Modified Liver Hanging Maneuver to Facilitate Left Hepatectomy and Caudate Lobe Resection for Hilar Bile Duct Cancer

The liver hanging maneuver (LHM) is a useful technique enabling a safe anterior approach, but it has several technical limitations for resection of the hepatic paracaval portion. We present a modified LHM that facilitates concurrent resection of the paracaval portion, a technique applicable to left liver resection for hilar bile duct (HBD) cancers. During 11 months from November 2006 to September 2007, 10 HBD cancer patients underwent left liver resection using the modified LHM. This method included initial partial transection of the caudal paracaval portion. Thus, subsequent blind tunneling over the retrohepatic inferior vena cava can become as short as 2–3 cm in length, resulting in effective prevention of short hepatic vein injury. The parenchyma transection plane was tailored to remove most of the paracaval portion. This modified LHM technique was safely and effectively applied to 10 consecutive patients, requiring a shorter time than conventional dissection method for caudate lobe dissection. No significant bleeding occurred during retrohepatic tunneling. The final parenchymal transection plane after left liver resection using modified LHM was the same as that following the conventional surgical technique for HBD cancers. In conclusion, we think that this modified LHM is an effective, technically simple procedure for resection of the left liver and caudate lobe in HBD patients.     

Bloodless liver resection using radiofrequency energy

BACKGROUND: Liver surgery carries the risk of intraoperative bleeding. In order to avoid bleeding, transection of the liver can be performed after coagulating the parenchyma by using monoplolar or bipolar radiofrequency energy. METHODS: 236 consecutive patients underwent liver resection with the radiofrequency-assisted technique using either a monopolar or a bipolar device. Data were collected prospectively to assess the outcome including, intraoperative blood loss, blood transfusion requirement, morbidity and mortality rates. RESULTS: There were 41 major hepatectomies and 195 minor resections. Overall mean intraoperative blood loss was 157 +/- 240 ml, while mean blood loss during liver transection was 90 +/- 105 ml. 10 patients (4%) received blood transfusion. 50 patients (21%) developed postoperative complications including 5 bile leaks (2%). The mortality rate was 2.1%. No patient was reoperated for postoperative haemorrhage or bile leak. The mean postoperative stay was 11 +/- 10 days. CONCLUSION: The radiofrequency-assisted liver resection technique offers hepatobiliary surgeons an additional method for performing liver resections with minimal blood loss, low transfusion requirement, and low morbidity and mortality rates.     

Early experience employing a linear hepatic parenchyma coagulation device

Background. In recent years, hepatic resection for primary and metastatic disease has been facilitated by improved anesthetic and surgical techniques, as well as by the application of new technologies. Historically, the major complications associated with hepatic resection have been postoperative bleeding, bile leak, and liver failure. Resection techniques and devices that minimize hemorrhage and bile leak, and enable the preservation of functional hepatic parenchyma, have been useful in the surgical management of liver tumors. Methods. Herein, the use of a radiofrequency powered device for the pretransection coagulation of hepatic tissue that simultaneously seals blood vessels and bile ducts 3 mm in diameter or smaller is described. Results. Early results from our single-center experience with the use of this linear radiofrequency device are reported. Seven patients underwent liver resection for either hepatocellular carcinoma or colorectal cancer metastases. There were no postoperative bile leaks, hemorrhage, or hepatic insufficiency. No transfusions were required, and the mean estimated blood loss for the parenchymal transection phase was less than 165 cc. Conclusions. The linear radiofrequency device is expedient for the pretransection coagulation of hepatic tissue and, thus, facilitates liver resection. Received: March 31, 2002 / Accepted: November 25, 2002 RID="*" ID="*" Offprint requests to: N. Joseph Espat Acknowledgments. Dr. Espat has received an unrestricted educational grant from TissueLink, Inc. (Dover, MA, USA).     

循肝静脉路径肝切除解剖学基础和临床价值

循肝静脉路径肝切除是解剖性肝切除的基本要求,已逐渐被认可并广泛应用于开腹和腹腔镜解剖性肝切除手术中。其解剖学基础是肝静脉走行于肝段之间的解剖界面内,是肝段之间的确切分界平面,且肝静脉走行与目标肝段缺血后形成的分界平面几乎重叠。临床价值主要是引导正确的肝实质离断平面,彻底切除缺少流入道和（或）流出道的无效肝组织,减少术中出血,降低术后并发症的发生率。在临床上,循肝静脉路径肝切除主要应用于肝细胞癌的外科治疗,能同时清除肿瘤及经门静脉播散的肝内微转移病灶,减少术后复发,提高术后存活率;也可应用于肝胆管结石和肝内胆管扩张症这类以肝段分布为主要特征的肝胆管疾病的外科治疗,以达到彻底去除目标病灶的病理学要求与最大化保留剩余功能性肝脏的生理学原则之间的统一。     

Right Hepatic Lobectomy Using the Staple Technique in 101 Patients

Background Application of linear stapling devices for extrahepatic vascular control in liver surgery has been well-established. However, the technique for use of stapling devices in hepatic parenchymal transection is not well defined. Purpose To describe the safety and efficacy of our technique for use of vascular stapling devices in hepatic parenchymal transection during open right hepatic lobectomy is the purpose of this study. Methodology We reviewed our experience with 101 consecutive open right hepatic lobectomies performed by a single surgeon between January 2003 and July 2006, in which vascular staplers were utilized for the parenchymal transection phase. Results Of the 101 patients who underwent resection, 53 (52%) were female. The mean age was 58 years. Malignant disease was the indication for resection in the majority of patients (88%). Of those with cancer, 78% (69 of 89) had metastatic colorectal cancer, 6% (5 of 89) had metastatic neuroendocrine tumor, 4% (4 of 89) had hepatocellular carcinoma, 4% (4 of 89) had cholangiocarcinoma, and the remaining 8% were other metastatic cancers. Twelve patients (12%) underwent resection for hepatic adenoma or symptomatic benign disease (FNH or hemangioma). Forty-eight patients (48%) underwent a major ancillary procedure at the time of hepatic resection. Thirty-nine patients (39%) had a nonanatomic wedge resection of a left lobe lesion, 27 patients (27%) had one or more lesions treated with radiofrequency ablation (RFA), and 6 patients (6%) were treated with a synchronous bowel resection. The median total operative time was 336 min (range 155–620 min). A Pringle maneuver for temporary vascular inflow occlusion was utilized in all cases, with a median time of 9 min (range 4–17 min). Ten patients (10%) required blood transfusion during surgery or in the postoperative period. The maximum transfusion was 2 U of packed red blood cells (PRBC) in seven patients and 1 U of PRBC in three patients. The mean nadir postoperative hematocrit was 28.2. All patients with malignant disease had tumor-free margins at the completion of the procedure. The average hospital length of stay was 6.0 days. One patient (1%) developed a clinically significant bile leak requiring a postoperative endoscopic retrograde cholangiography (ERCP). No patient required reoperation. The 30 and 60-day postoperative survival was 100%. Conclusion These findings indicate that application of vascular stapling devices for parenchymal transection in major hepatic resection is a safe technique, with low transfusion requirements and minimal postoperative bile leak. The technique allows for rapid transection of the entire right hepatic lobe in under 10 min. Short video clips of the technique will be demonstrated. Presented at the 2007 American Hepato–Pancreato–Biliary Association, Las Vegas, Nevada, April 19–22, 2007 (oral presentation/video presentation).     

Liver resection without hilus preparation and with selective intrahepatic hilus stapling for benign tumors and liver metastasis

Background Nowadays, liver resection is a routine operative procedure in surgical centers, and strategies must be aimed at avoiding additional risk factors. Extrahepatic isolation of portal vein, hepatic artery and hepatic duct, as well as lymphadenectomy of the liver hilum are generally accepted steps of liver resection, even for metastatic and benign indications. Our primary aim was to analyze the feasibility, blood loss, blood transfusion requirements, incidence of complications, and outcome using the approach for intrahepatic devascularization leaving the extrahepatic hilus untouched. Materials and methods Thirty-eight consecutive patients with resection for metastases and benign liver tumors were selected. After hilar examination, the extrahepatic structures remain intact, and during parenchyma dissection, the whole right or left or the appropriate bi-segmental pedicle is isolated intrahepatically and then transected using a stapler device. Results The used technique was feasible in all cases, and no intra- or postoperative surgical complications were observed. To date, no tumor recurrence was found in the hilum during the follow-up period. Conclusion The intrahepatic pedicle stapling technique appears to be feasible and safe in liver resection. Hilar dissection can, thus, be avoided in liver metastasis and benign liver tumors.     

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??Anatomical basis and clinical value of liver parenchyma transection guided by the hepatic vein ZHENG Shu-guo. Institute of Hepatobiliary Surgery??the First Hospital Affiliated to Army Medical University(Southwest Hospital)??Chongqing 400038??China
Abstract Liver parenchyma transection guided by the hepatic vein is the basic requirement of anatomical hepatectomy. The technique has been gradually accepted and widely used in open and laparoscopic anatomical hepatectomy. As the exact dividing plane between the hepatic segments??the hepatic vein is almost overlapping with the ischemia demarcation formed by occluding the inflow of the target hepatic segment??and these are the anatomical bases of this technique. The clinical value of the technique is mainly to guide the accurate transaction plane of the liver parenchyma??and eliminate the ineffective liver tissue lacking of inflow and / or outflow??reduce intraoperative bleeding and the incidence ofpostoperative complications. In clinical??the technique is mainly applied to liver resection for hepatocellular carcinoma??in which it can remove the tumor and intrahepatic micrometastases disseminating through portal vein simultaneously??reduce postoperative recurrence and improve survival rate. It can also be used in the surgical treatment of hepatolithiasis and intrahepatic bile duct dilatation which were characterized by introhepatic segment distribution of the lesions ??and to achieve a complete removal of the target lesion and maximizes the remaining functional liver.     

Laparoscopic left lateral hepatic lobectomy: a safer and faster technique

Background/Purpose Laparoscopy for liver resection is highly specialized field because laparoscopic liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. At present, a limited number of laparoscopic anatomical left lobectomies have been reported in the literature, but we believe that the use of stapling devices has made this technique safer and faster. Methods From January 2000 to May 2005, eight patients (five men, three women; mean age, 60.5 years) underwent laparoscopic anatomical left lobectomy at our department. Seven patients presented with hepatocellular carcinoma and cirrhosis, while one patient had a large symptomatic angioma. The average size of the lesions was 4.18 cm (range, 3.6–7.1 cm); all the lesions were localized in the anatomical left lobe (segments II–III). Transection of the liver parenchyma, together with sectioning of the vascular pedicle for segment II and III and of the left hepatic vein, was obtained by the use of stapling devices. Results The mean operative time was 142 min (range, 120–180 min). There were no intraoperative or postoperative complications, and blood transfusions were not required. The mean postoperative hospital stay was 5.75 days. Conclusions The key points of the technique are: late mobilization of the liver; no transection of the round ligament; no surrounding or taping of the portal pedicles or of the left hepatic vein; and the use of three consecutive linear staplers, turned to the left for transecting the liver parenchyma and vascular pedicle together. This technique, in our opinion, should be considered a new good option for patients with isolated lesions of the left lateral segments, but it must be performed by surgeons trained in both liver and advanced laparoscopic surgery.     

Perioperative outcome of laparoscopic left lateral liver resection is improved by using staple line reinforcement technique: A case report

Current laparoscopic stapling technology still cannot prevent bile leakage (<55%) along the resection margin. A new staple line reinforcement technique was used in the present case. This technique incorporates an absorbable polymer membrane into the stapler system, such that it buttresses the transected solid organ. The objectives of this novel procedure are to decrease hemorrhage at the staple line and to prevent bile duct leakage after liver resection. A 47-year-old man followed for status post biliopancreatic diversion with duodenal switch presented with epigastric pain. On imaging, he was found to have a lesion in segment 2–3 of the left lobe of the liver, which measured at least 3 cm in diameter. He was admitted to the hospital to undergo a laparoscopic left lateral liver resection. This procedure involved laparoscopic ultrasonography of the liver and transection of the left liver lobe with endoscopic linear staplers. The staple height of 3.5, 60 mm long, reinforced with an absorbable polymer membrane was used for liver transection to catch the portal branches. This required multiple firings in the liver parenchyma and additional division of some tissue using the Harmonic scalpel. The larger branch in the middle of segment 2–3 and the left hepatic vein were both transected with the novel staple line reinforcement technique. Bleeding or any bile leakage in this area could not be visualized. No drains were left. The patient’s postoperative course was uncomplicated, and he was discharged on postoperative day 3. Pathology results showed a cavernous hemangioma of 4.5 cm in diameter. Staple line reinforcement with the absorbable polymer membrane has the potential to decrease staple line hemorrhage and bile leakage.     

A suitable animal model for laparoscopic hepatic resection training

Background There is a growing interest in using laparoscopy for hepatic resection. However, structured training is lacking in part because of the lack of an ideal animal training model. We sought to identify an animal model whose liver anatomy significantly resembled that of the human liver and to assess the feasibility of learning laparoscopic hepatic inflow and outflow dissection and parenchyma transection on this model. Methods The inflow and outflow structures of the sheep liver were demonstrated via surgical dissection and contrast studies. Laparoscopic left major hepatic resections were performed. Results The portal hepatis of all 12 sheep (8 for anatomic study and 4 for laparoscopic hepatic resection) resembled that of human livers. The portal vein (PV) was located posteriorly; the common hepatic artery (CHA) and the common bile duct (CBD) were located anterior medially and anterior laterally with respect to the portal hepatis. The main PV bifurcated into a short right and a long left PV. The extrahepatic right PV then bifurcated into right posterior and anterior sectoral PV. The CBD and CHA bifurcated into left and right systems. The cystic duct originated from the right hepatic duct. The cystic artery originated from the right HA in 11/12 animals. The left hepatic vein drained directly into the inferior vena cava (IVC). The middle and the right hepatic veins formed a short common channel before entering the IVC. Multiple venous tributaries drained directly into IVC. Familiarity with sheep liver anatomy allowed laparoscopic left hepatic lobe (left medial and lateral segments) resection to be performed with accuracy and preservation of the middle hepatic vein. Conclusions The surgical anatomy of sheep liver resembled that of human liver. Laparoscopic major hepatic resection can be performed with accuracy using this information. Sheep is therefore an ideal animal model for advanced surgical training in laparoscopic hepatic resection.     

Perioperative outcome of laparoscopic left lateral liver resection is improved by using a bioabsorbable staple line reinforcement material in a porcine model

Hypothesis Laparoscopic liver surgery is significantly limited by the technical difficulty encountered during transection of substantial liver parenchyma, with intraoperative bleeding and bile leaks. This study tested whether the use of a bioabsorble staple line reinforcement material would improve outcome during stapled laparoscopic left lateral liver resection in a porcine model. Study design A total of 20 female pigs underwent stapled laparoscopic left lateral liver resection. In group A (n = 10), the stapling devices were buttressed with a bioabsorbable staple line reinforcement material. In group B (n = 10), standard laparoscopic staplers were used. Operative data and perioperative complications were recorded. Necropsy studies and histopathological analysis were performed at 6 weeks. Data were compared between groups with the Student’s t-test or the chi-square test. Results Operating time was similar in the two groups (64 ± 11 min in group A versus 68 ± 9 min in group B, p = ns). Intraoperative blood loss was significantly higher in group B (185 ± 9 mL versus 25 ± 5 mL, p < 0.05). There was no mortality. There was no morbidity in the 6-week follow-up period; however, two animals in group B had subphrenic bilomas (20%) at necropsy. At necropsy, methylene blue injection via the main bile duct revealed leakage from the biliary tree in four animals in group B and none in group A (p < 0.05). Histopathological examination of the resection site revealed minor abnormalities in group A while animals in group B demonstrated marked fibrotic changes and damaged vascular and biliary endothelium. Conclusion Use of a bioabsorbable staple line reinforcement material reduces intraoperative bleeding and perioperative bile leaks during stapled laparoscopic left lateral liver resection in a porcine model. This study was funded in part by a research grant from the Minimally Invasive Surgery Center of Mount Sinai School of Medicine and the Weill College of Medicine of Cornell University, which are supported by Karl Storz Endoscopy of America, Tyco Health and W.L. Gore.     

Monopolar Floating Ball Versus Bipolar Forceps for Hepatic Resection: A Prospective Randomized Clinical Trial

Background  Hepatic transection by Pean-clasia is the mainstream technique that can be used with different coagulators. Monopolar floating ball (MFB) is proposed for liver transection. Whether its value for liver transection is unclear, its efficiency as a coagulator only seems high. We compared in a prospective randomized study the standard Pean-clasia with bipolar forceps (BF) versus Pean-clasia with MFB in patients undergoing hepatic resection. Methods  Seventy-six patients scheduled for hepatectomy were randomized in two groups, according to the coagulator device: group A (MFB, n = 38) and group B (BF, n = 38). The two groups were homogeneous in terms of tumor presentation and background liver features. Blood loss, blood transfusions, transection time, number of ligatures, drain discharge, drain bilirubin levels at third, fifth, and seventh postoperative day, and postoperative morbidity and mortality were prospectively evaluated. Results  No significant differences between groups A and B were seen in terms of blood transfusions (11.5% versus 16.5%; p = 0.450), blood loss/cm² (mean 7.2 versus 7.6 ml; p = 0.450), transection time/cm² (mean 2.1 versus 2.3; p = 0.070), number of ligatures/cm² (mean 0.7 versus 0.7; p = 1), drain discharge (mean 55 versus 66.7 ml; p = 0.451), and drain bilirubin levels (mean 1.9 versus 2.1 mg/dl; p = 0.664). No mortality or major morbidity was recorded in both groups. Conclusions  This study showed that association of Pean-clasia with MFB was safe and minimized the blood loss during hepatic resection. However, MFB did not offer significant benefits over BF, while its cost is not negligible.     

Comparison of Two Methods of Selective Hepatic Vascular Exclusion for Liver Resection Involving the Roots of the Hepatic Veins

Background  Selective hepatic vascular exclusion (SHVE) is an effective hepatic vascular exclusion in controlling both inflow and outflow without interruption of caval flow, as it combines Pringle maneuver with extrahepatic selective occlusion of hepatic veins. But SHVE has not been widely used due to difficulty in extrahepatic dissection of hepatic veins. When the tumor is very close to the roots of the hepatic veins, dissecting the posterior wall of the hepatic vein may lead to rupture and massive bleeding of the hepatic vein. With our experience, clamping hepatic veins with Satinsky clamps is a safer and easier occlusion method by which the posterior wall of the hepatic veins does not need to be separated and encircled. In this report, we compared the results of selective hepatic vascular occlusion with tourniquet and Satinsky clamp for major liver resection involving the roots of the hepatic veins. Methods  Between January 2003 to June 2006, 180 patients who underwent major liver resection with SHVE were divided into two groups according to different methods of hepatic vascular occlusion: occlusion with tourniquet (tourniquet group, n = 95) and occlusion with Satinsky clamp (Satinsky clamp group, n = 85). In the tourniquet group, the hepatic veins were encircled and occluded with tourniquet. In the Satinsky clamp group, the hepatic veins were not encircled and clamped directly by Satinsky clamp. Results  Intraoperative and postoperative consequences of the patients were analyzed. The dissecting time for each hepatic vein was significantly shorter in the Satinsky group (6.2 ± 2.4 min vs 18.3 ± 6.2 min) than in the tourniquet group. In the tourniquet group, five hepatic veins (one right hepatic vein and four common trunk of left-middle hepatic veins) could not be dissected and encircled because the tumors involved the cava hepatic junction, and another common trunk of the left-middle hepatic vein had a small rupture during the dissection. These six patients then received successful occlusion with Satinsky clamp. There was no difference between the two groups regarding the operation duration, ischemia time, intraoperative blood loss, and postoperative complication rate. Conclusion  Both methods of the hepatic vein occlusion have the same effect on controlling hepatic vein bleeding, but occlusion with Satinsky clamp is safer, easier, and consumes less time in dissecting. Li Ai-Jun And Pan Ze-Ya contributed equally to this work.     

Laparoscopic intrahepatic Glissonian approach for right hepatectomy is safe,simple, and reproducible

Background Hemorrhage from portal and hepatic veins is a major concern with laparoscopic right hepatectomy (LRH). The standard hilar approach is dissection of the portal pedicle outside the liver parenchyma with separate transection of the right hepatic artery, portal vein, and bile duct [1–5, 7, 9]. Variations in anatomy can hamper vascular and biliary control. The intrahepatic Glissonian access avoids these risks by en masse ligation of the portal structures without dissection for each separately [6, 8]. This technique was performed laparoscopically for the last 2 among 10 LRHs, and the results are presented. Methods Total LRH was performed under ultrasound assistance for two patients with malignancy. After lymph node sampling at the hepatoduodenal ligament, dissection was started with the incision of liver parenchyma posterior and anterior to the hilum, then continued outside the portal pedicle bifurcation toward the right and left sheaths. An endoscopic vascular stapling device was placed to transect the right portal pedicle en masse under direct laparoscopic vision and cholangiography guidance. Parenchymal transection and vascular control of the right hepatic vein was accomplished with harmonic scalpel, cavitron ultrasonic aspirator, bipolar diathermy, clips, and endoscopic stapling device, as appropriate. No Pringle’s maneuver was used. The specimen was extracted through a suprapubic incision using an endobag. Results The operative times for the two patients were, respectively, 180 and 240 min. No blood loss occurred during the intrahepatic Glissonian dissection. Intraoperative blood loss (from the right hepatic vein) of 700 and 800 ml, respectively, was controlled laparoscopically. The postoperative periods were uneventful, with discharge, respectively, on days 6 and 7. The surgical resection margins were free of tumor. Conclusions The laparoscopic intrahepatic Glissonian approach used for right hepatectomy is safe, simple, and reproducible. It facilitates the hepatic hilar dissection with minimal operative risk. Further implementation of this technique is encouraged to improve the outcome for patients undergoing laparoscopic liver resection. Electronic supplementary material The online version of this article (doi: ) contains supplementary material, which is available to authorized users     

Right Portal Vein Ligation is as Efficient as Portal Vein Embolization to Induce Hypertrophy of the Left Liver Remnant

Background Aim of this retrospective study was to compare induction of left liver hypertrophy after right portal vein ligation (PVL) and right portal vein embolization (PVE) before right hepatectomy for liver metastases. Materials and Methods Between 1998 and 2005, 18 patients underwent a PVE, whereas 17 patients underwent a PVL during a first stage laparotomy. Results There was no complication related to PVE or PVL. After a similar interval time (7 ± 3 vs 8 ± 3 weeks), the increase of the left liver volume was similar between the two groups (35 ± 38 vs 38 ± 26%). After PVE and PVL, right hepatectomy was performed in 12 and 14 patients, respectively. Technical difficulties during the right hepatectomy were similar according to duration of procedure (6.4 ± 1 vs 6.7 ± 1 h, p = 0.7) and transfusion rates (33 vs 28%, p = 0.7). Mortality was nil in both groups, and morbidity rates were respectively 58% for the PVE group and 36% for the PVL group (p = 0.6). Conclusion Right PVL and PVE result in a comparable hypertrophy of the left liver. During the first laparotomy of a two-step liver resection, PVL can be efficiently and safely performed.     

Safety of Conservative Management of Bile Leakage after Hepatectomy with Biliary Reconstruction

Background  The risks associated with the conservative management of bile leakage after hepatectomy and associated cholangiojejunostomy are not well defined. Aim  The aim of this study was to evaluate incidence and severity of complications associated with bile leakages after liver resection with biliary reconstruction. Patients and methods  Clinical data from 1,034 consecutive patients who underwent liver resection were prospectively collected and reviewed. Bile leakage occurred in 25 out of 119 patients (21.0%) who underwent hepatectomy with biliary reconstruction (group 1) and in 42 out of 915 patients (4.6%) without biliary anastomosis (group 2; p < 0.001). Serum albumin and bilirubin levels were the only preoperative factors significantly different between the two groups. Lymphadenectomy was more frequently performed in patients of group 1 (88% vs 16.7, p < 0.001). Results  Mortality rates were similar in the two groups (8% in group 1 vs 2.3% in group 2, p = 0.28). One or more postoperative complications occurred in 68% in group 1 and in 40.4% in group 2 (p = 0.02). The incidence of sepsis (32% vs 7.1%, p = 0.01), intra-abdominal abscess (12% vs 0, p = 0.04), and abdominal bleeding (28% vs 0, p = 0.006) was significantly higher in group 1. Bile leaks spontaneously healed in 52% of patients in group 1 vs 76.2% in group 2 (p = 0.04). In order to identify independent predictive factors for abdominal bleeding, we compared clinical data of patients with abdominal bleeding (seven patients) and without abdominal bleeding (18 patients) after hepatectomy and biliary reconstruction. Stepwise logistic regression analysis identified the number of reconstructed bile ducts as an independent predictive factor of abdominal bleeding (p = 0.038). Conclusions  Conservative management of bile leakage after liver resection with biliary reconstruction is associated with higher rates of morbidity. The most severe complication is abdominal bleeding, which is related to the number of bile ducts requiring reconstruction.     

经腹腔镜左肝切除五例

目的 探讨腹腔镜解剖性左肝切除手术的临床经验。方法 经临床筛选病灶位于左半肝的病例5例，其中原发性肝癌3例、肝囊肿伴感染1例、肝血管瘤1例。应用电刀、超声刀和腔内直线形切割缝合器等多种断肝方法，采用钛夹夹闭、医用生物蛋白胶粘封等肝断面处理方法，在全气腹条件下经腹腔镜行左半肝切除2例，左外叶切除2例，肝方叶切除1例。结果 5例均在腹腔镜下完成肝切除手术，对各肝段的脉管先进行解剖分离，然后进行处理是手术控制出血的关键。使用垃圾袋将标本取出。术中未出现不能控制的并发症，腹腔引流管放置时间2～4d。术后未发生胆漏和出血等并发症，恢复顺利，术后平均住院7d，术后恢复时间较常规开腹方法肝切除病人明显缩短。结论 对位于左半肝的病灶，采用多种方法相结合行腹腔镜解剖性左肝切除手术是安全可行的手术方式，特别是创伤小的优点给伴有严重肝硬化而不能耐受开腹手术者提供了切除肿瘤的新途径。     

Hepatic Surgery Using the Ligasure Vessel Sealing System

Blood loss, a well-known risk factor for morbidity and mortality during liver resection, occurs during parenchymal transection, so many approaches and devices have been developed to limit bleeding. Surgical technique is an important factor in preventing intraoperative and postoperative complications. The aim of the present study was to determine whether the bipolar vessel sealing device allows a safe and careful liver transection, achieving a satisfactory hemostasis thus reducing blood loss and related complications.A total of 30 consecutive patients (18 male, 12 female with a mean age of 63 years) underwent major and minor hepatic resection in which the bipolar vessel sealing device was used without routine inflow occlusion. A crush technique followed by energy application was used to perform the parenchymal transection. No other devices were applied to achieve hemostasis. The bipolar vessel sealing device was effective in 27 cases of hepatic resection. It failed to achieve hemostasis in three patients, all of whom had a cirrhotic liver. Median blood loss was 250 ml (range: 100-1600 ml), and intraoperative blood transfusions were required in five patients (17%). Mean operative time was 200 minutes (range: 140-360 minutes). There was no clinical evidence of postoperative hemorrhage, bile leak, or intraabdorninal abscess.The postoperative complication rate was 17%. The bipolar vessel sealing device is a useful tool in standard liver resection in patients with a normal liver parenchyma, but its use should be avoided in cirrhotic livers.     

Making liver transection even safer: a novel use of microwave technology

Hepatic surgery has evolved significantly in the past decade. The current article describes the largest series of patients in United States undergoing liver resective therapy with the use of microwave technology for liver precoagulation. Glisson's capsule was incised after securing inflow and outflow control. Two antennae, 2 cm apart, connected to a 915-MHz generator, were inserted 5 cm into liver parenchyma at a 130° angle. Once the parenchyma was firm and changed its color to gray, the antennae were advanced along the line of transection. The parenchyma was divided with electrocautery. Intra- and postoperative data were analyzed. Thirty-five patients (24 men) underwent liver resections. Diseases treated were colorectal metastases (n = 9), hepatic adenoma (n = 3), gallbladder cancer (n = 3), hepatocellular carcinoma (n = 4), neuroendocrine tumor (n = 2), cholangiocarcinoma (n = 5), hemangioma (n = 2), focal nodular hyperplasia (n = 2), metastatic gastrointestinal stromal tumor (n = 1), hydatid cyst (n = 1), hepatoid carcinoma (n = 1), hepatolithiasis (n = 1), and suspected metastatic breast cancer (n = 1). Resections done were right hepatectomy (n = 19), segmental resection (n = 5), left hepatectomy (n = 4), extended right hepatectomy (n = 4), Segment IVb and Segment V resections during radical cholecystectomy (n = 2), and left lateral sectionectomy (n = 1). Median operative time for major resection was 188 and 251 minutes for minor resection. There was one postoperative mortality. Bile leak needing stenting occurred in one patient. Median blood loss for major resection was 500 mL and 265 mL for minor resection. Intraoperative transfusion was required in nine major and one minor resections. Other complications were ileus in four, deep vein thrombosis in two, intra-abdominal abscess in one, and cardiac events in two patients. Liver precoagulation with microwave technology is a novel and efficient technique with minimal morbidity and mortality for liver transection.     

腹腔镜肝切除术治疗肝癌的关键技术与实践

近年来腹腔镜肝切除术治疗肝癌的报道例数迅速增加。越来越多的研究证实腹腔镜肝切除术治疗肝癌具有创伤小、恢复快、并发症少等优点,其手术时间、手术切缘及远期疗效与开腹手术相当。本文结合我们实践体会,介绍腹腔镜肝切除术治疗肝癌的关键技术。选择适宜患者、合理布孔、精确定位肿瘤、制定恰当切线、选择性血流阻断、精细的肝实质离断、积极预防出血及严格的无瘤原则是腹腔镜肝切除术治疗肝癌成功的关键。