J Hepatobiliary Pancreat Sci (2015) 22:363–370 DOI: 10.1002/jhbp.216
TOPIC
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 Yuichiro Otsuka · Hironori Kaneko · Sean P. Cleary · Joseph F. Buell · Xiujun Cai · Go Wakabayashi Published online: 29 January 2015 © 2015 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract 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.
Y. Otsuka · H. Kaneko (✉) Deparment of Surgery, Toho University Faculty of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo 143-8541, Japan e-mail: [email protected]
The introduction of laparoscopy to liver resection started in the 1990s [1], but was limited due to technical difficulties such as hemostasis from the transection plane, controlling hemorrhage from intrahepatic vessels, and exploration of deep lesions in the liver. However, the continuing evolution of surgical technique and instrument technology used in laparoscopic liver resection has allowed the development and advancement of minimally invasive approaches to resection of hepatic lesions. Globally, the evolution of laparoscopic liver transection techniques has largely occurred based on instrument availability as well as surgeons’ and institutions’ preferences and experience with particular approaches, raising the question of what is the best device and surgical technique for parenchymal transaction? In this paper, we reviewed the literature to seek the best technique for parenchymal transection during laparoscopic liver resection (LLR), which was proposed as one of the important clinical question in the 2nd International Consensus Conference on Laparoscopic Liver Resection held on October 2014 in Morioka, Iwate prefecture, Japan.
S. P. Cleary Department of Surgery, University of Toronto, Toronto, Ontario, Canada J. F. Buell Tulane Transplant Institute, Department of Surgery, Tulane University, New Orleans, Louisiana, USA J. F. Buell School of Medicine, Loiusiana State University, New Orleans, Louisiana, USA X. Cai Department of General Surgery, Sir Run Run Shaw Hospital, Institute of Minimally Invasive Surgery of Zhejiang University, Zhejiang University, Hangzhou, China
G. Wakabayashi Department of Surgery, Iwate Medical University, Morioka, Iwate, Japan
Keywords Energy device · Laparoscopy · Liver surgery · Stapling device · Technique · Transection
Introduction
364
J Hepatobiliary Pancreat Sci (2015) 22:363–370
Method of literature review This document is based on a comprehensive review of the literature from 1991 to June 13, 2014. Publications describing parenchymal transection techniques used in LLR were found from keywords of “Laparoscopic liver resection” and “CUSA” or “Clamp crush” or “Vessel sealing system” or “Ultrasonic dissector” or “Stapler” or “ultrasonic surgery” or “Control of bleeding” or “Parenchymal transection” in the MEDLINE, Embase, PubMed and Cochrane databases. Conference abstracts were excluded. Results Among 105 selected articles identified using the above method, only 36 relevant articles were precisely reviewed. The search failed to identify any randomized controlled trials (RCT) or meta-analysis focused on the technique of liver parenchymal transection in LLR. All studies identified were reported as case-control studies, case series, case reports, experimental studies and reviews.
Comparative studies There were two retrospective unmatched comparative studies [2, 3] (Tables 1,2). Largest report from Buell et al. [2] was the only series which specified the surgical technique used in LLR using an international multi-center database. The data presented in this evaluation suggested that the parenchymal transection using stapler (Stapler hepatectomy: SH) provides several advantages: diminished blood loss, transfusion requirements and shorter operative times when compared to electrosurgical resection (ER) group. In the evaluation of oncologic outcomes, the SH group had smaller surgical margins,
but the recurrence rate and survival rate were similar. Rau et al. [3] reported the usefulness of the water-jet dissection technique for open and laparoscopic liver surgery in their study, which compared the techniques of blunt dissection, cavitron ultrasonic surgical aspirator (CUSA) and water jet. However, most of the cases were open surgery (509/550), and details of technique used in LLR were unknown.
Clinical series There were 15 clinical series [4–18] identified using the search strategy (Tables 3,4). These non-comparative series comprise the majority of current evidence in this topic. The surgical devices for liver parenchymal transection used in these studies were ultrasonic scalpel in 11, stapler in seven, vessel sealer in six, CUSA in five, diathermy in four, monopolar sealer (saline drip) in four, argon beam coagulator in four, bipolar diathermy in two, radiofrequency precoagulator in two, microwave pre-coagulator in one and water-jet in one. Crush-clamp approach was used with a vessel sealer in one publication (Fig. 1). Twelve studies used two or more devices, and six studies used three or more surgical devices during the hepatic parenchymal transection procedure varying from minor to major liver resections. All studies used some type of energy device during resection. No devicespecific complications were found in this review and no trend in postoperative complications (e.g. bile leak) was observed. Pre-coagulation of the hepatic transection plane using microwave, or radiofrequency electro-devices was suggested to be of value in controlling hemorrhage, particularly in patients with cirrhosis [5, 8, 11, 12, 14]. In terms of hepatic inflow control, eight papers reported routine or temporally use of total or hemi-Pringle’s maneuver, and others either did not use inflow occlusion or its use was not reported.
Table 1 Comparative studies for the techniques of parenchymal transection in laparoscopic liver resection Author
Year
Number of patients
LLR
OLR
Buell [2]
2013
1499
0
Rau [3]
2008
41
550
Type of legion
Comparison
HCC/Mets/Benign/ Other tumor/Living donor –
(LLR) 0/9/32/0/0
Stapler hepatctomy (SH) 764 / electrosurgical resection (ER) 735 Water-jet (WJ) 137 / CUSA 175 / blunt dissection (BD) 279
Type of hepatectomy
Pringle’s maneuver
Minor/major
Pr/ HPr/ TPr
Minormajor
No (SH) / yes (EH)
Minor
Yes (TPr) 0.13 ± 0.18 min/ cm2 (WJ) / 0.29 ± 0.67 (CUSA) /0.23 ± 0.56 (BD) P = NS
CUSA cavitron ultrasonic surgical aspirator, HA hand-assisted, HCC hepatocellular carcinoma, HPr hemi-Pringle, LLR laparoscopic liver resection, Mets metastatic liver tumor, OLR open liver resection, Pr Pringle, TPr temporary Pringle
2013
2008
Buell [2]
Rau [3]
5 (3.6%) (WJ) / 6 (3.4%) (CUSA) / 8 (2.8%) (BD) P = NS
–
Mortality
2 (0.5%) hyper carbonoxidemia, bleeding
12 (1.6%) (SH) / 92 (2.2%) (ER) P = 0.432
Conversion rate
121 (15.9%) (SH) / 92 (12.6%) (ER) P = 0.067
Total 4 (0.5%) (SH) / 16 (2.2%) (ER) P = 0.05
–
–
Ascites
8 (1.0%) (SH) / 4 (0.5%) (ER) P = 0.274
Hemorrhage
7 (5.1%) (WJ) / 11 (6.3%) (CUSA) / 15 (5.3%) (BD) P = NS
26 (3.4%) (SH) / 16 (2.2%) (ER) P = 0.153
Bile leak
Postoperative complications
4 (2.9%) (WJ) / 11 (6.3%) (CUSA) / 10 (3.5%) (BD) P = NS
–
Abscess
Liver dysfunction: 11 (8.0%) (WJ) / 22 (12.5%) (CUSA) / 27 (9.8%) (BD) P = NS
Liver failure: 7 (0.9%) (SH) / 7 (1.0%) (ER) P = 0.942
Others
2013
2009
2009
2009
2008
2008
2008
Wang [7]
Wakabayashi [8]
Somasundar [9]
Tokunaga [10]
Buell [11]
Kaneko [12]
Aldrigheti [13]
2002
O’Rourke [17]
Schmidbauer [18]
2
12
3
8
15
14
81
253
3
18
176
6
9
5
47
Patients
Yes
2/3/9/1/0
Malignant 1/Cyst 1
1/9/1/0/0
0/0/0/0/3
7/0/1/0/0
Yes
Yes
Yes
Yes
Yes
Yes
4/5/5/0/0
Yes
–
Yes
Yes
36/58/121/35/0
1/0/1/1/0
1/12/5/0/0
81/76/12/0/7
6/0/0/0
1/6/2/0/0
Yes
– 2/3/0/0/0
Ultrasonic scalpel
HCC/Mets/ Benign/Other tumor/ Living donor
Type of legion
Yes
Crush clamp
Yes
Yes
Yes
Yes
Yes
CUSA
CUSA cavitron ultrasonic surgical aspirator, HCC hepatocellular carcinoma, Mets metastatic liver tumor
2006
2003
Eguchi [16]
2007
2013
Uchiyama [6]
2006
2013
Zacharoulis [5]
Belli [15]
2014
Honda [4]
Nissen [14]
Year
Author
Yes
Yes
Bipolar
Table 3 Clinical series for the techniques of parenchymal transection in laparoscopic liver resection
Yes
Yes
Yes
Yes
Yes
Yes
Vessel sealer
Yes
Yes
Yes
Yes
Diathermy
Yes
Yes
Yes
Yes
Monopolar sealer (saline drip)
Yes
Yes
Radiofrequency pre-coagulator
Surgical instrument used for parenchymal transection
BD blunt dissection, CUSA cavitron ultrasonic surgical aspirator, ER electrosurgical resection, LLR laparoscopic liver resection, OLR open liver resection, SH stapler hepatectomy, WJ water-jet
Year
Author
Table 2 Results of comparative studies for the techniques of parenchymal transection in laparoscopic liver resection
Yes
Microwave precoagulator
Yes
Yes
Yes
(Yes)
(Yes)
Yes
Yes
(Yes)
(Yes)
Yes
Yes
(Yes)
Stapler (for large vessel)
10.57 ± 2 15.35 ml/cm (WJ) / 18.26 ± 30.13 (CUSA) / 72.72 ± 497.26 (BD) P = 0.002
100 (50–10000) (SH) / 200 (0–1500) (ER) P = 0.006
Blood loss (g)
Yes
Waterjet
Yes
Yes
Yes
Yes
Argon beam coagulator
Minor
Major
Major
Minor
Minor
Minor-major
Minor-major
Minor-major
Minor
Minor-major
Minor-major
Minor
Minor
Minor
Minor-major
Minor/ major
Yes
Yes
Yes
Yes
–
No
–
No
Yes
No
Yes
Yes
No
No
Yes
Pringle’s maneuver
Efficacy of WJ in LLR and OLR
Efficacy of stapler in LLR
Discussion point
Type of hepatectomy
Resection time 0.29 ± 2 0.67 min/cm (WJ) / 0.48 ± 0.85 (CUSA) / 0.77 ± 1.75 (BD) P = 0.043
2.6 (0.5–12.7) (SH) / 3.1 (0.5–7) (ER) P = 0.001
Operation time (min)
J Hepatobiliary Pancreat Sci (2015) 22:363–370 365
2014 2013 2013 2013 2009 2009 2009 2008 2008 2008 2007 2006 2006 2003 2002
Honda [4] Zacharoulis [5] Uchiyama [6] Wang [7] Wakabayashi [8] Somasundar [9] Tokunaga [10] Buell [11] Kaneko [12] Aldrigheti [13] Nissen [14] Belli [15] Eguchi [16] O’Rourke [17] Schmidbauer [18]
SSI surgical site infection
Year
Author
0 0 0 0 0 0 0 4 0 0 0 0 0 0 2
Mortality
2 (4.2%) 0 0 – 3 (1.7%) 0 0 6 (2.4%) 1 (1.2%) 0 0 0 0 2 (16.7%) 0
Conversion rate
5 (10.6%) 0 0 0 8 (4.5%) – 0 41 (16%) 11% 0 2 (13.3%) 0 1 (33%) 3 (25%) 0
Total 0 0 0 0 0 0 0 – – 0 0 0 0 0 0
Hemorrhage
Pleural effusion
2 (4.3%) 0 0 0 0 0 0 0 0 0 – – 0 0 – – – – 0 0 0 0 0 0 1 (33%) 0 0 1 (8.3%) 0 0
Ascites 1 (2.1%) 0 0 0 3 (1.7%) 0 0 4% – 0 0 0 0 1 (8.3%) 0
Bile leak
Postoperative complications
Table 4 Result of clinical series for the techniques of parenchymal transection in laparoscopic liver resection
SSI
0 0 0 0 0 0 0 0 2 (1.1%) 3 (1.7%) – – 0 0 – – – – 0 0 0 0 0 0 0 0 0 0 0 0
Abscess
2 (4.3%) 0 0 – 0 – 0 – – 0 2 (13.3%) 0 0 1 (8.3%) 0
Others 342 (5–795) Minimal Little–417 – 266 (1–1790) 178 ± 53 89 (30–150) 222 – 150 (100–250) – 170 (100–300) – – 50>
Blood loss (g)
366 (202–531) 75 (60–90) 187 (89–423) 232 (190–310) 238 (30–542) 114 ± 56 – 162 – 340 (290–400) – 142 (120–180) 237 (200–282) 300–420 –
Operation time (min)
366 J Hepatobiliary Pancreat Sci (2015) 22:363–370
J Hepatobiliary Pancreat Sci (2015) 22:363–370 12
Number of series used
Fig. 1 Surgical devices used for laparoscopic liver parenchymal transection in clinical series. CUSA cavitron ultrasonic surgical aspirator
367
10 8 6 4 2 0
Case reports There were nine case reports [19–27] found, from minor to major LLR (Table 5). Surgical devices used included ultrasonic scalpel in eight, stapler in four, vessel sealer in three, bipolar diathermy in two, CUSA in two, monopolar sealer in two, radiofrequency pre-coagulator in one, microwave precoagulator in one and robot in one. Stapler was also used for the division of major vasculatures in all of the major hepatectomy cases.
minimally invasive major hepatic resections. These reviews suggest that no other device is capable of effectively providing hemostasis, control of bile duct branches, and dividing parenchyma in every circumstance encountered during major hepatic resections. Additionally, laparoscopic devices which include the endoscopic stapler, pre-coagulators, CUSA, ultrasonic scalpels, and vessel sealing devices, each have a role in laparoscopic hepatic parenchymal transection.
Discussion Experimental studies In experimental animal studies, there was one randomized control study [28], four comparative non-randomized studies [29–32], and a case series [33] discussing the different techniques of laparoscopic hepatic parenchymal transection using porcine model (Table 6). The majority of these studies suggest that bipolar devices including cautery-based vessel sealing system were considered to be effective in terms of reduced blood loss.
Reviews Three review articles were found on laparoscopic parenchymal transection [34] including focused reviews on bipolar sealer [35] and stapler hepatectomy [36]. Gumb et al. [36] suggested that the stapler hepatectomy approach using multiple stapler firings has the potential disadvantage of hindering and even preventing attempts to achieve hemostasis of the raw liver surface with monopolar and bipolar electrocautery. The laparoscopic stapler device is, however, useful for transection of the main portal branches and hepatic veins during
Current consensus in best practice for techniques and devices for laparoscopic hepatic parenchymal transection is lacking. This fact is owing to the deficiency in prospective randomized trials with decisions being based on a limited number of small comparative studies. Most of these data have being case series or small case-control data. Perhaps this is easily explained by two factors: (1) liver parenchymal transection has traditionally been addressed by “surgeon’s preference”; and (2) an explosion of new technology with innovative techniques and devices. However, our review of the current literature indicates that the use of energy devices in LLR is essential. No surgical energy device shows a superior safety profile. Current literature would support incorporation of surgical energy devices in laparoscopic liver resection and confirm their essential role as a tool for laparoscopic liver parenchymal transection. Often times energy devices are used in combination based on surgeons’ preference, limitations in device function, capacity, the nature of the underlying liver parenchyma and the extent of liver resection. Several devices used in liver tissue transection were specifically examined including: ultrasonic scalpel, CUSA or vessel sealer, water-jet dissection and staplers. CUSA is specialized for isolation of intrahepatic vasculatures. Small vessels are
2009
2007
Machado [25]
Boggi [26]
Dulucq [27]
HCC
Mets
Hepatolithiasis
Mets
HCC/CCC
Adenoma
CCC
HCC
FNH
Type of legion
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Ultrasonic scalpel
Crush clamp
Yes
Yes
CUSA
Yes
Yes
Bipolar
Yes
Yes
Yes
Vessel sealer
Yes
Yes
Monopolar sealer (saline drip)
Yes
Radiofrequency pre-coagulator
Surgical instrument used for parenchymal transection
Yes
Microwave pre-coagulator
2007
2007
Saidi [31]
Jersenius [32]
8
12
14
8
8
16
Number
Yes
Yes
Yes
Yes
Yes
Ultrasonic scalpel
Yes
CUSA
Yes
Yes
Yes
Bipolar
Yes
Yes
Vessel sealer
Surgical instrument used for parenchymal transection
CUSA cavitron ultrasonic surgical aspirator, LLR laparoscopic liver resection, RCT randomized controlled trial
1996
2007
Yao [30]
Matern [33]
2009
Chopra [29]
Case series
2009
Eirikson [28]
Comparative RCT studies
Year
Author
Study type
Table 6 Experimental studies for the techniques of parenchymal transection in laparoscopic liver resection
Yes
Diathermy
Yes
Yes
Yes
Robot
Efficacy of vessel sealer and stapler in LLR. Stapler was associated with increase in cost Bleeding and operation time are greatest with the ultrasonic dissector. Gas emboli was more frequent with vessel sealer
–
–
Efficacy of Pringle’s maneuver in Lap partial hepatectomy
Efficacy of inline bipolar in both stapler and diathermical hepatectomy
–
Yes
Efficacy of 1064 nm and 1318 nm YAG lasers in LLR
100>
–
180
200
180
210
357
565
240
Operation time (min)
–
Object
0
1200
50
Minimum
Minimum
200
66
665
TOPIC
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 Yuichiro Otsuka · Hironori Kaneko · Sean P. Cleary · Joseph F. Buell · Xiujun Cai · Go Wakabayashi Published online: 29 January 2015 © 2015 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract 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.
Y. Otsuka · H. Kaneko (✉) Deparment of Surgery, Toho University Faculty of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo 143-8541, Japan e-mail: [email protected]
The introduction of laparoscopy to liver resection started in the 1990s [1], but was limited due to technical difficulties such as hemostasis from the transection plane, controlling hemorrhage from intrahepatic vessels, and exploration of deep lesions in the liver. However, the continuing evolution of surgical technique and instrument technology used in laparoscopic liver resection has allowed the development and advancement of minimally invasive approaches to resection of hepatic lesions. Globally, the evolution of laparoscopic liver transection techniques has largely occurred based on instrument availability as well as surgeons’ and institutions’ preferences and experience with particular approaches, raising the question of what is the best device and surgical technique for parenchymal transaction? In this paper, we reviewed the literature to seek the best technique for parenchymal transection during laparoscopic liver resection (LLR), which was proposed as one of the important clinical question in the 2nd International Consensus Conference on Laparoscopic Liver Resection held on October 2014 in Morioka, Iwate prefecture, Japan.
S. P. Cleary Department of Surgery, University of Toronto, Toronto, Ontario, Canada J. F. Buell Tulane Transplant Institute, Department of Surgery, Tulane University, New Orleans, Louisiana, USA J. F. Buell School of Medicine, Loiusiana State University, New Orleans, Louisiana, USA X. Cai Department of General Surgery, Sir Run Run Shaw Hospital, Institute of Minimally Invasive Surgery of Zhejiang University, Zhejiang University, Hangzhou, China
G. Wakabayashi Department of Surgery, Iwate Medical University, Morioka, Iwate, Japan
Keywords Energy device · Laparoscopy · Liver surgery · Stapling device · Technique · Transection
Introduction
364
J Hepatobiliary Pancreat Sci (2015) 22:363–370
Method of literature review This document is based on a comprehensive review of the literature from 1991 to June 13, 2014. Publications describing parenchymal transection techniques used in LLR were found from keywords of “Laparoscopic liver resection” and “CUSA” or “Clamp crush” or “Vessel sealing system” or “Ultrasonic dissector” or “Stapler” or “ultrasonic surgery” or “Control of bleeding” or “Parenchymal transection” in the MEDLINE, Embase, PubMed and Cochrane databases. Conference abstracts were excluded. Results Among 105 selected articles identified using the above method, only 36 relevant articles were precisely reviewed. The search failed to identify any randomized controlled trials (RCT) or meta-analysis focused on the technique of liver parenchymal transection in LLR. All studies identified were reported as case-control studies, case series, case reports, experimental studies and reviews.
Comparative studies There were two retrospective unmatched comparative studies [2, 3] (Tables 1,2). Largest report from Buell et al. [2] was the only series which specified the surgical technique used in LLR using an international multi-center database. The data presented in this evaluation suggested that the parenchymal transection using stapler (Stapler hepatectomy: SH) provides several advantages: diminished blood loss, transfusion requirements and shorter operative times when compared to electrosurgical resection (ER) group. In the evaluation of oncologic outcomes, the SH group had smaller surgical margins,
but the recurrence rate and survival rate were similar. Rau et al. [3] reported the usefulness of the water-jet dissection technique for open and laparoscopic liver surgery in their study, which compared the techniques of blunt dissection, cavitron ultrasonic surgical aspirator (CUSA) and water jet. However, most of the cases were open surgery (509/550), and details of technique used in LLR were unknown.
Clinical series There were 15 clinical series [4–18] identified using the search strategy (Tables 3,4). These non-comparative series comprise the majority of current evidence in this topic. The surgical devices for liver parenchymal transection used in these studies were ultrasonic scalpel in 11, stapler in seven, vessel sealer in six, CUSA in five, diathermy in four, monopolar sealer (saline drip) in four, argon beam coagulator in four, bipolar diathermy in two, radiofrequency precoagulator in two, microwave pre-coagulator in one and water-jet in one. Crush-clamp approach was used with a vessel sealer in one publication (Fig. 1). Twelve studies used two or more devices, and six studies used three or more surgical devices during the hepatic parenchymal transection procedure varying from minor to major liver resections. All studies used some type of energy device during resection. No devicespecific complications were found in this review and no trend in postoperative complications (e.g. bile leak) was observed. Pre-coagulation of the hepatic transection plane using microwave, or radiofrequency electro-devices was suggested to be of value in controlling hemorrhage, particularly in patients with cirrhosis [5, 8, 11, 12, 14]. In terms of hepatic inflow control, eight papers reported routine or temporally use of total or hemi-Pringle’s maneuver, and others either did not use inflow occlusion or its use was not reported.
Table 1 Comparative studies for the techniques of parenchymal transection in laparoscopic liver resection Author
Year
Number of patients
LLR
OLR
Buell [2]
2013
1499
0
Rau [3]
2008
41
550
Type of legion
Comparison
HCC/Mets/Benign/ Other tumor/Living donor –
(LLR) 0/9/32/0/0
Stapler hepatctomy (SH) 764 / electrosurgical resection (ER) 735 Water-jet (WJ) 137 / CUSA 175 / blunt dissection (BD) 279
Type of hepatectomy
Pringle’s maneuver
Minor/major
Pr/ HPr/ TPr
Minormajor
No (SH) / yes (EH)
Minor
Yes (TPr) 0.13 ± 0.18 min/ cm2 (WJ) / 0.29 ± 0.67 (CUSA) /0.23 ± 0.56 (BD) P = NS
CUSA cavitron ultrasonic surgical aspirator, HA hand-assisted, HCC hepatocellular carcinoma, HPr hemi-Pringle, LLR laparoscopic liver resection, Mets metastatic liver tumor, OLR open liver resection, Pr Pringle, TPr temporary Pringle
2013
2008
Buell [2]
Rau [3]
5 (3.6%) (WJ) / 6 (3.4%) (CUSA) / 8 (2.8%) (BD) P = NS
–
Mortality
2 (0.5%) hyper carbonoxidemia, bleeding
12 (1.6%) (SH) / 92 (2.2%) (ER) P = 0.432
Conversion rate
121 (15.9%) (SH) / 92 (12.6%) (ER) P = 0.067
Total 4 (0.5%) (SH) / 16 (2.2%) (ER) P = 0.05
–
–
Ascites
8 (1.0%) (SH) / 4 (0.5%) (ER) P = 0.274
Hemorrhage
7 (5.1%) (WJ) / 11 (6.3%) (CUSA) / 15 (5.3%) (BD) P = NS
26 (3.4%) (SH) / 16 (2.2%) (ER) P = 0.153
Bile leak
Postoperative complications
4 (2.9%) (WJ) / 11 (6.3%) (CUSA) / 10 (3.5%) (BD) P = NS
–
Abscess
Liver dysfunction: 11 (8.0%) (WJ) / 22 (12.5%) (CUSA) / 27 (9.8%) (BD) P = NS
Liver failure: 7 (0.9%) (SH) / 7 (1.0%) (ER) P = 0.942
Others
2013
2009
2009
2009
2008
2008
2008
Wang [7]
Wakabayashi [8]
Somasundar [9]
Tokunaga [10]
Buell [11]
Kaneko [12]
Aldrigheti [13]
2002
O’Rourke [17]
Schmidbauer [18]
2
12
3
8
15
14
81
253
3
18
176
6
9
5
47
Patients
Yes
2/3/9/1/0
Malignant 1/Cyst 1
1/9/1/0/0
0/0/0/0/3
7/0/1/0/0
Yes
Yes
Yes
Yes
Yes
Yes
4/5/5/0/0
Yes
–
Yes
Yes
36/58/121/35/0
1/0/1/1/0
1/12/5/0/0
81/76/12/0/7
6/0/0/0
1/6/2/0/0
Yes
– 2/3/0/0/0
Ultrasonic scalpel
HCC/Mets/ Benign/Other tumor/ Living donor
Type of legion
Yes
Crush clamp
Yes
Yes
Yes
Yes
Yes
CUSA
CUSA cavitron ultrasonic surgical aspirator, HCC hepatocellular carcinoma, Mets metastatic liver tumor
2006
2003
Eguchi [16]
2007
2013
Uchiyama [6]
2006
2013
Zacharoulis [5]
Belli [15]
2014
Honda [4]
Nissen [14]
Year
Author
Yes
Yes
Bipolar
Table 3 Clinical series for the techniques of parenchymal transection in laparoscopic liver resection
Yes
Yes
Yes
Yes
Yes
Yes
Vessel sealer
Yes
Yes
Yes
Yes
Diathermy
Yes
Yes
Yes
Yes
Monopolar sealer (saline drip)
Yes
Yes
Radiofrequency pre-coagulator
Surgical instrument used for parenchymal transection
BD blunt dissection, CUSA cavitron ultrasonic surgical aspirator, ER electrosurgical resection, LLR laparoscopic liver resection, OLR open liver resection, SH stapler hepatectomy, WJ water-jet
Year
Author
Table 2 Results of comparative studies for the techniques of parenchymal transection in laparoscopic liver resection
Yes
Microwave precoagulator
Yes
Yes
Yes
(Yes)
(Yes)
Yes
Yes
(Yes)
(Yes)
Yes
Yes
(Yes)
Stapler (for large vessel)
10.57 ± 2 15.35 ml/cm (WJ) / 18.26 ± 30.13 (CUSA) / 72.72 ± 497.26 (BD) P = 0.002
100 (50–10000) (SH) / 200 (0–1500) (ER) P = 0.006
Blood loss (g)
Yes
Waterjet
Yes
Yes
Yes
Yes
Argon beam coagulator
Minor
Major
Major
Minor
Minor
Minor-major
Minor-major
Minor-major
Minor
Minor-major
Minor-major
Minor
Minor
Minor
Minor-major
Minor/ major
Yes
Yes
Yes
Yes
–
No
–
No
Yes
No
Yes
Yes
No
No
Yes
Pringle’s maneuver
Efficacy of WJ in LLR and OLR
Efficacy of stapler in LLR
Discussion point
Type of hepatectomy
Resection time 0.29 ± 2 0.67 min/cm (WJ) / 0.48 ± 0.85 (CUSA) / 0.77 ± 1.75 (BD) P = 0.043
2.6 (0.5–12.7) (SH) / 3.1 (0.5–7) (ER) P = 0.001
Operation time (min)
J Hepatobiliary Pancreat Sci (2015) 22:363–370 365
2014 2013 2013 2013 2009 2009 2009 2008 2008 2008 2007 2006 2006 2003 2002
Honda [4] Zacharoulis [5] Uchiyama [6] Wang [7] Wakabayashi [8] Somasundar [9] Tokunaga [10] Buell [11] Kaneko [12] Aldrigheti [13] Nissen [14] Belli [15] Eguchi [16] O’Rourke [17] Schmidbauer [18]
SSI surgical site infection
Year
Author
0 0 0 0 0 0 0 4 0 0 0 0 0 0 2
Mortality
2 (4.2%) 0 0 – 3 (1.7%) 0 0 6 (2.4%) 1 (1.2%) 0 0 0 0 2 (16.7%) 0
Conversion rate
5 (10.6%) 0 0 0 8 (4.5%) – 0 41 (16%) 11% 0 2 (13.3%) 0 1 (33%) 3 (25%) 0
Total 0 0 0 0 0 0 0 – – 0 0 0 0 0 0
Hemorrhage
Pleural effusion
2 (4.3%) 0 0 0 0 0 0 0 0 0 – – 0 0 – – – – 0 0 0 0 0 0 1 (33%) 0 0 1 (8.3%) 0 0
Ascites 1 (2.1%) 0 0 0 3 (1.7%) 0 0 4% – 0 0 0 0 1 (8.3%) 0
Bile leak
Postoperative complications
Table 4 Result of clinical series for the techniques of parenchymal transection in laparoscopic liver resection
SSI
0 0 0 0 0 0 0 0 2 (1.1%) 3 (1.7%) – – 0 0 – – – – 0 0 0 0 0 0 0 0 0 0 0 0
Abscess
2 (4.3%) 0 0 – 0 – 0 – – 0 2 (13.3%) 0 0 1 (8.3%) 0
Others 342 (5–795) Minimal Little–417 – 266 (1–1790) 178 ± 53 89 (30–150) 222 – 150 (100–250) – 170 (100–300) – – 50>
Blood loss (g)
366 (202–531) 75 (60–90) 187 (89–423) 232 (190–310) 238 (30–542) 114 ± 56 – 162 – 340 (290–400) – 142 (120–180) 237 (200–282) 300–420 –
Operation time (min)
366 J Hepatobiliary Pancreat Sci (2015) 22:363–370
J Hepatobiliary Pancreat Sci (2015) 22:363–370 12
Number of series used
Fig. 1 Surgical devices used for laparoscopic liver parenchymal transection in clinical series. CUSA cavitron ultrasonic surgical aspirator
367
10 8 6 4 2 0
Case reports There were nine case reports [19–27] found, from minor to major LLR (Table 5). Surgical devices used included ultrasonic scalpel in eight, stapler in four, vessel sealer in three, bipolar diathermy in two, CUSA in two, monopolar sealer in two, radiofrequency pre-coagulator in one, microwave precoagulator in one and robot in one. Stapler was also used for the division of major vasculatures in all of the major hepatectomy cases.
minimally invasive major hepatic resections. These reviews suggest that no other device is capable of effectively providing hemostasis, control of bile duct branches, and dividing parenchyma in every circumstance encountered during major hepatic resections. Additionally, laparoscopic devices which include the endoscopic stapler, pre-coagulators, CUSA, ultrasonic scalpels, and vessel sealing devices, each have a role in laparoscopic hepatic parenchymal transection.
Discussion Experimental studies In experimental animal studies, there was one randomized control study [28], four comparative non-randomized studies [29–32], and a case series [33] discussing the different techniques of laparoscopic hepatic parenchymal transection using porcine model (Table 6). The majority of these studies suggest that bipolar devices including cautery-based vessel sealing system were considered to be effective in terms of reduced blood loss.
Reviews Three review articles were found on laparoscopic parenchymal transection [34] including focused reviews on bipolar sealer [35] and stapler hepatectomy [36]. Gumb et al. [36] suggested that the stapler hepatectomy approach using multiple stapler firings has the potential disadvantage of hindering and even preventing attempts to achieve hemostasis of the raw liver surface with monopolar and bipolar electrocautery. The laparoscopic stapler device is, however, useful for transection of the main portal branches and hepatic veins during
Current consensus in best practice for techniques and devices for laparoscopic hepatic parenchymal transection is lacking. This fact is owing to the deficiency in prospective randomized trials with decisions being based on a limited number of small comparative studies. Most of these data have being case series or small case-control data. Perhaps this is easily explained by two factors: (1) liver parenchymal transection has traditionally been addressed by “surgeon’s preference”; and (2) an explosion of new technology with innovative techniques and devices. However, our review of the current literature indicates that the use of energy devices in LLR is essential. No surgical energy device shows a superior safety profile. Current literature would support incorporation of surgical energy devices in laparoscopic liver resection and confirm their essential role as a tool for laparoscopic liver parenchymal transection. Often times energy devices are used in combination based on surgeons’ preference, limitations in device function, capacity, the nature of the underlying liver parenchyma and the extent of liver resection. Several devices used in liver tissue transection were specifically examined including: ultrasonic scalpel, CUSA or vessel sealer, water-jet dissection and staplers. CUSA is specialized for isolation of intrahepatic vasculatures. Small vessels are
2009
2007
Machado [25]
Boggi [26]
Dulucq [27]
HCC
Mets
Hepatolithiasis
Mets
HCC/CCC
Adenoma
CCC
HCC
FNH
Type of legion
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Ultrasonic scalpel
Crush clamp
Yes
Yes
CUSA
Yes
Yes
Bipolar
Yes
Yes
Yes
Vessel sealer
Yes
Yes
Monopolar sealer (saline drip)
Yes
Radiofrequency pre-coagulator
Surgical instrument used for parenchymal transection
Yes
Microwave pre-coagulator
2007
2007
Saidi [31]
Jersenius [32]
8
12
14
8
8
16
Number
Yes
Yes
Yes
Yes
Yes
Ultrasonic scalpel
Yes
CUSA
Yes
Yes
Yes
Bipolar
Yes
Yes
Vessel sealer
Surgical instrument used for parenchymal transection
CUSA cavitron ultrasonic surgical aspirator, LLR laparoscopic liver resection, RCT randomized controlled trial
1996
2007
Yao [30]
Matern [33]
2009
Chopra [29]
Case series
2009
Eirikson [28]
Comparative RCT studies
Year
Author
Study type
Table 6 Experimental studies for the techniques of parenchymal transection in laparoscopic liver resection
Yes
Diathermy
Yes
Yes
Yes
Robot
Efficacy of vessel sealer and stapler in LLR. Stapler was associated with increase in cost Bleeding and operation time are greatest with the ultrasonic dissector. Gas emboli was more frequent with vessel sealer
–
–
Efficacy of Pringle’s maneuver in Lap partial hepatectomy
Efficacy of inline bipolar in both stapler and diathermical hepatectomy
–
Yes
Efficacy of 1064 nm and 1318 nm YAG lasers in LLR
100>
–
180
200
180
210
357
565
240
Operation time (min)
–
Object
0
1200
50
Minimum
Minimum
200
66
665
