperative haemorrhage and bile leak. This report presents the evaluation of a novel bipolar radiofrequency (RF) energy device for PCT used for laparoscopic hepatic resection. MethodsPatients undergoing laparoscopic hepatic resection using the Enseal™ device (SurgRx Inc.) were identified from the prospectively maintained hepatobiliary database. Information on patient demographics, procedures and postoperative complications was collected and analysed; complications were grouped into early (at <30 days) and late (at ≥30 days) events. ResultsA total of 18 patients, of whom 13 had malignant tumours (12 colorectal metastases and one hepatocellular carcinoma) and five had benign tumours (two hepatic adenomas and three haemangiomas) underwent 18 hepatic procedures, including two formal hemi-hepatectomies, four left lateral sections, three posterior sections and nine atypical non-anatomic resections. Estimated blood loss did not differ from institutional historical control data; no postoperative haemorrhage, bile leaks or hepatic abscess or necrosis were identified (n=18). ConclusionsThis initial experience using the laparoscopic bipolar RF device demonstrates an acceptable safety profile in terms of the outcomes analysed.

Laparoscopic Hepatectomy for a Modified Right Graft in Adult-to-Adult Living Donor Liver Transplantation

Background We performed a modified right hepatectomy completely by laparoscopic techniques preserving the middle hepatic vein (MHV) branches in adult-to-adult living donor liver transplantation (LDLT). Patients and Methods Two young women (24 and 25 years old) volunteered to be live donors for their parents who had hepatocellular carcinomas. As the donors expressed concerns about scarring, we performed a laparoscopic procedure using a hand port device. Mobilization of the right liver and the hepatic parenchymal transection were performed under pneumoperitoneum. Parenchymal transection was performed using a laparoscopic ultrasonic aspirator without the Pringle maneuver. During parenchymal transection, major MHV branches >5 mm were preserved using Hem-o-lock clips. The graft was extracted through the hand port site. On the back table, the 3 MHV branches were reconstructed using an artificial vascular graft. The livers were transplanted without complications. Results The operative times for the donors were 765 and 898 minutes. The donors did not require transfusions or reoperation; they were discharged on postoperative days 10 and 14 with normal liver functions. Conclusion A hepatectomy performed completely by laparoscopic techniques for a right graft with preservation of the MHV branches was technically feasible.

Laparoscopic Partial Splenectomy Using Radiofrequency Ablation

Epidermoid cysts are believed to be congenital in origin and often present in the pediatric population. Because of the concerns of compromised immunologic function after total splenectomy and increasing demand for minimally invasive approaches, interest has increased in performing the partial splenectomy in this patient population by laparoscopic techniques. Nonetheless, concerns for adequate hemostasis have limited its widespread adoption. Because radiofrequency ablation for the partial splenectomy has been done in a laparoscopic porcine model with good results, we used this technology with the goal of limiting blood loss and postoperative hemorrhagic complications. A 25-year-old female presented with complaints of right shoulder pain. Abdominal ultrasound and a computed tomography (CT) scan revealed a 10-cm cystic lesion of the spleen. Serology was negative for hydatid cyst pathology. The patient underwent an uneventful partial splenectomy by minimally invasive techniques with the aid of a laparoscopic radiofrequency ablative device and the placement of a hemostatic medicated sponge along the line of transection. Estimated blood loss was less than 30 mL. Final pathology was consistent with an epidermoid splenic cyst, and the patient was discharged uneventfully on postoperative day 5. Techniques for the treatment of symptomatic splenic cysts range from total splenectomy to cyst fenestration and placement of the omentum in the splenic defect. The use of radiofrequency ablation has been traditionally used for hepatic parenchymal transection but seems equally suited for the partial splenectomy. This technology, and the addition of hemostatic sponges, seems to provide excellent results in minimizing blood loss, intraoperatively and postoperatively, during the laparoscopic partial splenectomy; however, randomized, prospective trials will be necessary to see if they will be superior to traditional techniques.

Hepatic parenchymal transection with vascular staplers: a comparative analysis with the crush-clamp technique

Background This retrospective study compares the safety and efficacy of hepatic parenchymal transection using vascular staplers (VS) and the crush-clamp (CC) technique. Methods Demographics, clinicopathologic data, treatments, and postoperative outcomes from patients who underwent VS or CC hepatic parenchymal transection were compared. Results From 1996–2006, 99 and 112 patients underwent hepatic transection with VS and CC, respectively. Compared to CC, VS transection was associated with less operative time (median 210 vs 275 minutes), blood loss (median 250 vs 500 mL), and postoperative red blood cell (RBC) transfusion (29% vs 44%), all P < .05. VS transection was not associated with RBC transfusion on multivariate analysis. There were no differences in rates of positive resection margins (9% vs 13%), postoperative mortality (2% vs 4%), overall morbidity (32% vs 29%), and severe morbidity (20% vs. 23%), all P > .05. Conclusion Hepatic parenchymal transection with VS can be accomplished with similar safety and efficacy as CC transection.

Hepatectomy using traditional Péan clamp–crushing technique under intermittent Pringle maneuver

Background The clamp-crushing technique has been proved to be the most cost-efficient approach for hepatectomy. If the advantageous characteristics, such as lower blood loss and morbidity, could be utilized, this method could be ideal. Methods The records of 380 patients who underwent hepatectomy using the clamp-crushing technique with intermittent inflow occlusion between 2002 and 2006 were retrospectively reviewed. One hundred fifty patients underwent major hepatectomy, and 230 underwent minor hepatectomy. Results Thirteen (3.4%) patients received red cell transfusion, and 21 (5.5%) patients received fresh frozen plasma. According to Clavien's classification system, grade I complications occurred in 42 (11.1%), grade II in 32 (8.4%), grade III in 14 (3.7%), grade IV in 1 (0.3%), and grade V in 2 (0.5%) patients. Female sex, preoperative albumin-to-globulin ratio, and type of resection were independent factors predictive of blood loss. Conclusions The present patient series, who underwent traditional Péan clamp–crushing technique under intermittent Pringle maneuver, had a low risk of complications. This procedure is an acceptable technique for hepatic parenchymal transection.

QS443. Hepatic Parenchymal Transection With the Aid of the Novel Inline® Multichannel Radiofrequency Device (ILMRD): Report of Initial Experience

QS443. Hepatic Parenchymal Transection With the Aid of the Novel Inline® Multichannel Radiofrequency Device (ILMRD): Report of Initial Experience