Clinical usefulness of endo intestinal clips during Pringle's maneuver in laparoscopic liver resection: a technical report

Right-Lateral Pringle Maneuver Using Endovascular Clip for Open and Laparoscopic Hepatectomy After Esophagectomy (with Video)

BACKGROUND

Laparoscopic hepatectomy after esophageal cancer surgery is a technically challenging procedure as it is difficult to control hepatic inflow due to adhesion 1. Ann Hepatobiliary Pancreat Surg. 22:344-349; 2. Dis Esophagus. 28:483-487; 3. Surg Endosc. 35:5375-5380; 4. Surg Laparosc Endosc Percutan Tech. 23:e103-105. Thus, we introduce our technique for hepatic inflow control using an endovascular clip.

METHODS

After the confirmation of space between the right and dorsal side of the hepatoduodenal ligament and the inferior vena cava, an endovascular clip was introduced laterally from the right side of the hepatoduodenal ligament to control hepatic inflow. The control of hepatic inflow was confirmed using intraoperative Doppler ultrasound and then a hepatic parenchymal transection was performed. The video demonstrates our technique using an endovascular clip for hepatic inflow control to perform safe open or laparoscopic hepatectomy after esophageal cancer surgery. Patient 1 was an 82-year-old woman with a history of laparoscopic assisted esophagectomy for esophageal neuroendocrine cancer. She underwent open anatomical resection of segment 3 for a 38-mm liver tumor. Patient 2 was a 71-year-old man with a history of laparoscopic esophagectomy for esophageal cancer. He underwent laparoscopic partial resection of segment 6 for a 24-mm liver tumor.

RESULTS

The operation times were 105 and 123 min, and the estimated blood loss was 30 g and 10 g, respectively. The patients' postoperative courses were uneventful and the patients were discharged on postoperative days 9 and 8, respectively.

CONCLUSION

Right-lateral Pringle maneuver using an endovascular clip may be a safe and feasible technique in both open and laparoscopic hepatectomy after esophagectomy.

Predictors of a difficult Pringle maneuver in laparoscopic liver resection and evaluation of alternative procedures to assist bleeding control

PURPOSE

To evaluate the predictors of a difficult Pringle maneuver (PM) in laparoscopic liver resection (LLR) and to assess alternative procedures to PM.

METHODS

Data from patients undergoing LLR between 2013 and 2020 were reviewed retrospectively. Univariate and multivariate analyses were performed and the outcomes of patients who underwent PM or alternative procedures were compared.

RESULTS

Among 106 patients who underwent LLR, PM could not be performed in 18 (17.0%) because of abdominal adhesions in 14 (77.8%) and/or collateral flow around the hepatoduodenal ligament in 5 (27.8%). Multivariate analysis revealed that Child-Pugh classification B (p = 0.034) and previous liver resection (p < 0.001) were independently associated with difficulty in performing PM in LLR. We evaluated pre-coagulation of liver tissue using microwave tissue coagulators, saline irrigation monopolar, clamping of the hepatoduodenal ligament using an intestinal clip, and hand-assisted laparoscopic surgery as alternatives procedures to PM. There were no significant differences in blood loss (p = 0.391) or transfusion (p = 0.518) between the PM and alternative procedures.

CONCLUSIONS

Child-Pugh classification B and previous liver resection were identified as predictors of a difficult PM in LLR. The alternative procedures were found to be effective.

How to minimize conversion to open surgery during laparoscopic liver resection: the point of view of hemostasis

It has been 30 years since laparoscopic liver resection was first introduced, and, in the beginning, wedge resection or nonanatomical liver resection was mainly performed. With the development of surgical techniques and instruments, many centers are currently performing major liver resections and even difficult anatomical liver resections such as segment VI, VII, and VIII and caudate segment. However, laparoscopic surgery has limitations in instrument manipulation, and due to the nature of liver resection surgery, massive bleeding may occur. Therefore, it is necessary to make efforts to minimize the bleeding and reduce the conversion to laparotomy due to bleeding.

EXTERNAL PRINGLE MANEUVER IN LAPAROSCOPIC LIVER RESECTION: A SAFE, CHEAP AND REPRODUCIBLE WAY TO PERFORM IT

BACKGROUND

Tourniquet for right hepatectomy tightened and secured with forceps (arrow). Laparoscopic liver resection is performed worldwide. Hemorrhage is a major complication and bleeding control during hepatotomy is an important concern. Pringle maneuver remains the standard inflow occlusion technique.

AIM

Describe an extracorporeal, efficient, fast, cheap and reproducible way to execute the Pringle maneuver in laparoscopic surgery, using a chest tube.

METHODS

From January 2014 to March 2020, our team performed 398 hepatectomies, 63 by laparoscopy. We systematically encircle the hepatoduodenal ligament and prepare a tourniquet to perform Pringle maneuver. In laparoscopy, we use a 24 Fr chest tube, which is inserted in the abdominal cavity through a small incision. We thread the cotton tape through the tube, pulling it out through the external end, outside the abdomen. To perform the tourniquet, we just need to push the tube as we hold the tape, clamping both with one forceps.

RESULTS

The 24 Fr chest tube is firm and works perfectly to occlude blood inflow as the cotton band is tightened. It has an internal diameter of 5,5 mm, sufficient for a laparoscopic grasper pass through it to catch the cotton band, and an external diameter of 8 mm, which allows to be inserted in the abdomen through a tiny incision. The cost of this tube and the cotton band is less than US$ 1. No complications related to the method were identified in our patients.

CONCLUSIONS

The extracorporeal Pringle maneuver presented here is a safe, cheap and reproducible method, that can be used for bleeding control in laparoscopic liver surgery.

The usefulness of the totally intra-corporeal pringle maneuver with Penrose drain tube during laparoscopic left side liver resection

Backgrounds/Aims

The Pringle maneuver is generally performed to reduce the amount of blood loss during hepatic resection. During laparoscopic liver resection, the Pringle maneuver can be used in several ways. We have developed a new Pringle maneuver (PM) with Penrose drain tube to sufficiently control blood loss during laparoscopic liver resection. This study was performed to determine the safety and outcome during laparoscopic left-sided hepatectomy performed using this new method.

Methods

We describe the technique and results of the left-sided liver resection with totally intracorporeal PM with Penrose drain tube. We performed 37 laparoscopic left-sided hepatic resections with (PM group) or without the Penrose PM (No PM group). We retrospectively compared the short-term operative outcome between the No PM group (n=12) and the PM group (n=25) during laparoscopic left-sided liver resection.

Results

Median PM duration was 34.3 min. The median duration of the surgery using the totally intracorporeal PM with Penrose drain tube was 174 min, while the surgical duration required for resection without the PM was 156 min. The median volume of operative blood loss was lower in the PM group than in the No PM group (No PM group (341 ml) vs. PM group (165 ml)). There was no postoperative mortality and no open conversion.

Conclusions

The totally intracorporeal PM with Penrose drain tube for laparoscopic hepatectomy is safe, reproducible, and can facilitate liver dissection during left-sided liver resection.

Useful maneuvers for precise laparoscopic liver resection

Laparoscopic liver resection has evolved over the past decade and nearly replaced open exploration. This procedure not only provides comparable oncological outcomes, but it also has improved recovery after surgery. Many of the challenges presented by limitations of instruments and techniques have been overcome through adaptations and new developments, and it is possible that the remaining obstacles will be overcome within a few years. Moreover, as surgeons continue to gain experience, their technical knowledge has supported further improvement in minimally invasive approaches. This review examines every important procedures in performing a precise laparoscopic liver resection.

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.

Short- and long-term outcomes of laparoscopic versus open hepatectomy for small malignant liver tumors: a single-center experience

BACKGROUND

Laparoscopic hepatectomy (Lap-Hx) has been increasingly performed for patients with liver tumors as surgical techniques and devices have progressed. However, the long-term outcomes of Lap-Hx for malignant liver tumors are not oncologically guaranteed. This study compared the short- and long-term outcomes between Lap-Hx and open hepatectomy (Open-Hx) for malignant liver tumors by matched-pair analysis.

METHODS

The indications for Lap-Hx at our department are a tumor size of <5 cm and fewer than two lesions without macroscopic vascular invasion or the need for biliary reconstruction. In total, 135 patients underwent Lap-Hx for malignant liver tumors through December 2013. We compared the short- and long-term outcomes between Lap-Hx and Open-Hx in patients who met the above-mentioned indications.

RESULTS

With respect to short-term outcomes, the operation time, blood loss, postoperative hospital stay, white blood cell count, and C-reactive protein level after Lap-Hx were significantly better than those after Open-Hx in both the patients who underwent partial resection and those who underwent lateral sectionectomy. In patients who underwent partial resection, the incidence of postoperative complications after Lap-Hx was significantly lower than that after Open-Hx; in particular, wound infection and respiratory complications were significantly lower. Furthermore, when the tumor was located in the posterosuperior segments, the operation time for Lap-Hx was not shorter than that for Open-Hx. With respect to long-term outcomes of hepatocellular carcinoma, neither overall nor disease-free survival differed between the two groups. With respect to long-term outcomes of colorectal liver metastases, the disease-free survival rate was similar between Lap-Hx and Open-Hx; however, the overall survival rate was significantly better for Lap-Hx than for Open-Hx.

CONCLUSIONS

Lap-Hx is a good option for selected patients with malignant liver tumors. The short- and long-term outcomes of Lap-Hx also are considered to be acceptable.