The vessel sealing system (LigaSure) in hepatic resection: a randomized controlled trial. Ann Surg. 2009;250:199-203. [PMID: 19638927 DOI: 10.1097/sla.0b013e3181a334f9]

Use of a vessel-sealing device compared with Jaboulay's technique for adult hydrocelectomy surgery: a retrospective cohort study

Hydrocele is a common benign scrotal condition affecting adult men. The gold standard of treatment includes hydrocelectomy, with the use of Winkelman's/Jaboulay's technique or Lord's procedure. The vessel-sealing device (VSD) is a blood vessel-sealing system, known to enhance patient's postoperative outcomes in multiple different surgeries. The aim of this study was to compare the procedural and postoperative outcomes of a novel hydrocelectomy method using a VSD to the conventional hydrocelectomy using the Jaboulay's technique. We performed A retrospective review for all adult cases who underwent surgical hydrocelectomy at Hillel Yaffe Medical Center between 2011 and 2022. Study cases were grouped into one of two groups, patients undergoing conventional hydrocelectomy, or patients undergoing hydrocelectomy with the use of a VSD. Patients operated using other techniques were excluded. Data collected included demographic data and operative and postoperative parameters. Among 102 patients, 47 underwent Jaboulay's technique and 55 underwent hydrocelectomy using a VSD. We observed significantly shorter duration of hospitalization (1.18 vs 1.53, P = 0.038) and shorter surgery time (31.87 vs 37.4, P = 0.003) when using the VSD during a hydrocelectomy compared to conventional surgical hydrocelectomy. Both techniques indicated low complication rates and no recurrent hydrocele was observed in either group. We report our experience with a novel surgical technique that includes hydrocelectomy with the use of VSD. Our findings demonstrated shorter surgery time and length of hospitalizations, which may indicate improved patient's postoperative outcomes with the use of the VSD for hydrocelectomy.

Laparoscopic Liver Resection Utilizing a Water Jet Scalpel for Patients With Liver Fibrosis

Introduction A variety of devices are utilized in order to resect liver parenchyma in laparoscopic liver resection. However, liver fibrosis makes hepatectomy problematic because the liver is rigid and prone to bleeding. The water jet scalpel, which dissociates the liver parenchyma with a jet stream has no thermal damage and is clinically utilized in liver resection, but its safety and efficacy during laparoscopic liver resection for patients with liver fibrosis remain unknown. Methods We analyzed patients who underwent laparoscopic liver resection utilizing the water jet scalpel with liver fibrosis at our hospital. A water jet scalpel was used for liver parenchymal transection, and a saline-linked ball-tipped electrocautery was simultaneously used for hemostasis. Results Subsectionectomy was one case, left lateral sectionectomy was two cases, and non-anatomical liver resection was three cases. The median blood loss was 70 mL (24-104 mL). There was no need for the intraoperative Pringle's maneuver. No perioperative blood transfusion was performed, and there were no postoperative complications, including posthepatectomy liver failure. Conclusion It was suggested that laparoscopic liver resection in patients with liver fibrosis can be safely performed with the water jet scalpel.

Comparison of transection techniques in pediatric major hepatectomy: a matched pair analysis

BACKGROUND

Evidence on safety and efficacy of different liver transection techniques in pediatric major hepatectomy is completely lacking, as no study has been conducted so far. The use of stapler hepatectomy has never before been reported in children.

METHODS

Three liver transection techniques were compared: (1) ultrasonic dissector (CUSA), (2) tissue sealing device (LigaSure™), and (3) stapler hepatectomy. All pediatric hepatectomies performed at a referral center in a 12-year study period were analyzed, patients were pair-matched in a 1:1:1-fashion. Intraoperative weight-adjusted blood loss, operation time, use of inflow occlusion, liver injury (peak-transaminase levels), postoperative complications (CCI), and long-term outcome were compared.

RESULTS

Of 57 pediatric liver resections, 15 patients were matched as triples based on age, weight, tumor stage, and extent of resection. Intraoperative blood loss was not significantly different between the groups (p = 0.765). Stapler hepatectomy was associated with significantly shorter operation time (p = 0.028). Neither postoperative death nor bile leakage occurred, and no reoperation due to hemorrhage was needed in any patient.

CONCLUSION

This is the first comparison of transection techniques in pediatric liver resection and the first report on stapler hepatectomy in children. All three techniques can be safely applied and may harbor individual advantages in pediatric hepatectomy each.

The preoperative M2BPGi score predicts operative difficulty and the incidence of postoperative complications in laparoscopic liver resection

BACKGROUND

Liver fibrosis or cirrhosis frequently makes parenchymal transection more difficult, but the difficulty score of laparoscopic liver resection (LLR), including the IWATE criteria, does not include a factor related to liver fibrosis. Therefore, this study aimed to evaluate M2BPGi as a predictor of the difficulty of parenchymal transection and the incidence of postoperative complications in LLR.

METHODS

Data from 54 patients who underwent laparoscopic partial liver resection (LLR-P) and 24 patients who underwent laparoscopic anatomical liver resection between 2017 and 2019 in our institution were retrospectively analyzed. All cases were classified according to M2BPGi scores, and reserve liver function, intraoperative blood loss, and postoperative complications were compared among these groups.

RESULTS

Sixteen cases (29.6%) were M2BPGi negative (cut-off index < 1.0), 25 cases (46.3%) were 1+ (1.0 ≤ cut-off index < 3.0), and 13 cases (24.1%) were 2+ (cut-off index ≥ 3.0). M2BPGi-positive cases had significantly worse hepatic reserve function (K-ICG: 0.16 vs 0.14 vs 0.08, p < 0.0001). Intraoperative bleeding was significantly greater in M2BPGi-positive cases [50 ml vs 150 ml vs 200 ml, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.045]. Postoperative complications (Clavien-Dindo ≥ II) were significantly more frequent in M2BPGi-positive cases [0% vs 4% vs 33%, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.001].

CONCLUSION

M2BPGi could predict surgical difficulty and complications in LLR-P. In particular, it might be better not to select M2BPGi (2+) cases as teaching cases because of the massive bleeding during parenchymal transection.

Prospective validation to prevent symptomatic portal vein thrombosis after liver resection

BACKGROUND

Portal vein thrombosis (PVT) after liver resection is rare but can lead to life-threatening liver failure. This prospective study evaluated patients using contrast-enhanced computed tomography (E-CT) on the first day after liver resection for early PVT detection and management.

AIM

To evaluate patients by E-CT on the first day after liver resection for early PVT detection and immediate management.

METHODS

Patients who underwent liver resection for primary liver cancer from January 2015 were enrolled. E-CT was performed on the first day after surgery in patients undergoing anatomical resection, multiple resections, or with postoperative bile leakage in the high-risk group for PVT. When PVT was detected, anticoagulant therapy including heparin, warfarin, and edoxaban was administered. E-CT was performed monthly until PVT resolved.

RESULTS

The overall incidence of PVT was 1.57% (8/508). E-CT was performed on the first day after surgery in 235 consecutive high-risk patients (165 anatomical resections, 74 multiple resections, and 28 bile leakages), with a PVT incidence of 3.4% (8/235). Symptomatic PVT was not observed in the excluded cohort. Multivariate analyses revealed that sectionectomy was the only independent predictor of PVT [odds ratio (OR) = 12.20; 95% confidence interval (CI): 2.22-115.97; P = 0.003]. PVT was found in the umbilical portion of 75.0% (6/8) of patients, and sectionectomy on the left side showed the highest risk of PVT (OR = 14.10; 95%CI: 3.17-62.71; P < 0.0001).

CONCLUSION

Sectionectomy on the left side should be chosen with caution as it showed the highest risk of PVT. E-CT followed by anticoagulant therapy was effective in managing early-phase PVT for 2 mo without adverse events.

Safety and effectiveness evaluation of a two-handed technique combining harmonic scalpel and laparoscopic Peng's multifunction operative dissector in laparoscopic hemihepatectomy

OBJECTIVES

This study was designed to evaluate the safety and effectiveness of a two-hand technique combining harmonic scalpel (HS) and laparoscopic Peng's multifunction operative dissector (LPMOD) in patients who underwent laparoscopic hemihepatectomy (LHH).

METHODS

We designed and conducted a case-control study nested in a prospectively collected laparoscopic liver surgery database. Patients who underwent LHH for liver parenchyma transection using HS + LPMOD were defined as cases (n = 98) and LPMOD only as controls (n = 47) from January 2016 to May 2018. Propensity score matching (1:1) between the case and control groups was used in the analyses.

RESULTS

The case group had significantly less intraoperative blood loss in milliliters (169.4 ± 133.5 vs. 221.5 ± 176.3, P = 0.03) and shorter operative time in minutes (210.5 ± 56.1 vs. 265.7 ± 67.1, P = 0.02) comparing to the control group. The conversion to laparotomy, postoperative hospital stay, resection margin, the mean peak level of postoperative liver function parameters, bile leakage rate, and others were comparable between the two groups. There was no perioperative mortality.

CONCLUSIONS

We demonstrated that the two-handed technique combing HS and LPMOD in LHH is safe and effective which is associated with shorter operative time and less intraoperative blood loss compared with LPMOD alone. The technique facilitates laparoscopic liver resection and is recommended for use.

Effects of intraoperative blood loss during liver resection on patients’ outcome: a single- center experience

Background/aim

Operative bleeding is one of the major determinants of outcome in liver surgery. This study aimed to describe the impact of intraoperative blood loss on the postoperative course of liver resection (LR).

Materials and methods

The data of 257 patients who were treated with LR between January 2007 and October 2018 were retrospectively analyzed. LRs were performed via intermittent portal triad clamping (PTC) under low central venous pressure.

Results

LRs were performed for 67.7% of patients with a malignant disease and 32.3% of patients with a benign disease. Major LR was performed in 89 patients (34.6%). The mean PTC period was 20.32 min (±13.7). The median intraoperative bleeding amount was 200 mL (5–3500 mL), the 30-day mortality rate was 4.3%, and the morbidity rate was 31.9%. The hospital stay (p = 0.002), morbidity (p = 0.009), and 30-day mortality (p = 0.041) of patients with a bleeding amount of more than 500 mL significantly increased.

Conclusion

Surgeons should consider the adverse effects of intraoperative bleeding during liver resection on patients’ outcome. Favorable outcomes would be obtained with diligent postoperative care.

Feasibility of Microwave-Based Scissors and Tweezers in Partial Hepatectomy: An Initial Assessment on Canine Model

Purpose: This study aimed to assess the feasibility of partial hepatectomy (PH) simplified by using microwave-based devices in animal experiments.

Methods: PH was performed on 16 beagles using either Acrosurg Scissors (AS) or Acrosurg Tweezers (AT) without hepatic pedicle (HP) control. Parenchymal transection time, Glissonean pedicle (GP) seal time, bleeding volume, bile leak, and burst pressure were recorded. Probable complications were investigated after 4 weeks.

Results: Transection time (6.5 [6.0–7.6] vs. 11.8 [10.5–20.2] min, p < 0.001) with AT were significantly shorter than with AS. GP sealing times (60 [55–60] vs. 57 [46–91] s, p = 0.859) by both devices were nearly similar. Bleeding volume in the AT group was approximately one-fourth of that in the AS group (6.7 [1.4–22] vs. 28.8 [5.8–48] mL, p = 0.247). AT created higher burst pressure on the bile duct stumps (p = 0.0161). The two devices did not differ significantly in morbidity and mortality after four-week follow-up.

Conclusion: Acrosurg devices achieved a safe PH without HP control owing to microwave-based sealing. AS could be used alone in PH, whereas the clamp-crushing function of AT seemed more advantageous in reducing the transection time and blood loss.

Clinical benefits of vessel sealing system (LigaSure™) during surgery for soft tissue sarcoma: a propensity score matching analysis

BACKGROUND

Soft tissue sarcomas arise in the deep sites of the buttocks and lower extremities. Since a tourniquet is not applied during surgery for soft tissue sarcomas at such sites, excessive intraoperative blood loss may occur. Various devices, including LigaSure™ (Medtronic, Dublin, Ireland), are used as electrothermal bipolar vessel sealers. However, its clinical relevance in soft tissue sarcomas surgery remains unclear. This study aimed to assess the effectiveness of LigaSure™ in soft tissue sarcomas surgery.

METHODS

This study included 168 patients who underwent surgeries for soft tissue sarcomas in the deep sites in the buttocks and lower extremities between January 2004 and March 2018. The primary outcome was intraoperative blood loss, and secondary outcomes were surgery duration, wound complications, perioperative haemoglobin concentrations and intraoperative blood transfusion. To reduce selection biases, propensity score matching was applied. We defined the matched cases wherein LigaSure™ was used as the 'using group' and the other matched cases as the 'non-using group'. Outcomes were compared between both groups.

RESULTS

From each group, 35 cases were selected using propensity score matching. The intraoperative blood loss was significantly smaller statistically in the using group (181.5 ± 240.4 ml vs. 394.7 ± 547.3 ml, respectively; P = 0.041). The duration of operation was longer in the using group (189.9 ± 97.6 min vs. 140.6 ± 75.7 min, respectively; P = 0.007). There were no significant differences in other outcomes.

CONCLUSION

By using LigaSure™ for soft tissue sarcomas occurring in the buttocks and lower extremities, we observed a trade-off between reduced intraoperative blood loss and longer operative time.

Ideal Surgical Margin to Prevent Early Recurrence After Hepatic Resection for Hepatocellular Carcinoma

BACKGROUNDS AND AIMS

Postoperative early recurrence after hepatic resection for hepatocellular carcinoma (HCC) poses a challenge to surgeons, and the effect of a surgical margin is still controversial. This study aimed to identify an ideal margin to prevent early recurrence.

METHODS

A total of 226 consecutive patients who underwent primary curative hepatic resection for solitary and primary HCC were enrolled. The definition of early recurrence was determined using the minimum P value approach. Logistic regression analysis was used to identify the risk factors of early recurrence. The receiver-operating characteristic (ROC) curve was used to identify the optimal cut-off of the surgical margin and early recurrence.

RESULTS

Recurrence within 8 months induced the poorest overall survival (P = 2×10^-15). ROC analysis showed that the optimal cut-off value of the surgical margin was 7 mm. The risk factors of early recurrence (≤ 8-month recurrence) were preoperative alpha-fetoprotein levels ≥ 100 ng/ml (Odds ratio [OR] 4.92 [2.28-10.77], P < 0.0001) and a surgical margin < 7 mm (OR 3.09 [1.26-8.85], P = 0.01) by multivariable analysis. The probability of early recurrence ranged from 5.0% in the absence of any factors to 43.5% in the presence of both factors. Among patients with alpha-fetoprotein levels ≥ 100 ng/ml, non-capsule formation, or microvascular invasion, there was a significant difference in 5-year overall survival between surgical margins of < 7 mm and ≥ 7 mm.

CONCLUSIONS

A > 7-mm margin is important to prevent early recurrence. Patients with HCC and alpha-fetoprotein levels > 100 ng/ml, non-capsule formation, or microvascular invasion may have a survival benefit from a ≥ 7-mm margin.

Efficiency of a radiofrequency sealer (Aquamantys) for parenchymal transection during laparoscopic hepatectomy

INTRODUCTION

The methods of liver parenchymal transection vary across institutions. In this study, we used a radiofrequency (RF) sealer (Aquamantys) as a hemostatic device during laparoscopic liver transection; we also evaluated the usefulness of RF sealers.

METHODS

From April 2016 to May 2019, 113 consecutive laparoscopic hepatectomy patients, excluding patients with combined resection of other organs, were examined. Patient characteristics, operative factors, and postoperative complications were compared between the Cavitron ultrasonic surgical aspirator (CUSA) + soft coagulation system (VIO) group; (n = 32) and the CUSA + Aquamantys group; (n = 81). The former underwent liver transection by CUSA and VIO from April 2016 to March 2017, while the latter underwent liver transection using CUSA and Aquamantys from April 2017 to May 2019.

RESULTS

The median difficulty score was significantly higher in the CUSA + VIO group (5.5 points vs 5.0 points; P = .04). Blood loss per unit area and the liver parenchymal transection speed were not significantly different between the groups. After propensity score matching, blood loss per unit area was similar between the groups, but the parenchymal transection speed of the CUSA + Aquamantys group was significantly higher (0.92 cm² /min vs 0.64 cm² /min; P = .017). Postoperative complications were similar between the groups.

CONCLUSION

In laparoscopic hepatectomy, hemostasis of the transection plane with an RF sealer did not reduce blood loss during parenchymal transection. However, the liver parenchymal transection speed was increased.

Towards Standardization of Liver Resections in India: Five Hundred Consecutive Oncological Liver Resections- Trends, Techniques and Outcomes

PURPOSE

To study the trends, techniques, outcomes and improvisations of liver resections over the study period.

METHODS

We analysed prospectively maintained database of patients undergoing liver resections for oncological indications at Tata Memorial Centre, Mumbai, India from June 2010 to October 2016.

RESULTS

Five hundred sixteen patients were operated with median age of 55 years and male to female ratio of 1.6:1. Most commonly operated neoplasms were hepatocellular carcinoma (N = 166), cholangiocarcinoma (N = 72) and metastases from colorectal cancer (N = 129). We performed 219 major hepatic resections (≥3 segments) with overall morbidity of 22.9% (N = 118) and mortality of 4.0% (N = 21). Complex hepatectomies were performed in 78 patients. In order to study the time trends, data was divided into pre-liver clinic era and post liver clinic era. Trend analysis showed improvements in complication grade, hospital stay, blood loss, and overall survival status in post liver clinic era. Liver transection in all our patients was carried out without Pringle manoeuvre under normotensive anaesthesia, only 0.7% of our patients had significant transaminitis beyond POD 5.

CONCLUSION

A dedicated multidisciplinary treatment approach along with standardization of liver resections culminates into optimal treatment outcomes.

A systematic review and network meta-analysis of parenchymal transection techniques during hepatectomy: an appraisal of current randomised controlled trials

BACKGROUND

Major liver resection can lead to significant morbidity and mortality. Blood loss is one of the most important factors predicting a good outcome. Although various transection methods have been reported, there is no consensus on the best technique. This systematic review and network meta-analysis aims to characterise and identify the best reported technique for elective parenchymal liver transection based on published randomised controlled trials (RCT's).

METHODS

A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Central to identify RCT's up to 5th June 2019 that examined parenchymal transection for liver resection. Data including study characteristics and outcomes including intraoperative (blood loss, operating time) and postoperative measures (overall and major complications, bile leaks) were extracted. Indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analyses (NMA) which maintains randomisation within trials.

RESULTS

This study identified 22 RCT's involving 2360 patients reporting ten parenchymal transection techniques. Bipolar cautery has lower blood loss and shorter operating time than stapler (mean difference: 85 mL; 22min) and Tissue Link (mean difference: 66 mL; 29min). Bipolar cautery was ranked first for blood loss and operating time followed by stapler and TissueLink. Harmonic scalpel is associated with lower overall complications than Hydrojet (Odds ratio (OR): 0.48), BiClamp forceps (OR: 0.46) and clamp crushing (OR: 0.41).

CONCLUSION

Bipolar cautery techniques appear to best at reducing blood loss and associated with shortest operating time. In contrast, Harmonic scalpel appears best for overall and major complications. Given the paucity of data and selective outcome reporting, it is still hard to identify what is the best technique for liver resection. Therefore, further high-quality large-scale RCT's are still needed.

Randomized clinical trial of stapler hepatectomy versus LigaSure™ transection in elective hepatic resection

BACKGROUND

Previous studies have demonstrated stapler hepatectomy and use of various energy devices to be safe alternatives to the clamp-crushing technique in elective hepatic resection. In this randomized trial, the effectiveness and safety of stapler hepatectomy were compared with those of parenchymal transection with the LigaSure™ vessel sealing system.

METHOD

Patients scheduled for elective liver resection at two tertiary-care centres were randomized during surgery to stapler hepatectomy or transection with the LigaSure™ device. Total intraoperative blood loss was the primary efficacy endpoint. Transection time, duration of operation, perioperative complications and length of hospital stay were recorded as secondary endpoints.

RESULTS

A total of 138 patients were analysed, 69 in the LigaSure™ and 69 in the stapler hepatectomy group. Baseline characteristics were well balanced between the groups. Mean intraoperative blood loss was significantly higher in the LigaSure™ group than the stapler hepatectomy group: 1101 (95 per cent c.i. 915 to 1287) versus 961 (752 to 1170) ml (P = 0·028). The parenchymal transection time was significantly shorter in the stapler group (P = 0·005), as was the total duration of operation (P = 0·027). Surgical morbidity did not differ between the groups, nor did the grade of complications.

CONCLUSION

Stapler hepatectomy was associated with reduced blood loss and a shorter duration of operation than the LigaSure™ device for parenchymal transection in elective partial hepatectomy. Registration number: NCT01858987 (http://www.clinicaltrials.gov).

Possible underestimation of blood loss during laparoscopic hepatectomy

Background

Previous studies have documented potential advantages of laparoscopic hepatectomy in decreasing blood loss compared with open surgery. This study aimed to compare intraoperative blood loss estimated using four different methods in open versus laparoscopic hepatectomy.

Methods

Patients undergoing liver resection between 2014 and 2017 were evaluated prospectively, differentiating between the laparoscopic and open approach. Groups were compared using univariable and multivariable analyses. Intraoperative blood loss was estimated using three formulas based on the postoperative decreases in haematocrit, haemoglobin or red blood cell volume, and using the conventional method of the sum of suction fluid amounts and gauze weight. In addition, blood loss per hepatic transection area was calculated to compare groups.

Results

Some 125 patients who underwent hepatectomy were selected, including 56 open hepatectomies and 69 laparoscopic liver resections. Intraoperative blood loss per hepatic transection area estimated by the conventional method was significantly less in the laparoscopic than the open group (3·6 (range 0·2-50·0) versus 6·6 (1·2-82·5) ml/cm² respectively; P < 0·001). In contrast, there were no significant differences between groups in blood loss estimated based on the decrease in haematocrit (12·9 (0-65·2) versus 8·1 (0-123·7) ml/cm²; P = 0·818), haemoglobin or red blood cell volume. Blood loss estimation using three formulas showed significant linear correlations with the blood loss estimated by the conventional method in the open group (r _s = 0·758 to 0·762), but not in the laparoscopic group (r _s = -0·019 to 0·031).

Conclusion

The conventional method of calculating blood loss in laparoscopic hepatectomy can underestimate losses.

Red blood cell transfusion in liver resection

BACKGROUND

Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes.

PURPOSE

Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion.

RESULTS

Following hepatic surgery, 25.2-56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods.

CONCLUSION

Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.

Evaluation of THUNDERBEAT® in open liver resection- a single-center experience

Background

THUNDERBEAT® (TB) (Olympus Medical Systems Corp., Tokyo, Japan) is a dynamic energy system device that simultaneously delivers ultrasonically generated frictional heat energy and electrically generated bipolar energy. TB is being routinely used in various operative procedures, however, less is known about its utility in liver resection. We, herein, report our early experience of using TB in open liver resection particularly in patients with normal or near-normal liver parenchyma.

Methods

We retrospectively reviewed the clinical characteristics, and evaluated the perioperative outcome of twenty-eight patients who underwent liver resection with TB, and twenty-four patients who underwent liver resection with basic procedure in our institution. The resection type was stratified into: major hepatectomy; resection of 3 or more than 3 Couinauds segments, and minor hepatectomy; resection of less than 3 Couinauds segments.

Results

Liver resection time (mean ± SD) in TB group with major hepatectomy was significantly shorter: 16.7 ± 8.8 compared to 62.8 ± 39.4 min in basic procedure group (P < 0.0001). Accordingly, the liver resection time (mean ± SD) in TB group with minor hepatectomy was also significantly shorter, 8.3 ± 2.9 min compared to 45.2 ± 23.9 min in liver resection with basic procedure (P < 0.001). No significant difference was observed between the groups in terms of intraoperative blood transfusion ratio, postoperative complication and postoperative liver dysfunction.

Conclusion

TB as a new energy device can offer a safe, reliable and substantially rapid liver resection particularly in patients with normal or near-normal liver parenchyma.

SEALIVE: the use of technical vessel-sealing devices for recipient hepatectomy in liver transplantation: study protocol for a randomized controlled trial

Background

The surgical technique used in liver transplantation has undergone constant evolution in an effort to develop a safe, highly standardized procedure. Despite this, the initial step of recipient hepatectomy has not been the focus of clinical research thus far. Due to advanced coagulopathy in liver transplant recipients, this part of the operation still carries the risk of severe hemorrhage. This trial is designed to compare an electrothermal bipolar vessel sealing device (LigaSure™) and an ultrasound dissector (HARMONIC ACE®+7) with standard surgical techniques during the recipients’ hepatectomy in liver transplantation.

Methods/design

In a single-center, prospective, randomized, controlled, parallel, three-armed, confirmatory, open trial, LigaSure™ and HARMONIC ACE®+7 will be compared with standard surgical techniques that use titanium clips and conventional knot-tying ligations during recipient hepatectomy in liver transplantation. Intraoperative total blood loss is the primary endpoint of the trial. Secondary endpoints include blood loss during hepatectomy, the duration of both the hepatectomy and the entire surgical procedure, and blood transfusion requirements of the procedure. To generate reliable data, intraoperative blood loss will be recorded with respect to all rinse fluids during surgery, ascites, and by weighing used swabs. At 80% power and an alpha of 0.025 for both of the experimental groups, 23 subjects will be analyzed per protocol in each study arm in order to detect clinically relevant reduction of intraoperative blood loss. The intention-to-treat analysis will include 69 patients. The follow-up period for each patient will be 90 days for safety reasons, whereas all clinical outcomes will be measured within the first 10 postoperative days.

Discussion

To our knowledge, this is the first prospective, randomized trial comparing two innovative technical methods of vessel sealing and dissection with standard techniques for recipient hepatectomy. This will be done to detect relevant reduction of intraoperative blood loss during liver transplant. The results of the trial are expected to improve patient outcome and safety after liver transplant and to increase the general safety of this procedure.

Trial registration

ClinicalTrials.gov, NCT 03323242. Registered on October 26, 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2778-1) contains supplementary material, which is available to authorized users.

Surgical techniques and strategies for the treatment of primary liver tumours: hepatocellular and cholangiocellular carcinoma

Background

Owing to remarkable improvements of surgical techniques and associated specialities, liver surgery has become the standard of care for hepatocellular carcinoma and cholangiocarcinoma. Although applied with much greater safety, hepatic resections for primary liver tumours remain challenging and need to be integrated in a complex multidisciplinary treatment approach.

Methods

This literature review gives an update on the recent developments regarding basics of open and laparoscopic liver surgery and surgical strategies for primary liver tumours.

Results

Single-centre reports and multicentre registries mainly from Asia and Europe dominate the surgical literature on primary liver tumours, but the numbers of randomized trials are slowly increasing. Perioperative outcomes of open liver surgery for hepatocellular and cholangiocellular carcinoma have vastly improved over the last decades, accompanied by some progress in terms of oncological outcome. The laparoscopic approach is increasingly being applied in many centres, even for patients with underlying liver disease, and may result in decreased morbidity. Liver transplantation represents a cornerstone in the treatment of early hepatocellular carcinoma and is indispensable to achieve long-term survival. In contrast, resection remains the gold standard for cholangiocarcinoma in most countries, but interventional techniques are on the rise.

Conclusion

Liver surgery for primary tumours is complex, with a need for high expertise in a multidisciplinary team to achieve acceptable outcomes. Technical developments and clinical stratification tools have optimized individual care, but further improvements in oncological survival will likely require enhanced pre- and postoperative systemic and local treatment options.

BiClamp® vessel-sealing device for open hepatic resection of malignant and benign liver tumours: a single-institution experience

BACKGROUND

Intraoperative blood loss during hepatectomy worsens prognosis, and various tools have been used to improve perioperative safety and feasibility. We aimed to retrospectively evaluate the feasibility and safety of the BiClamp® device for open liver resection.

METHODS

We included 84 patients undergoing liver resection from a single centre, with all patients operated by the same surgical group. All hepatectomies were performed using BiClamp® (Erbe Elektromedizin GmbH, Tubingen, Germany), an electrosurgical device that simultaneously transects liver parenchyma and seals vessels <7 mm in diameter. We collected data on intraoperative blood loss, resection time, and perioperative complications, comparing cirrhotic and non-cirrhotic patients.

RESULTS

The 84 patients enrolled in this study included 56 cirrhotic and 28 non-cirrhotic patients. All patients underwent hepatectomy (30 major and 54 minor hepatectomies) using the BiClamp®, exclusively, and 54 patients required inflow occlusion (Pringle manoeuvre). Overall intraoperative blood loss (mean ± standard deviation) was 523.5 ± 558.6 ml, liver parenchymal transection time was 36.3 ± 16.5 min (range, 13-80 min), and the mean parenchymal transection speed was 3.0 ± 1.9 cm²/min. Twelve patients received perioperative blood transfusion. The cost of BiClamp® for each patient was 800 RMB (approximately 109€). There were no deaths, and the morbidity rate was 25%. The mean (standard deviation) hospital stay was 9.3 (2.3) days. Comparisons between cirrhotic and non-cirrhotic patients revealed no difference in blood loss (491.0 ± 535.7 ml vs 588.8 ± 617.5 ml, P = 0.598), liver parenchymal transection time (34.1 ± 14.8 min vs 40.9 ± 19.2 min, P = 0.208), mean parenchymal transection speed (3.3 ± 2.1 cm²/min vs 2.5 ± 1.3 cm²/min, P = 0.217), and operative morbidity (28.6% vs 14.3%, P = 0.147).

CONCLUSIONS

The reusable BiClamp® vessel-sealing device allows for safe and feasible major and minor hepatectomy, even in patients with cirrhotic liver.

TRIAL REGISTRATION

This trial was retrospectively registered and the detail information was as followed. Registration number: ChiCTR-ORC-17011873 (Chinese Clinical Trial Registry). Registration Date: 2017-07-05.

Preoperative Assessment of Hepatocellular Carcinoma with Split-Bolus Combined Phase Contrast-Enhanced Computed Tomography

Background

The aim of this study was to investigate the feasibility of a split-bolus combined phase contrast-enhanced computed tomography protocol in evaluation of liver vasculature in hepatocellular carcinoma (HCC) patients for the purpose of surgery guidance.

Material/Methods

Two groups of patients were recruited for the study: 24 consecutive cases of HCC who underwent multiphasic CT examination, and 22 consecutive cases who afterwards underwent split-bolus combined phase CT examination. The multiphasic protocol included an unenhanced scan and 3 image acquisitions after contrast injection. The injection of contrast medium was 440 mgI/kg in a single bolus. The split-bolus combined phase protocol included unenhanced scan and combined phase. The injection of contrast medium was 440 mgI/kg for the first bolus and 220 mgI/kg for the second bolus. The vascular delineation was evaluated with Likert scales. The CT values were measured, and the contrast-to-noise ratio (CNR) was calculated. We also compared the effective radiation dose (ED) of the 2 protocols.

Results

All mean CT values were significantly higher in the split-bolus protocol than in the multiphasic protocol (all P<.05), except for the hepatic vein (P>.05). The ED was significantly lower in the split-bolus protocol, corresponding to a dose reduction of 66% compared to the multiphasic protocol (P<.05). The scores of the branches of the hepatic vein in the split-bolus protocol were not lower than those in the multiphasic protocol.

Conclusions

For the preoperative HCC patients, the split-bolus combined phase CT examination meets the diagnostic requirement of surgical planning, with approximately 60% reduction in the radiation dose.

Current technical aspects of oncological hepatic surgery

BACKGROUND

With the recent advances in oncological hepatic surgery, major liver resections became more widely utilized procedures. The era of modern hepatic surgery witnessed improvements in patients care in preoperative, intraoperative and postoperative aspects. This significantly improved surgical outcomes regarding morbidity and mortality. This review article focuses on the recent advances in oncological hepatic surgery.

DATA SOURCES

This review includes only data from peer-reviewed articles and journals. PubMed database was utilized as the primary source of the supporting literature to this review article on the latest advances in oncological hepatic surgery. Comprehensive and high sensitivity search strategies were performed to search related studies exhaustively up till June 2016. We critically and independently assessed over 50 recent publications written on this topic according to the selection criteria and quality assessment standard. We paid particular attention to the studies published in high impact journals that address the use of the surgical techniques mentioned in the articles in well-known institutions.

RESULTS

Among all utilized approaches aiming at the preoperative assessment of the liver function, Child-Turcotte-Pugh classification remains the most reliable tool correlating with survival outcome. Although the primary radiological tools including ultrasonography, computed tomography and magnetic resonance imaging remain on top of the menu of tests utilized in assessment of focal hepatic lesions, intraoperative ultrasonography projects to be a powerful additional tool in terms of sensitivity and specificity compared to the other conventional techniques in assessment of the liver in the operative setting, a procedure that can change the surgical strategy in 27.2% of the cases and consequently improve the oncological surgical outcome. In addition to the conventional surgical techniques of liver resection and portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy "ALPPS" projects to be an alternative option in patients with marginally resectable tumors with an inadequate size of future liver remnant with an accepted surgical oncological outcome.

CONCLUSIONS

Considering the clinicopathological nature of hepatic lesions, the comprehensive assessment and proper choice of the liver resection technique in highly selected patients is associated with improved surgical oncological outcome. Patients with underlying marginal future liver remnant volumes can now safely benefit from a wider range of surgical intervention, a breakthrough that significantly improved morbidity and mortality in this group of patients.

Randomized clinical trial of ligasure™ versus conventional splenectomy for injured spleen in blunt abdominal trauma

BACKGROUND

Spleen is the most common organ damaged in cases of blunt abdominal trauma and splenectomy and splenorrhaphy are the main surgical procedures that are used in surgical treatment of such cases. In routine open splenectomy cases, after laparotomy, application of sutures in splenic vasculature is the most widely used procedure to cease the bleeding. This clinical trial evaluates the role and benefits of the Ligasure™ system in traumatic splenectomy without using any suture materials and compares the result with conventional method of splenectomy.

METHODS

After making decision for splenectomy secondary to a blunt abdominal trauma, patients in control group (39) underwent splenectomy using conventional method with silk suture ligation of splenic vasculature. In the interventional group (41) a Ligasure™ vascular sealing system was used for ligating of the splenic vein and artery. The results of operation time, volume of intra-operation bleeding and post-operative complications were compared in both groups.

RESULTS

The mean operation times in control and interventional group were 21 and 12 min respectively (p < 0.05). The average volume of bleeding in control group during open splenectomy was 280 cc, but in the interventional group decreased significantly to 80 ml (p < 0.05) using the Ligasure system. Post-operative complications such as bleeding were non-existent in both groups.

CONCLUSION

The application of Ligasure™ in blunt abdominal trauma for splenectomy not only can decrease the operation time but also can decrease the volume of bleeding during operation without any additional increase in post-operative complications. This method is recommendable in traumatic splenic injuries that require splenectomy in order to control the bleeding as opposed to use of traditional silk sutures.

Use of a saline-coupled bipolar sealer open liver resection for hepatic malignancy: Medical resource use and costs

AIM

To evaluate outcomes associated with use of a saline coupled bipolar sealer during open partial liver resection.

METHODS

This retrospective analysis utilized the United States Premier™ insurance claims database (2010-2014). Patients were selected with codes for liver malignancy and partial hepatectomy or lobectomy. Cases were defined by use the saline-coupled bipolar sealer; controls had no use. A Propensity Score algorithm was used to match one case to five controls. A deviation-based cost modeling (DBCM) approach provided an estimate of cost-effectiveness.

RESULTS

One hundred and forty-four cases and 720 controls were available for analysis. Patients in the case cohort received fewer transfusions vs controls (18.1% vs 29.4%, P = 0.007). In DBCM, more patients in the case cohort experienced “on-course” hospitalizations (53.5% vs 41.9%, P = 0.009). The cost calculation showed an average savings in total hospitalization costs of $1027 for cases vs controls. In multivariate analysis, cases had lower odds of receiving a transfusion (OR = 0.44, 95%CI: 0.27-0.71, P = 0.0008).

CONCLUSION

Use of a saline-coupled bipolar sealer was associated with a greater proportion of patients with an “on course” hospitalization.

Methods to decrease blood loss during liver resection: a network meta-analysis

BACKGROUND

Liver resection is a major surgery with significant mortality and morbidity. Specialists have tested various methods in attempts to limit blood loss, transfusion requirements, and morbidity during elective liver resection. These methods include different approaches (anterior versus conventional approach), use of autologous blood donation, cardiopulmonary interventions such as hypoventilation, low central venous pressure, different methods of parenchymal transection, different methods of management of the raw surface of the liver, different methods of vascular occlusion, and different pharmacological interventions. A surgeon typically uses only one of the methods from each of these seven categories. The optimal method to decrease blood loss and transfusion requirements in people undergoing liver resection is unknown.

OBJECTIVES

To assess the effects of different interventions for decreasing blood loss and blood transfusion requirements during elective liver resection.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Science Citation Index Expanded to September 2015 to identify randomised clinical trials. We also searched trial registers and handsearched the references lists of identified trials.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or publication status) comparing different methods of decreasing blood loss and blood transfusion requirements in people undergoing liver resection.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and collected data. We assessed the risk of bias using Cochrane domains. We conducted a Bayesian network meta-analysis using the Markov chain Monte Carlo method in WinBUGS 1.4, following the guidelines of the National Institute for Health and Care Excellence Decision Support Unit guidance documents. We calculated the odds ratios (OR) with 95% credible intervals (CrI) for the binary outcomes, mean differences (MD) with 95% CrI for continuous outcomes, and rate ratios with 95% CrI for count outcomes, using a fixed-effect model or random-effects model according to model-fit. We assessed the evidence with GRADE.

MAIN RESULTS

We identified 67 randomised clinical trials involving a total of 6197 participants. All the trials were at high risk of bias. A total of 5771 participants from 64 trials provided data for one or more outcomes included in this review. There was no evidence of differences in most of the comparisons, and where there was, these differences were in single trials, mostly of small sample size. We summarise only the evidence that was available in more than one trial below. Of the primary outcomes, the only one with evidence of a difference from more than one trial under the pair-wise comparison was in the number of adverse events (complications), which was higher with radiofrequency dissecting sealer than with the clamp-crush method (rate ratio 1.85, 95% CrI 1.07 to 3.26; 250 participants; 3 studies; very low-quality evidence). Among the secondary outcomes, the only differences we found from more than one trial under the pair-wise comparison were the following: blood transfusion (proportion) was higher in the low central venous pressure group than in the acute normovolemic haemodilution plus low central venous pressure group (OR 3.19, 95% CrI 1.56 to 6.95; 208 participants; 2 studies; low-quality evidence); blood transfusion quantity (red blood cells) was lower in the fibrin sealant group than in the control (MD -0.53 units, 95% CrI -1.00 to -0.07; 122 participants; 2; very low-quality evidence); blood transfusion quantity (fresh frozen plasma) was higher in the oxidised cellulose group than in the fibrin sealant group (MD 0.53 units, 95% CrI 0.36 to 0.71; 80 participants; 2 studies; very low-quality evidence); blood loss (MD -0.34 L, 95% CrI -0.46 to -0.22; 237 participants; 4 studies; very low-quality evidence), total hospital stay (MD -2.42 days, 95% CrI -3.91 to -0.94; 197 participants; 3 studies; very low-quality evidence), and operating time (MD -15.32 minutes, 95% CrI -29.03 to -1.69; 192 participants; 4 studies; very low-quality evidence) were lower with low central venous pressure than with control. For the other comparisons, the evidence for difference was either based on single small trials or there was no evidence of differences. None of the trials reported health-related quality of life or time needed to return to work.

AUTHORS' CONCLUSIONS

Paucity of data meant that we could not assess transitivity assumptions and inconsistency for most analyses. When direct and indirect comparisons were available, network meta-analysis provided additional effect estimates for comparisons where there were no direct comparisons. However, the paucity of data decreases the confidence in the results of the network meta-analysis. Low-quality evidence suggests that liver resection using a radiofrequency dissecting sealer may be associated with more adverse events than with the clamp-crush method. Low-quality evidence also suggests that the proportion of people requiring a blood transfusion is higher with low central venous pressure than with acute normovolemic haemodilution plus low central venous pressure; very low-quality evidence suggests that blood transfusion quantity (red blood cells) was lower with fibrin sealant than control; blood transfusion quantity (fresh frozen plasma) was higher with oxidised cellulose than with fibrin sealant; and blood loss, total hospital stay, and operating time were lower with low central venous pressure than with control. There is no evidence to suggest that using special equipment for liver resection is of any benefit in decreasing the mortality, morbidity, or blood transfusion requirements (very low-quality evidence). Radiofrequency dissecting sealer should not be used outside the clinical trial setting since there is low-quality evidence for increased harm without any evidence of benefits. In addition, it should be noted that the sample size was small and the credible intervals were wide, and we cannot rule out considerable benefit or harm with a specific method of liver resection.

Reducing inflow occlusion, occlusion duration and blood loss during hepatic resections

BACKGROUND

To assess the changes in blood loss during hepatic resection with improved haemostatic devices such as a bipolar sealing device and a topical haemostatic agent.

METHODS

This retrospective clinical study of prospectively collected data will assess hepatic resections performed by a single surgeon between 2005 and 2013, with the introduction of the two haemostatic techniques in 2009.

RESULTS

A total of 371 hepatic resections (214 from 2005 to 2008 and 157 from 2009 to 2013) were included in this study. Compared with the conventional hepatic resection (2005-2008), the use of haemostatic techniques (2009-2013) significantly reduced the need for inflow occlusion (OR: 0.37, 95% CI: 0.24-0.57, P < 0.001), overall occlusion time (20.8 min versus 25.9 min, P = 0.04) and transfusion requirement (4.6% versus 12%, OR: 0.35, 95% CI: 0.14-0.90, P = 0.02). Mean overall blood loss was reduced post-2009; however, the decrease was not statistically different (401.3 mL versus 470.8 mL, P = 0.27). Subgroup analysis revealed that blood loss was more than halved post-2009 compared with pre-2009 for patients who received pre-operative chemotherapy (324.6 mL versus 738.5 mL, P = 0.005).

CONCLUSION

The use of a bipolar sealing device and a topical haemostatic agent reduces the need for inflow occlusion, overall occlusion time and transfusions in all patients compared with conventional hepatic resections.

Randomized clinical trial comparing two vessel-sealing devices with crush clamping during liver transection

Background

Previous RCTs have failed to demonstrate the usefulness of combining energy devices with the conventional clamp crushing method to reduce blood loss during liver transection. Here, the combination of an ultrasonically activated device (UAD) and a bipolar vessel-sealing device (BVSD) with crush clamping was investigated.

Methods

Patients scheduled to undergo hepatectomy at the University of Tokyo Hospital or Nihon University Itabashi Hospital were eligible for this parallel-group, single-blinded randomized study. Patients were assigned to a control group (no energy device used), an UAD group or a BVSD group. The primary endpoint was the volume of blood loss during liver transection. Outcomes of the control group and the combined energy device groups (UAD plus BVSD) were first compared. Pairwise comparisons among the three groups were made for outcomes for which the combined energy device group was superior to the control group.

Results

A total of 380 patients were enrolled between July 2012 and May 2014; 116 patients in the control group, 122 in the UAD group and 123 in the BVSD group were included in the final analysis. Median blood loss during liver transection was lower in the combined energy device group (245 patients) than in the control group (116 patients): median 190 (range 0–3575) versus 230 (range 3–1570) ml (P = 0·048). Pairwise comparison revealed that blood loss was lower in the BVSD group than in the control group (P = 0·043).

Conclusion

The use of energy devices combined with crush clamping reduced blood loss during liver transection. Registration number: C000008372 (www.umin.ac.jp/ctr/index.htm).

Expert opinion on advanced techniques for hemostasis in liver surgery

BACKGROUND

Reduction of perioperative blood loss and intraoperative transfusion are two major factors associated with improving outcomes in liver surgery. There is currently no consensus as to the best technique to achieve this.

METHODS

An international Panel of Experts (EP), made up of hepatobiliary surgeons from well-known high-volume centres was assembled to share their experience with regard to the management of blood loss during liver resection surgery. The process included: a review of the current literature by the panel, a face-to-face meeting and an on-line survey completed by the EP prior to and following the face-to-face meeting, based on predetermined case scenarios. During the meeting the most frequently researched surgical techniques were appraised by the EP in terms of intraoperative blood loss.

RESULTS

All EP members agreed that high quality research on the subject was lacking. Following an agreed risk stratification algorithm, the EP concurred with the existing research that a haemostatic device should always be used along with any user preferred surgical instrumentation in both open and laparoscopic liver resection procedures, independently from stratification of bleeding risk. The combined use of Ultrasonic Dissector (UD) and saline-coupled bipolar sealing device (Aquamantys(®)) was the EP preferred technique for both open and laparoscopic surgery.

CONCLUSIONS

This EP propose the use of a bipolar sealer and UD for the best resection technique and essential equipment to minimise blood loss during liver surgery, stratified according to transfusion risk, in both open and laparoscopic liver resection.

Energy vessel sealing systems versus mechanical ligature of the inferior mesenteric artery in laparoscopic sigmoidectomy

PURPOSE

With the development of new devices, our ligation technique of the inferior mesenteric artery changed from mechanical ligature (ML) to energized vessel sealing systems (EVSS) ligature. The aim of this study was to determine if EVSS could be considered as safe and effective as the more convention ML of the inferior mesenteric vessels division during elective laparoscopic left colectomy.

METHODS

Between 2001 and 2014, 200 consecutive patients (111 males) of mean age 54.1 years were operated laparoscopically for a symptomatic sigmoid diverticulitis. Vascular interruptions were performed using mechanical ligatures including double clipping, staples or surgical thread (100 patients) or, starting from 2006, with EVSS thereafter (100 patients). Section of the inferior mesenteric artery is performed systematically at its origin in our institution for teaching purposes. Technical results were prospectively collected perioperatively and postoperatively.

RESULTS

There was no mortality. Mean operating time was 253.7 and 200.7 min in the ML and EVSS groups, respectively (p < 0.001). Mean hospital stay was 10.4 and 8.1 days (p < 0.001). Thirty-day complications occurred in 31 versus 25 % of patients (p = 0.26). Leakage with peritonitis occurred in 3 patients in the ML group. Hemorrhagic events occurred in both groups (2 in ML group versus 1 in EVSS group). Limitations of the study are its retrospective design and the bias due to the comparison of two historical cohorts.

CONCLUSIONS

EVSS for the inferior mesenteric artery are as safe and effective as ML in elective sigmoidectomy for diverticular disease with lower operative time and hospital stay.

Electrosurgical devices: are we closer to finding the ideal appliance? A critical review of current evidence for the use of electrosurgical devices in general surgery

Over the last decade, the use of electrosurgical devices has become commonplace across all surgical specialities. The current market is large enough to warrant a comparative review of each device. This has even more impetus given the budgetary constraints of NHS organisations. This review aims to compare the benefits and drawbacks of the most popular electrosurgical devices, whilst conducting a critical review of the literature. Structured searches using databases Medline and EMBASE were conducted. The search was restricted to English language papers only. Due to the abundance of literature, this review will focus on common general surgical procedures alone. Despite a plethora of available devices, individual preference still dictates use. Conventional diathermy may always have its place, but may see a decline in use if costs improve. Newer devices have shown comparable precision and added advantages.

Impact of energy devices during liver parenchymal transection: a multicenter randomized controlled trial

OBJECTIVE

To clarify the benefit of energy devices such as ultrasonically activated device and bipolar vessel sealing device in liver surgeries.

BACKGROUND

Several studies have suggested the benefit of energy devices in liver transection, while a randomized trial has found no association between their use and surgical outcomes.

PATIENTS AND METHODS

Patients scheduled to undergo open liver resection were eligible for this multicenter non-blinded randomized study. They were randomized to receive an energy device (experimental group) or not (control group) during liver transection. The primary endpoint was the proportion of patients with intraoperative blood loss >1,000 mL. The primary aim was to show non-inferiority of hepatectomy with energy device to that without energy device.

RESULTS

A total of 212 patients were randomized and 211 (105 and 106 in the respective groups) were analyzed. Intraoperative blood loss >1,000 mL occurred in 15.0% patients with energy device and 20.2% patients without energy device. The experimental minus control group difference was -5.2% (95% confidence interval -13.8 to 3.3%; non-inferiority test, p = 0.0248). Hepatectomy with energy device resulted in a shorter median liver transection time (63 vs. 84 min; p < 0.001) and a lower rate of postoperative bile leakage (4 vs. 16%; p = 0.002).

CONCLUSIONS

The hypothesis that hepatectomy with energy device is not inferior to that without energy device in terms of blood loss has been demonstrated. The use of energy devices during liver surgery is clinically meaningful as it shortens the liver transection time and reduces the incidence of postoperative bile leakage.

Short- and long-term outcomes of LigaSure versus conventional surgery for curative gastric cancer resection: a matched pair analysis

BACKGROUND

The LigaSure vessel sealing system allows dissection and hemostasis in a safe and quick way, and it has been reported to be an effective tool to shorten operative time and reduce intraoperative blood loss for various surgeries. However, short- and long-term outcomes in comparison with conventional surgery for gastric cancer resection are limited.

METHODS

Between January 2005 and December 2009, 121 patients underwent curative resection for gastric cancer with LigaSure. Perioperative and long-term results were compared with those of 242 matched patients who received curative resection for gastric cancer with the conventional technique. Immediate operation outcomes, operation morbidity, recurrence and survival were compared between groups.

RESULTS

In the LigaSure group compared with the conventional group, operation time was 156 versus 183 min (P < 0.0001), intraoperative blood loss was 181 versus 236 ml (P = 0.042), intraoperative blood transfusion was 68 versus 161 ml (P = 0.014), and hospital stay was 11.9 versus 13.6 days (P = 0.001). There were no differences in operation morbidity, recurrence rates, overall and disease-free survival between the LigaSure and conventional groups.

CONCLUSIONS

LigaSure is associated with shorter operation time and hospital stay, less blood loss and transfusion, and comparable operation morbidity and long-term outcomes in comparison with conventional surgery for curative gastric cancer resection.

Efficacy of a half-grip technique using a fine tip LigaSure™, Dolphin Tip Sealer/Divider, on liver dissection in swine model

BACKGROUND

Recently, a lot of energy devices in the surgical field, especially in the liver surgery, have been developed, and a fine tip LigaSure™, Dolphin Tip Sealer/Divider (DT-SD) also has been used frequently to dissect liver parenchyma as well as ultrasonically activated device (USAD). However, the utility of this instrument for liver dissection (LD) is still unknown. Moreover, to reduce bleeding during LD, a half-grip technique (HGT) was contrived. We herein report an experimental study in swine model to evaluate the feasibility and effectiveness of HGT using DT-SD for LD.

METHODS

The swine model experiment was carried out under general anesthesia by veterinarians. LD was performed repeatedly by DT-SD with the HGT (Group A, n = 6), or the conventional clamp-crush technique (CCT) (Group B, n = 6), and by variable mode USAD (Group C, n = 6). The dissection length and depth (cm) as well as bleeding volume (g) were measured carefully, and the dissection area (cm(2)) and speed (cm(2)/min) were calculated precisely. Histological examinations of the dissection surfaces were also executed. Mann-Whitney's U test was used for Statistical analyses with variance at a significance level of 0.05.

RESULTS

Among the three groups, the three averages of dissection lengths were unexpectedly equalized to 8.3 cm. The dissection area (cm(2)) was 9.9 ± 5.1 in Group A, 9.8 ± 4.7 in Group B, and 9.9 ± 4.5 in Group C. The mean blood loss during LD was 10.6 ± 14.8 g in Group A, 41.4 ± 39.2 g in Group B, and 34.3 ± 39.2 g in Group C. For Group A, the bleeding rate was the least, 0.9 ± 1.0 g/cm(2), and the average depth of coagulation was the thickest, 1.47 ± 0.29 mm, among the three groups (p < 0.05). The dissection speed in Group A (1.3 ± 0.3 cm(2)/min) was slower, than that in Group C (p < 0.05).

CONCLUSIONS

This report indicates firstly that the HGT using DT-SD bring the least blood loss when compared with CCT or USAD. Although the HGT is feasible and useful for LD, to popularize the HGT, further clinical studies will be needed.

[Liver transection: modern procedure: Technique, results and costs]

Liver resection has developed into the current standard procedure due to modern resection techniques, profound knowledge of the liver anatomy and optimized surgical and anesthesiological strategies to allow extended resections with both low morbidity and mortality. Initially major blood loss was the biggest concern with liver resection and a Pringle's manoeuvre was necessary. Nowadays, biliary leakage is the major problem after liver surgery. Besides the classical conventional clamp crushing technique for parenchymal transection, various devices including ultrasound, microwaves and staplers have been introduced. Minimally invasive techniques have become increasingly important for liver resection but are still applied in selected patients only. The selection of the resection technique and device mainly depends on the extent of the resection and also on the liver parenchyma, the liver disease, costs, personal experiences and preferences. This article presents a selection of techniques used in modern parenchymal transection during liver resection with special focus on transection time, blood loss, bile leakage and costs.

Role of surgical resection for hepatocellular carcinoma based on Japanese clinical guidelines for hepatocellular carcinoma

In the Algorithm for Diagnosis and Treatment in the Japanese Evidence-Based Clinical Practice Guidelines for Hepatocellular Carcinoma, the treatment strategy is determined by three major factors: liver function and the number and size of tumors. The algorithm is quite simple, consisting of fewer components than the Barcelona-Clinic Liver Cancer staging system. In this article, we describe the roles of the treatment algorithm in hepatectomy and perioperative management of hepatocellular carcinoma.

Impact of energy devices during liver parenchymal transection: a multicenter randomized controlled trial

OBJECTIVE

To clarify the benefit of energy devices such as ultrasonically activated device and bipolar vessel sealing device in liver surgeries.

BACKGROUND

Several studies have suggested the benefit of energy devices in liver transection, while a randomized trial has found no association between their use and surgical outcomes.

PATIENTS AND METHODS

Patients scheduled to undergo open liver resection were eligible for this multicenter non-blinded randomized study. They were randomized to receive an energy device (experimental group) or not (control group) during liver transection. The primary endpoint was the proportion of patients with intraoperative blood loss >1,000 mL. The primary aim was to show non-inferiority of hepatectomy with energy device to that without energy device.

RESULTS

A total of 212 patients were randomized and 211 (105 and 106 in the respective groups) were analyzed. Intraoperative blood loss >1,000 mL occurred in 15.0% patients with energy device and 20.2% patients without energy device. The experimental minus control group difference was -5.2% (95% confidence interval -13.8 to 3.3%; non-inferiority test, p = 0.0248). Hepatectomy with energy device resulted in a shorter median liver transection time (63 vs. 84 min; p < 0.001) and a lower rate of postoperative bile leakage (4 vs. 16%; p = 0.002).

CONCLUSIONS

The hypothesis that hepatectomy with energy device is not inferior to that without energy device in terms of blood loss has been demonstrated. The use of energy devices during liver surgery is clinically meaningful as it shortens the liver transection time and reduces the incidence of postoperative bile leakage.

Bleeding control during laparoscopic liver resection: a review of literature

Despite the established advantages of laparoscopy, bleeding control during laparoscopic liver resection (LLR) is a liver-specific improvement. The 2nd International Consensus Conference on Laparoscopic Liver Resection was held in October 2014 at Morioka, Japan. One of the most capital questions was: What is essential in bleeding control during LLR? In order to correctly address this question, we conducted a comprehensive review of the literature. Essential points based on personal experience of the expert panel are also discussed. A total of 54 publications were identified. Based on this analysis, the working group built these recommendations: (1) a pneumoperitoneum of 10-14 mmHg should be used as it allows a good control of the bleeding without significant modifications of hemodynamics; (2) a low central venous pressure (<5 mmHg) should be used; (3) laparoscopy facilitates inflow and outflow control; and (4) surgeons should be experienced with the use of all surgical devices for liver transection and should master laparoscopic suture before starting LLR. Precoagulation with radiofrequency can be useful, particularly in cases of atypical resection. These recommendations are mostly based on experts' opinions and on B or C quality of evidence grade studies. More prospective data are required to confirm these results.

Experience with a simple clamp-crush technique devoid of other devices for liver resections in a surgical oncology practice

BACKGROUND

Parenchyma transection techniques during liver resection (LR) are linked to intraoperative blood loss and postoperative morbidity, with a recent increased use of energy devices over traditional clamp-crush hepatotomy (CCH).

METHODS

Prospectively collected data from 191 consecutive patients undergoing LR with exclusive CCH by a single surgeon were examined.

RESULTS

There were 94 men and 97 women, with 25% primary and 59% secondary malignancies or other conditions (16%). Forty-nine percent of LRs were major, 65% anatomic, and 32% included extrahepatic components. Median Pringle time was 23 minutes (9 to 76), blood loss 300 mL (20 to 5,000), and red blood cell transfusion rate 14%. Morbidity rate was 27% with 6 deaths. Significant relationships were observed for blood loss with complex resections, transfusions, major morbidity, and length of stay, but not between Pringle time and any outcomes.

CONCLUSION

A CCH technique as employed in this LR experience without any use of additional devices can yield good postoperative results.

Metzenbaum-assisted liver resection: a safe and effective liver resection technique

AIM

We hereby present and evaluate a technique for hepatic parenchymal transection based on the application of Metzenbaum scissors and clips during liver ischemia.

METHODS

Our technique was retrospectively evaluated in 32 noncirrhotic, noncholestatic patients with intrahepatic cholangiocarcinoma and 32 patients with hepatocellular carcinoma (23 of whom cirrhotic, 71.9%). Patient data were retrieved from our Hepatobiliary Surgery Database. Type and duration of vascular clamping, blood transfusion requirements, marginal status and immediate postoperative complications were analyzed.

RESULTS

Twenty-seven extended (>4 liver segments; 42.2%) and 37 nonextended (≤4 liver segments; 57.8%) liver resections were analyzed. Warm liver ischemia duration was 14 (interquartile range: 11-17.8) min. Thirty-three patients (51.6%) were transfused with a median of 2 (1.5-3) units of packed red blood cells. Tumor-free margins were achieved in 90.6% of cases (n = 58). The overall morbidity rate was 18.8% with a 4.7% mortality rate. Our technique allowed for excellent identification and safe dissection and preservation, or ligation of major liver vessels.

CONCLUSIONS

The proposed technique is simple, fast, safe and with low cost. It is associated with limited postoperative complications while from an oncologic standpoint it enables the surgeon to achieve a high percentage of tumor-free margins while protecting major vascular structures.