Ultrasonic Dissection Research Articles

A Prospective Randomised Controlled Study Comparing Ultrasonic Dissector with Electrocautery for Axillary Dissection in Patients of Carcinoma Breast

BackgroundAxillary dissection is one of the important components of modified radical mastectomy (MRM). The present study was conducted to compare surgical outcomes by using monopolar electrocautery and ultrasonic dissector for axillary dissection in MRM.MethodsA parallel randomised controlled single blinded study was conducted with a sample size of 70 patients who were randomised into two groups. One group underwent MRM using ultrasonic dissector (Group A) and the other one using electrocautery (Group B). Intra- and post-operative outcomes were compared.ResultsGroup A had an average operating time of 30.86 min, which was statistically less than that of Group B. The mean mop count and the daily drain output in Group A were less as compared to Group B and the differences were statistically significant. Drain was removed early in Group A as compared to Group B. However, post-operative pain scores and seroma formation were not statistically significant among the two groups.ConclusionUltrasonic dissector group had significantly lesser intra-operative bleeding, operating time and post-operative drain output when compared to electrocautery group. However, the two groups had no significant difference in post-operative pain scores and seroma formation.

Laparoscopic liver resection of giant intrahepatic cholangiocarcinoma

Laparoscopic liver resection had been widely adapted in daily practice for surgeons. Many instruments and energy devices were emerged for improvement of laparoscopic techniques. Facing with large or giant tumor, it was challenging to perform laparoscopic resection. Here we reported one case laparoscopic liver resection for giant intrahepatic cholangiocarcinoma, with simple instrument and ultrasonic dissector. A male 58 year old with large liver mass at segment 2-3. Abdominal CT scan showed liver mass suspected cholangiocarcinoma with size 16 x 14 cm. Perioperative preparation had done and proceeded to surgery. Left lateral sectionectomy had been done with ultrasonic dissector and surgical clips. And continue to lymph nodes dissection at hillar area. Operation time was 3 hours and 45 minutes with blood loss 200ml. Then patient discharged from hospital within 5 days after operation. Laparoscopic liver resection for giant tumor is possible with good results only use simple instruments and energy devices.

At Centres with Limited Access to Ultrasonic Dissector, Bipolar Electrosurgical Energy Can Accomplish Laparoscopic Cholecystectomy (LC) in Patients with Cardiac Implantable Electronic Device (CIED)

Background: Patients with symptomatic cholelithiasis and CIED (e.g. pacemakers) present challenging clinical scenario for smooth LC for surgeons practicing in low - middle income countries (LMIC). Monopolar electrosurgical energy (MEE) is not recommended for use in such patients while use of ultrasonic dissector (UD) may be restricted by lack of equipment or cost constraints. For more than 2 decades, bipolar electrosurgical energy (BEE) is recognized to be safe and its use recommended for laparoscopy especially in anatomically crowded areas. BEE has several attributes that make it particularly suitable for LC in patients with CIED. Key Steps: Standard 4 port LC with BEE as sole energy source (video)-Calot's triangle dissection-Gallbladder dissection from liver bed Outcomes:-Patients: 6 patients with symptomatic cholelithiasis with CIED-Setting: Tertiary care hospital-Period: August 2017 - December 2019-Operation time (mean): 48 minutes-No adverse cardiac event-Number of times the camera lens cleaned (mean): 1.5-Gallbladder perforation: 1/6-No major bilio-vascular injury or conversion Advantages - Safety profile•Current flow limited only to tissue between the arms of forceps electrodes; no adverse effect on CIED•prevents damage to adjacent structures•less chances of accidental burns to the patient-Ease of use - less smoke-Easy availability of equipment with no recurring costs Conclusion: LC can be safely performed using BEE as sole energy source. BEE: Particularly useful in CIED patients in LMIC hospitals with limited access to UD

Ligation-free single scrotal incision orchiectomy with ultrasonic scalpel: Xinhua Zhang Procedure

Background: To explore the efficacy and safety of a new type of testicular excision with ultrasonic dissector. Methods: A retrospective analysis was performed on 69 patients with advanced prostate cancer undergoing orchiectomy in our hospital between June 2017 and June 2019. All patients were divided into a traditional surgery group (n = 27) and an ultrasonic scalpel surgery group (n = 42). The operation time, intraoperative blood loss, postoperative hospital stay and postoperative complication rates were compared. Results: The ultrasonic scalpel surgery group had significantly shorter operation times and less intraoperative blood loss than the traditional surgery group (each P < 0.01). Moreover, the incidence of postoperative complication differed significantly between the traditional surgery group (18.52%) and the ultrasonic scalpel surgery group (0%) (P < 0.01). However, there was no significant difference in postoperative hospital stay between the two groups (P > 0.05). Conclusions: The surgery time for testicular excision using the ultrasonic knife is short, the operation is simple and the complications are few and thus it may become a form of replacement for traditional testicular excision.

Open right hepatectomy for hepatocellular carcinoma via anterior approach

Introduction: Anterior approach is a well-established technique for large, challenging hepatocellular carcinoma (HCC) in the right liver. Improved oncologic outcomes and disease-free survival is attributed to decreased manipulation of the tumor prior to vascular ligation and parenchymal transection. We present the case of a large HCC safely resected with an anterior approach. Method: A 66-year-old gentleman presented with weight loss, fatigue and right upper quadrant (RUQ) pain. Imaging was consistent with 13.6cm HCC and underlying liver disease. The tumor replaced much of the right liver. Initial future liver remnant (FLR) to total liver volume (TLV) ratio was 30%. Given the underlying liver disease, the patient underwent portal vein embolization with FLR hypertrophy, resulting in FLR/TLV ratio of 44%. The patient proceeded with open right hepatectomy via anterior approach. Results: Abdominal access is obtained through an extended J-shaped thoracoabdominal incision to maximize RUQ exposure. The inferior coronary ligament is opened to isolate the inferior vena cava (IVC). A Rummel tourniquet is placed, to be applied during dissection if necessary. Extrahilar dissection was performed, followed by transection of the right hepatic artery and right portal vein. The latter is closed with continuous suture to avoid stapling across embolization material. Parenchymal transection is performed via anterior approach—with an ultrasonic dissection device for parenchyma, and clips and sutures for structures—using the middle hepatic vein identified on intraoperative ultrasound as the resection margin. The right main pedicle is identified intrahepatically and divided with a stapler. Due to backbleeding, the tourniquet is temporarily applied on the IVC, allowing safe division of the right hepatic vein and branches from the middle hepatic vein. An omental patch is placed at the bed of transection. The patient tolerated procedure well, with estimated blood loss of 200mL. Conclusion: Anterior approach for large HCC is associated with improved perioperative morbidity and mortality as compared to conventional approach with posterior mobilization. IVC clamping is an established technique for controlling hepatic vein backbleeding, particularly in the anterior approach to reduce blood loss.

A randomised controlled trial comparing ultrasonic dissection with electrocautery for axillary dissection in breast cancer

A randomised controlled trial comparing ultrasonic dissection with electrocautery for axillary dissection in breast cancer

Эндоназальная дакриоцисториностомия как способ лечения острого абсцедирующего дакриоцистита

Aim. Estimation of acute abscessed dacryocystitis endosurgery treatment long term results. Methods. A retrospective analysis of a group including 16 patients with acute dacryocystitis and lacrimal sac abscess in whom endonasal dacryocystorhinostomy was performed as a primary procedure. Mean age was 57 years. All operations were performed under general anesthesia. To remove the mucous membrane of the lateral wall of the nose and the medial wall of the lacrimal sac, we used the Coblator® II radio wave cold plasma ablator (RF8000E) (USA). The bone window was formed using a SONOCA 185 ultrasonic bone dissector from Soring (Germany) with an oscillation frequency of 35 kHz. The operation was completed by bicanalicular intubation with FCI’s Bika silicone system. Results. Mean post-op follow-up period was 6 months. Lacrimal ducts passability was achieved in 13 of 16 patients (81,25 %). Three patients (18,75 %) had recurrent epiphora after surgery and underwent reoperations. In one of them (6,25 %) granuloma formation around the dacryostoma was found and in two (12,5 %) membranous obstruction of the anastomosis occurred. In all the patients pain has ceased within 3 days post-oр. Medial eyelids edema and erythema have gradually ceased in 2 days and completely resolved in 7–10 days. Conclusions. Success rate (81,25 %) in long-term functional results of endonasal dacryocystorhinostomy operations shows high efficacy of our methods of nasolacrimal anastomosis formation in the treatment of patients with acute dacryocystitis and lacrimal sac abscess. Key words: endonasal dacryocystorhinostomy; lacrimal sac abscess; ultrasound bone dissection; cold plasma ablation.

Predictors of pancreatic fistula healing time after distal pancreatectomy.

Postoperative pancreatic fistula (POPF) is common after distal pancreatectomy (DP). Whilst extensive investigation into potential predictors has been carried out, there is little evidence regarding POPF healing time. This is a retrospective analysis of all consecutive DPs performed at the Department of General and Pancreatic Surgery, University of Verona Hospital Trust, from 2015 to 2019. Perioperative variables were analyzed identifying possible predictors of POPF healing time defined as days between surgery and last drain removal due to POPF. A total of 496 patients were included. POPF rate was 28.2% and median POPF healing time was 30days (95% CI 28-31). Independent predictors of POPF were body mass index (BMI) (OR 1.073, 95% CI 1.010-1.147, p=0.040), operative time (OR 95% CI 1.002-1.009, P=.003), and postoperative acute pancreatitis (OR 3.793, 95% CI, 1.852-7.767, P<.001). Independent predictors of POPF healing time were female sex (HR 1.323, 95% CI 1.093-1.998, P=.042), preoperative pancreatic enzyme replacement therapy (HR 2.319, 95% CI 1.195-4.498, P=.013), ASA score 3 (HR 0.278, 95% CI 0.119-0.646, P=.003), pancreatic transection with ultrasonic dissector (HR 0.605, 95% CI 0.404-0.907, P=.015), and positive drain cultures (HR 0.635, 95% CI 0.443-0.910, P=.013). POPF healing after DP is a slow process since only half of patients recover within 30days of surgery. A longer healing time can be predicted early in the postoperative period with significant implications in therapeutic choices.

Facial nerve transfer for facial reanimation with parotidoplasty approach.

Facial paralysis has a profound impact on quality of life in affected individuals, primarily through loss of verbal and nonverbal communication. Common facial nerve reanimation techniques include coaptation to the masseteric or hypoglossal nerve. Most techniques require nerve grafts to achieve a tension-free neurorrhaphy. Our report aims to show a surgical adaption to current facial reanimation procedures using a partial parotidoplasty approach in order to avoid challenges caused by interpositional nerve grafts through primary neurorrhaphy. The modified surgical approach was performed on four patients, aged 30-67. Length of paralysis ranged from 6 to 13 months. Cause of paralysis included one patient with Bell's palsy in one patient, prior surgery in two patients, and traumatic fracture in the remaining patient. A modified Blair approach is used to expose the parotid capsule. The facial nerve is dissected proximally toward the stylomastoid foramen and distally toward the masseter. The parotid gland substance is sectioned overlying each branch of the facial nerve using ultrasonic dissection or hemostatic scalpel, allowing mobilization of the proximal segment and upper and lower divisions of the facial nerve. The superficial lobe of the parotid is preserved in most cases. The House-Brackmann (H-B) functional scale was used to assess facial nerve function pre- and post-operatively. All patients showed H-B score V or greater prior to reanimation. Follow-up was conducted at 3-, 6-, and 12-months in all patients with resultant improvement of H-B scores of I in three patients and II in the remaining patient. Only one complication was noted, with one patient developing a right postauricular hematoma that was adequately managed without sequelae. All remaining patients experienced an uncomplicated post-operative course. Our modified approach to facial nerve reanimation works well with a planned parotidoplasty allowing for successful reanimation outcomes without the need for interpositional grafting. This technique may be considered in masseteric and hemi-hypoglossal nerve transfers for the reinnervation of facial muscles.

Laparoscopic Management of an Interstitial Ectopic Pregnancy

Study Objective An ectopic pregnancy, also known as a cornual ectopic pregnancy, is rare form of tubal ectopic pregnancy and is associated with high maternal mortality (2-2.5%). The objective of this film is to review the epidemiology, presentation, diagnosis and management of an ectopic pregnancy. Design This is a case report of a patient who presented with an ectopic pregnancy. Setting The preoperative, intraoperative and postoperative course took place at a center for minimally invasive gynecologic surgery. The surgery was performed with the patient in dorsal lithotomy position. Patients or Participants N/A Interventions In this film, we review the specific technique for performing a laparoscopic cornual wedge resection with a laparoscopic ultrasonic dissector and removal of the specimen through a laparoscopic specimen retrieval bag. We also identify surgical principles for reducing intraoperative blood loss and improving patient outcomes. Lastly, we review postoperative and fertility outcomes and expectations. Measurements and Main Results Key strategies were employed to minimize intraoperative blood loss including administration of tranexamic acid at the start of the procedure, myometrial infiltration with dilute vasopressin and maintaining view of anatomic landmarks to avoid encountering the utero-ovarian vasculature. The ectopic pregnancy was successfully resected, and the patient's fertility was preserved. Conclusion After watching the film, the viewer should be able to diagnose an ectopic pregnancy on transvaginal pelvic ultrasound by identifying the interstitial line sign and be able to reasonably differentiate it from other forms of ectopic pregnancy. The viewer will understand the management options including both local and systemic methotrexate, as well as surgical options, including laparoscopic cornual wedge resection. The viewer will have a grasp of the surgical principles employed to reduce intraoperative blood loss and the evidence for counseling patients regarding future fertility.

Robotic hepatic parenchymal transection: a two-surgeon technique using ultrasonic dissection and irrigated bipolar coagulation.

Liver transection is the most challenging part of hepatectomy due to the risk of hemorrhage which is associated with postoperative morbidity and mortality and reduced long-term survival. Parenchymal ultrasonic dissection (UD) with bipolar coagulation (BPC) has been widely recognized as a safe, effective, and standard technique during open and laparoscopic hepatectomy. We here introduce our technique of robotic liver transection using UD with BPC and report on short-term perioperative outcomes. From a single-institution prospective liver surgery database, we identified patients who underwent robotic liver resection. Demographic, anesthetic, perioperative, and oncologic data were analyzed. Fifty patients underwent robotic liver resection using UD and BPC for liver malignancies (n = 42) and benign lesions (n = 8). The median age of the patients was 67years and 28 were male. According to the difficulty scoring system, 60% (n = 30) of liver resection were considered difficult. Three cases (6%) were converted to open surgery. The median operative time was 240min, and the median estimated blood loss was 200ml; 2 patients required operative transfusions. The overall complication rate was 38% (grade I, 29; grade II, 15; grade III, 3; grade IV, 1). Seven patients (14%) experienced biliary leakage. The median length of hospital stay post-surgery was 7 (range 3-20) days. The R0 resection rate was 92%. Robotic parenchymal transection using UD and irrigated BPC appears a simple, safe, and effective technique. However, our results must be confirmed in larger series or in randomized controlled trials.

Smoke Evacuation Filters After the COVID-19 Pandemic

Smoke Evacuation Filters After the COVID-19 Pandemic

Robotic Resection of a Central Liver Solitary Fibrous Tumor (with Video)

BackgroundSolitary fibrous tumor is a mesenchymal tumor rare in liver parenchyma 1 but must be considered as a differential diagnosis of a single large hepatic mass. Surgical resection is the treatment because of its potential malignancy, and previous interventions reported were open hepatectomy 2. Robotic assets could improve accessibility for difficult liver resection 3. We present the video of a robotic left hepatectomy extended to caudate lobe and median hepatic vein for central liver tumor. MethodsA central liver tumor was incidentally detected during abdominal ultrasonography in a 30-year-old man with no medical history. Laboratory tests were normal. CT scan and MRI revealed a solid mass measuring 9 cm involving segments I–IV–VIII and median/left hepatic veins. Percutaneous biopsy confirmed diagnosis of benign liver solitary fibrous tumor. Surgical resection by left hepatectomy extended to segment 1 and median hepatic vein was planned. ResultsDa Vinci X system was docked from patient’s head. Four robotic ports were placed in right hypochondrium. Two laparoscopic ports were placed for the second surgeon. Extended left hepatectomy was performed with hilar approach. Parenchymal transection was led on the right side of median hepatic vein using laparoscopic ultrasonic dissector and robotic irrigated bipolar. Segment 1 was released with a mediocaudal approach. Procedure was facilitated by good exposure of operative field with arm 4, stable vision, articulated instrumentation and a “4-hand parenchymal dissection”. ConclusionMinimal invasive resection of liver solitary fibrous tumor seems safe and feasible. Because of its advantages compared with laparoscopy, robotic approach could improve accessibility to central tumors liver resection.

Laparoscopic liver resection of the spiegel lobe by a lef-sidad approach preserving an accessory left hepatic artery

Presenter: Víctor Molina | Hospital de la Santa Creu i Sant Pau Background: Caudate lobe of the liver can be divided in three portions: Spiegel lobe, para-caval portion and caudate process . The anatomy of the caudate lobe and its proximity to major vascular structures makes this operation a difficult resection, especially for laparoscopic liver surgery. For that reason the Iwate criteria proposed to classify this surgery at the “2nd International Consensus Conference on Laparoscopic Liver Resection” as intermediate or advanced difficulty depending on the type of resection, and the size of the tumor . For tumors located in the Spiegel lobe, the left side approach is preferred Methods: We present a 69-year-old woman with liver metastasis from previously resected sternal condrosarcoma. A Spiegel lobe resection with left side approach preserving an accessory left hepatic artery was performed. Results: The patient was positioned in supine position. Six ports were used, 4 of 12mm and 2 of 5mm. We started the surgery with the left lateral segment mobilization. The gastrohepatic ligament was opened to expose the caudate lobe. In this case we only opened part of the ligament to preserve the accessory left hepatic artery. We continued retracting to the right the hepatic hilium with tissue band used as the external Pringle tourniquet to expose de caudate process and the right side of the Spiegel lobe. The transection of the liver was started with Thunderbeat and ultrasonic dissector. The portal branches to the Spiegel lobe were dissected and controlled with clips. We continued with the blunt dissection of the Spiegel lobe from the inferior vena cava. The fibrous ligament of the Spigel lobe to the crus of the diaphragm was cut and the retrocaudate vessels to the inferior vena cava were individualized and ligated with clips. Finally, we opened the gastrohepatic ligament behind the artery, pulled up the caudate lobe, and finished the liver transection. A closed aspirative drainage was left in place. The specimen was removed from an enlargement of the left subcostal 12mm port. The operative time was 180 min and the total Pringle time was 30 min. Patient was discharged at the 4 postoperative day and there were no postoperative complications. Conclusion: Laparoscopic liver resection of the caudate lobe for condrosarcoma liver metastasis is feasible and safe. Left approach seems the best option for Spiegel lobe resections even in patients with accessory left hepatic artery.

Ultrasonic dissection versus electrocautery for immediate prosthetic breast reconstruction.

BackgroundUltrasonic dissection devices cause less thermal damage to the surrounding tissue than monopolar electrosurgical devices. We compared the effects of using an ultrasonic dissection device or an electrocautery device during prosthetic breast reconstruction on seroma development and short-term postoperative complications.MethodsWe retrospectively reviewed the medical records of patients who underwent implant-based reconstruction following mastectomy between March 2017 and September 2018. Mastectomy was performed by general surgeons and reconstruction by plastic surgeons. From March 2017 to January 2018, a monopolar electrosurgical device was used, and an ultrasonic dissection device was used thereafter. The other surgical methods were the same in both groups.ResultsThe incidence of seroma was lower in the ultrasonic dissection device group than in the electrocautery group (11 [17.2%] vs. 18 [31.0%]; P=0.090). The duration of surgery, total drainage volume, duration of drainage, overall complication rate, surgical site infection rate, and flap necrosis rate were comparable between the groups. Multivariate analysis revealed that the risk of seroma development was significantly lower in the ultrasonic dissection device group than in the electrocautery group (odds ratio for electrocautery, 3.252; 95% confidence interval, 1.242–8.516; P=0.016).ConclusionsThe findings of this study suggest that the incidence of seroma can be reduced slightly by using an ultrasonic dissection device for prosthesis-based breast reconstruction. However, further randomized controlled studies are required to verify our results and to assess the cost-effectiveness of this technique.

Multi-Level Anterior Cervical Decompression in Multi-Level Cervical Spondylotic Myelopathy without Extending the Corpus Resection: A Cadaveric Study of a Novel Surgical Technique.

To perform three-level decompression with a single-level corpectomy by modifying the fusion with anterior cervical corpectomy (ACC-F) method on a cadaver. The anterior cervical region of four whole-head cadavers was dissected. The corpectomy was performed under a surgical microscope with a MT4-20+ ultrasonic bone dissector (UBD) tip. Superior and inferior decompression were conducted and viewed with a 70° neuroendoscope using two types (vertically and horizontally oriented) of specially designed 23 mm-long, 90°-angled UBD tips. After neck dissection and the removal of the thyroid and cricoid cartilages, C5 corpectomy and adjacent-level discectomies were performed. Following discectomy and corpectomy, superior and inferior decompression were conducted with specially designed UBD tips and viewed with a 70° neuroendoscope. A three-level anterior cervical decompression was provided with a single-level corpectomy. This study demonstrated that two more level decompression is possible with a single-level corpectomy in the cervical region using the new technique.

Laparoscopic paracaval adenoma

Presenter: Paola Tarchi University Hospital of Trieste Background: A 29 years old lady underwent an abdominal ultrasound for an aspecific pain and an incidental paracaval liver lesion was found. Subsequent contrast-enhanced US and MRI were strongly suggestive for a liver adenoma. The MRI with Primovist showed a 3.3 x 3.2 cm adenoma in S9 with interesting proximity both to the confluence of a big inferior right hepatic vein into the IVC and to the posterior aspect of the right portal pedicle. The patient did not have a surgical indication but the clinical scenario was complicated by the strong desire of the patient to get pregnant. The management of liver adenomas smaller than 5 cm during pregnancy is not clear in the Literature, as some Authors suggest only active surveillance. Our decision was to perform a laparoscopic resection of the adenoma with the aim to avoid its risk of rupture due to increased hormone-induced growth during pregnancy. Methods: Patient was placed in a standard French position and 5-operative 12 mm trocars were placed in the abdomen, resembling a reverse J shaped letter. The extracorporeal Pringle manouvre was prepared by encircling the hepatic pedicle with an umbilical tape, extracted through a chest tube from the left flank. Mobilization of the right hemiliver is crucial for the exposure of the operative field and for this purpose the falciform, posterior coronary and right triangular ligaments were interrupted. The right lobe was lifted up through the partial incision of the lower aspect of the hepatocaval ligament with a caudal approach and following the IVC axis. The parenchymal transaction was performed using a combination of an ultrasonic dissector and an energy device. Results: The transaction line followed the margin of the pseudocapsule of the adenoma, from left to right. Bloodless transaction was allowed thanks to the hypovolemic state managed by keeping the stroke volume variation between 15 and 20%. Conclusion: The final histopathology showed a hepatocellular adenoma of steatotic type with focal dysplastic hepatocytes, in the context of a microvescicular steatosis.

Reinforced stapler vs. ultrasonic dissector for pancreatic transection and stump closure for distal pancreatectomy: a propensity-matched analysis

Reinforced stapler vs. ultrasonic dissector for pancreatic transection and stump closure for distal pancreatectomy: a propensity-matched analysis

Laparoscopic S7 atypical resection

Presenter: Paola Tarchi | University Hospital of Trieste Background: This is the case of a 67-years old male with a past surgical history of laparoscopic right hemicolectomy for a pT4aN2 colic cancer treated with subsequent 6-cycles of adjuvant chemotherapy (Xelox). One and a half year later, during the follow up, a single 18 mm liver metastases in segment 7 was seen at the CT scan. Diagnostic work up was completed with liver-specific contrast-enhanced MRI that allowed a characterization of the lesion and the exclusion of further smaller metastases. The proximity of the nodule to a RHV branch and to a ventral branch of S7 portobiliary pedicle was noted. Methods: A laparoscopic atypical resection of S7 was planned. Patient was placed in a standard French position and 5-operative 12 mm trocars were placed in the abdomen, resembling a reverse J shaped letter. During surgery the table is turned left and in reverse anti-Trendelenburg tilt. The extracorporeal Pringle manouvre was prepared by encircling the hepatic pedicle with an umbilical tape, extracted through a chest tube from the left flank. Mobilization of the right hemiliver is crucial for the exposure of the operative field and for this purpose the falciform, posterior coronary and right triangular ligaments were interrupted. The right lobe was lifted up through the incision of the hepatocaval ligament with a caudal approach and following the IVC axis. The liver was examined by intraoperative ultrasonography that allowed to identify the lesion, the relation with the portobiliary pedicle and hepatic vein branch and to mark the transaction plane and vessels direction on the glissonian surface. Transection margins were checked under ultrasound guidance. The parenchymal transaction was performed using a combination of an ultrasonic dissector and an energy device. Results: Exposure of S7 becomes effortless as the segment can be lowered and anteriorized, no permanent retraction is needed and the first assistant instruments have a 90° angle, the camera in line with the transaction plane. The aim of the mobilization of the right hemiliver is in fact to turn a postero-superior segment into an antero-inferior position, allowing an easier laparoscopic resection. Conclusion: The final histopathology showed a KRAS-mutated colorectal liver metastasis with negative margins.

Ultrasonic Dissection without Cystic Artery Clipping Versus Classical Electro-Dissection in Laparoscopic Cholecystectomy: A Randomized Control Trial

Background: Laparoscopic cholecystectomy is the most common surgery performed for cholelithiasis. Monopolar electrocautery is being used in dissection for so many years. The ultrasonic technique of dissection is useful for safe and faster laparoscopic surgery. Material and Method: We conducted a prospective randomized control trial between classical electrocautery and ultrasonic group. The study included 100 patients over 9 months 12 days. The randomization was done using the envelop method and fifty cases were allocated in each group. The Statistical analysis was done by using the SPSS software (IBM SPSS for windows version 23.0, 2015, Armonk, NY: IBM Corp.). The ordinal data were described using median and Interquartile Range (IQR) and compared using the Chi-Square test and Mann-Whitney U test. Result: The operative time was significantly less in the ultrasonic group (p-value 0.017). VAS score for postoperative pain in the harmonic group was significantly less compared to the classic group (p-value 0.001). The incidence of gallbladder perforation was almost double in the classic group compared to the ultrasonic group but it was statistically not significant (p-value 0.74). The drain was inserted in 14 (28%) patients in the classic group while it was inserted in 7 (14%) patients in the harmonic group, but this difference was not statistically significant (p-value 0.086). The length of hospital stay was not significantly different in the two groups (p=0.89). All patients had no complications and conversion to open surgery Conclusion: Ultrasonic dissection of callot’s triangle and division of the cystic artery without clipping is safe in laparoscopic cholecystectomy. It has certain advantages over electrocautery like shorter operative time and less postoperative pain. However, no additional benefits to decrease the chances of gallbladder perforation, requirement of drain insertion and hospital stay.