Totally laparoscopic left hepatectomy using the Torsional Ultrasonic Scalpel

Treatment of hepatic venous system hemorrhage and carbon dioxide gas embolization during laparoscopic hepatectomy via hepatic vein approach

With the improvement of laparoscopic surgery, the feasibility and safety of laparoscopic hepatectomy have been affirmed, but intraoperative hepatic venous system hemorrhage and carbon dioxide gas embolism are the difficulties in laparoscopic hepatectomy. The incidence of preoperative hemorrhage and carbon dioxide gas embolism could be reduced through preoperative imaging evaluation, reasonable liver blood flow blocking method, appropriate liver-breaking device, controlled low-center venous pressure technology, and fine-precision precision operation. In the case of blood vessel rupture bleeding in the liver vein system, after controlling and reducing bleeding, confirm the type and severity of vascular damage in the liver and venous system, take appropriate measures to stop the bleeding quickly and effectively, and, if necessary, transfer the abdominal treatment in time. In addition, to strengthen the understanding, prevention and emergency treatment of severe CO2 gas embolism in laparoscopic hepatectomy is also the key to the success of surgery. This study aims to investigate the methods to deal with hepatic venous system hemorrhage and carbon dioxide gas embolization based on author's institutional experience and relevant literature. We retrospectively analyzed the data of 60 patients who received laparoscopic anatomical hepatectomy of hepatic vein approach for HCC. For patients with intraoperative complications, corresponding treatments were given to cope with different complications. After the operation, combined with clinical experience and literature, we summarized and discussed the good treatment methods in the face of such situations so that minimize the harm to patients as much as possible.

Surgery

This chapter provides a comprehensive background from basic to applied knowledge of surgical anatomy which is necessary for the surgical treatment of cholangiocarcinoma (CCA) patients. Significant advances that have been made in the surgical treatment of CCA were examined. For instance, in-depth details are provided for appropriate preoperative assessment and treatment to optimize patient status and to improve the outcome of surgical treatment(s). Comprehensive details are provided for the surgical techniques and outcomes of treatments for each type of CCA with clear illustrations and images. This chapter also describes the role of minimally invasive surgery and liver transplantation in CCA treatment.

The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology

At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.

Comparison of Outcomes Between Open Major Hepatectomy Using CUSA and Laparoscopic Major Hepatectomy Using "Lotus" Liver Blade. A Propensity Score Matched Analysis

Introduction: Evolution in laparoscopic liver surgery during the past two decades is an indisputable fact. According to the second international consensus conference for laparoscopic liver resection held in Morioka, Japan in 2014 major resections are still regarded as innovative procedures in the exploration phase. On this basis, our study aims to explore the efficacy and safety of laparoscopic vs. open major liver resection and therefore increase the existing evidence on major laparoscopic liver surgery. Methods: All consecutive patients who underwent major liver resection, open and laparoscopic from January 2016 to May 2018 were identified from our prospectively maintained database. Propensity score matching analysis was performed using R statistical tool in SPSS to isolate matched open and laparoscopic cases which were compared for intraoperative and postoperative short-term outcomes. Lotus ultrasonic energy device was used for parenchymal transection in laparoscopic cases vs. CUSA in open procedures. Results: Propensity score matching analysis was performed on 82 consecutive patients (61 open and 21 laparoscopic major hepatectomies) resulting in 40 matched patients, 20 in each group. The mean total duration of surgery and duration of parenchymal transection were slightly longer in the laparoscopic group (p = 0.419, p = 0.348). There was no difference in the intraoperative and postoperative transfusion rates. Patients after laparoscopic surgery were discharged 2 days earlier on average (p = 0.310). No difference was observed in complication rates and mortality. Conclusion: Our data did not reveal inferiority of the laparoscopic major hepatectomy vs. the open approach in any parameter compared. The use of the Lotus ultrasonic energy device appeared to be efficient and safe for parenchymal transection in the laparoscopic procedures.

Laparoscopic ultrasonic dissectors: technology update by a review of literature

The evolution of minimally invasive surgery has brought forward the appearance of new advances in the course of the most recent couple of years and has introduced energy-based devices. The newest among them today are the ultrasonically activated devices, which are utilized with a great deal of components in-play, including ergonomics and financial aspects amid surgery. The methodology embraced was finding significant investigations through studies from PubMed, Medline and Google Scholar on current ultrasonic dissectors, which are Ethicon’s Harmonic Scalpel (ACE^®), Covidien’s Sonicision™ (SNC), Conmed’s SonoSurg^® (SS) and Olympus’s Thunderbeat^®, to describe their efficacy in terms of vessel sealing speed, vessel burst pressure, visibility, operation time and thermal speed. We found postmarketing evidence to determine which device exhibits the better performance. Animal studies showed that emissivity values and maximum temperatures for coagulation are similar among devices but maximum cutting temperatures are significantly different: ACE = 191.1°C, SNC = 227.1°C, SS = 184.8°C (p < 0.001). Cooling times are significantly different among devices: 35.7 s for ACE, 38.7 s for SNC and 27.4 s for SS (p < 0.001). Cooling times of passive jaws to reach 60°C after activation were also significantly different: 25.4 s for ACE, 5.7 s for SNC, and 15.4 s for SS (p < 0.001). The perfect device would unify brilliant hemostatic outcomes with visual sharpness while permitting none or insignificant thermal damage at the place of use.

Laparoscopic versus open liver resection for hepatocellular carcinoma: initial experience in Greece

Background

Liver resection represents the treatment of choice for a small proportion of patients with hepatocellular carcinoma (HCC), amenable to surgery. The remarkable evolution in surgical techniques during the last decades introduced laparoscopic hepatectomy in the operative management of HCC, even in the presence of liver cirrhosis. No comparative study on laparoscopic or open liver resection for HCC has been conducted in Greece yet.

Methods

Patients undergoing liver resection for HCC by one senior hepatobiliary surgeon in our Institution during the period 11/2011-02/2016 were prospectively sampled and retrospectively analyzed for the purposes of this study. Statistical analysis encompassed Student’s t-test, Fisher’s exact test, the Kaplan-Meier method/log rank test and Cox proportional hazard regression analyses.

Results

Eleven patients underwent laparoscopic and 21 open liver resection, respectively. Statistical differences between the 2 groups were observed for tumor size (P=0.04), major resections (P=0.01), Pringle maneuver (P=0.008), intraoperative blood transfusion (P=0.03), and duration of operation (P=0.004). Resection margins, and tumor recurrence showed no statistical differences. Three-year postoperative survival after laparoscopic and open hepatectomy was 100%, and 67%, respectively (P=0.06). Regression analysis for patient survival revealed prognostic value for BCLC staging, γ-glutamyl transferase levels, laparoscopic hepatectomy, UICC stage, Dindo-Clavien classification, and hospital stay. Laparoscopic hepatectomy remained as independent predictor of survival by multivariate analysis (P=0.0142).

Conclusion

Laparoscopic hepatectomy for HCC in chronic liver disease represents a safe and innovative treatment tool in the management of these patients under the presupposition of careful patient selection.

What is the best technique in parenchymal transection in laparoscopic liver resection? Comprehensive review for the clinical question on the 2nd International Consensus Conference on Laparoscopic Liver Resection

The continuing evolution of technique and devices used in laparoscopic liver resection (LLR) has allowed successful application of this minimally invasive surgery for the treatment of liver disease. However, the type of instruments by energy sources and technique used vary among each institution. We reviewed the literature to seek the best technique for parenchymal transection, which was proposed as one of the important clinical question in the 2nd International Consensus Conference on LLR held on October 2014. While publications have described transection techniques used in LLR from 1991 to June 2014, it is difficult to specify the best technique and device for laparoscopic hepatic parenchymal transection, owing to a lack of randomized trials with only a small number of comparative studies. However, it is clear that instruments should be used in combination with others based on their functions and the depth of liver resection. Most authors have reported using staplers to secure and divide major vessels. Preparation for prevention of unexpected hemorrhaging particularly in liver cirrhosis, the Pringle's maneuver and prompt technique for hemostasis should be performed. We conclude that hepatobiliary surgeons should select techniques based on their familiarity with a concrete understanding of instruments and individualize to the procedure of LLR.

What kind of energy devices should be used for laparoscopic liver resection? Recommendations from a systematic review

Transection methods and hemostasis achievement have an impact on blood loss, and consequently on outcome and survival. However, no consensus exists on parenchymal transection or hemostasis techniques in laparoscopic liver resection (LLR). The aim of this review is to clarify the role of energy devices (ED) in LLR. ED is a generator of mechanic or electric energy transfer to an operating tool, used for transection, sealing or both. Searches were performed in PubMed, PubMed Central, Cochrane, Embase, Google Scholar in human or animal experimental models. Each study quality was graded following the GRADE system. From 1996 to 2014, 30 studies were found: five comparative, one prospective, two case-control, and 16 case series and some case reports, with level of evidence ranging from Moderate to Very Low. Since 2012, the Research and Development of new tools raised quicker than clinical studies could follow. The two main techniques emerged are blind transection versus sharp dissection: due to the low quality and heterogeneity of the studies, no firm conclusion can be drawn, but meticulous dissection of vessels usually never leads to vascular damage. As a matter of fact, ED, though efficient and reliable, cannot replace the basic skills of hepatic surgery: sharp dissection, vascular control and elective sealing.