Modified conventional clamp-crushing technique in liver parenchymal transection

Feng Xia, Wan-Yee Lau, Kuan-Sheng Ma and Ping Bie

Chongqing, China

Modified conventional clamp-crushing technique in liver parenchymal transection

Feng Xia, Wan-Yee Lau, Kuan-Sheng Ma and Ping Bie

Chongqing, China

Significant intraoperative bleeding and injuries to vital structures in the liver remnant can occur during liver parenchymal transection using the conventional clampcrushing technique. We performed liver resection on 242 patients using a mosquito clamp-crushing technique combined with a self-assembled saline-linked diathermy for liver parenchymal transection. The mean blood loss was 215 mL (range 20-1100). There was no damage to the vital structures in the liver remnant. The mean liver transection time was 53 minutes (range 15-125). Our technique has the advantages of reducing blood loss, exposing vessles clearly and being simple, cheap and efficacious.

hepatectomy; hepatocellular carcinoma; liver neoplasm

Introduction

Liver resection has been regularly performed in many centers around the world since the introduction of the clamp-crushing technique in the 1970s.[1-3]In recent years, various novel devices for liver parenchymal transection have been developed, including the cavitron ultrasonic surgical aspirator (CUSA), water-jet dissector, ultrasonic dissector, LigaSure vessel sealing system, heat coagulation dissecting sealer, and vascular stapler.[4-6]There are two recently published meta-analysis and systematic review on the techniques for liver parenchymal transaction.[7,8]Both came to the same conclusion that the clamp-crushing technique is the method of choice in liver parenchymal transection as it does not require any special equipment, whereas the newer techniques do not offer any significant benefit in decreasing intraoperative blood loss or transfusion requirement. Although the mortality rates of patients who receive liver resection are substantially reduced within the last two decades, strategies to reduce complications are still urgently required as the morbidity after liver resection remains high (30%-40%). Significant intraoperative bleeding, together with injuries to vital structures in the liver remnant, can occur during liver parenchymal transection using the clamp-crushing technique.[3-6]We designed a simple and inexpensive technique to modify the conventional clamp-crushing technique using a mosquito clamp-crushing technique combined with a self-assembled saline-linked diathermy for liver parenchymal transection. Its easy-availability and advantages are described.

Surgical technique

The surgery was done with a right subcostal incision or midline incision with a right horizontal extension as we have previously reported.[9,10]The liver was fully mobilized after transection of its ligaments. Intraoperative ultrasonography was routinely performed to delineate the extent of tumor involvement, to detect tumor nodules in the contralateral lobe and invasion of the tumor into major blood vessels, and to plan and mark the plane of parenchymal transection. Liver hilar dissection was then performed and the right or left hepatic artery and portal vein were controlled for anatomical hemihepatectomy. The lobe of the liver to be resected together with the tumor was then completely mobilized. The small caval venous branches running into the posterior aspects of the liver were individually ligated and divided if necessary. A low central venous pressure (1-5 cmH2O) approach was used in all patients. An intermittent Pringle's maneuver consisting of a5-minute unclamp after 15-minute clampping was routinely used. Inflow occlusion was achieved using a 4 mm tape as a tourniquet around the portal triad.

Liver transection was carried out using parenchymal crushing with a mosquito clamp, and the small jaws of this clamp avoided avulsion of vessels. A self-assembled saline-linked diathermy was used to coagulate the small vessels of less than 3 mm in diameter. The diathermy which was attached to a transfusion tube connected to a saline solution bag (Fig. 1) was connected to an electrosurgical generator (Force FX-8C; Valleylab, Tyco Healthcare, Boulder, CO.), with an output power set at 70 W. The energy was focused at the tip and conveyed into the liver tissues by a low flow of saline solution (one drop per second) through the tube to the tip of the diathermy to induce thermocoagulation of the liver tissues. The continuous flow of saline cooled the tissues to a temperature below 100℃, thus preventing charring and escar formation. Small vessels (<3 mm in diameter) were simply sealed using the self-assembled salinelinked diathermy and divided (Fig. 2). Larger vessels were ligated or sutured. The surgeon used the mosquito clamp to gently dissect out the vessels, separating the jaws of the clamp for less than 1 cm, while the assistant sealed off the small vessels with the salinelinked diathermy. Liver parenchymal transection was conducted slowly, usually at a rate of 0.5 cm2per minute. Any bleeding site was coagulated. As the structures along the transection plane were exposed clearly, they could be dealt with easily. After liver parenchymal transection had been completed, the surface of the remnant liver was inspected and any oozing point was coagulated using the saline-linked diathermy (Fig. 3).

From January 2008 to May 2011, we carried out liver resections on 242 patients. There were 189 men and 53 women, and their average age was 41.6 years (range 17-78). Two hundred and six patients suffered from hepatocellular carcinoma, with a mean tumor size of 8.5 cm in diameter (range 3.6-21). Twenty-one patients had liver metastasis with a mean tumor size of 6.8 cm in diameter (range 2.4-16). The other patients had benign liver tumors. The mean blood loss was 215 mL (range 20-1100). There was no injury to the major structures in the liver remnant. The mean liver transection time was 53 minutes (range 15-125). One patient died from liver failure because of a small-sized remnant. Complications developed in 21 (8.7%) of 242 patients, with biliary leak which resolved with percutaneous drainage in 6 patients, wound infection in 5 patients, pleural effusion in 10 patients, and intra-abdominal abscess which resolved with percutaneous drainage in 4 patients. The mean postoperative hospital stay was 11 days (range 10-38).

Fig. 1. A self-assembled saline mediated diathermy. The diathermy is attached to a commonly used transfusion tube which is connected to a saline solution bag.

Fig. 2. A mosquito clamp used to crush the liver parenchyma to expose the vessels (A). A self-assembled saline-linked diathermy used to coagulate any small vessels less than 3 mm (B). Bigger vessels need to be ligated.

Fig. 3. The raw liver surface after liver transection using a selfassembled saline-linked diathermy.

Discussion

The clamp-crushing technique has been shown to be the most cost-effective method for hepatectomy by two recent meta-analyseis and systematic review.[7,8]The technique generally involves the use of a Kelly or a Pean clamp which crushes the softer liver parenchyma to expose the tougher blood vessels and bile ducts. These structures are then divided after tying or clipping. Some surgeons even use the clamp-and-cut technique to complete the liver transection in 10 to 15 minutes, before they tie the vessels and remove the clamps.[11-16]The pitfalls of the conventional clamp-crushing technique include excessive bleeding and accidentally injury to major structures. Excessive bleeding occurs when vessels are avulsed by a large clamp which crushes through the liver parenchyma, especially for veins with thin walls. The major structures in the liver may be difficult to protect when a large clamp is used, especially during massive bleeding. Our mosquito clamp-crushing technique combined with a self-assembled saline-linked diathermy for liver parenchymal transection is an innovative technique which modifies the conventional clamp-crushing technique. A mosquito clamp is smaller than a Kelly or a Pean clamp, and its jaws can be opened less widely. This limits the volume of liver parenchyma which can be crushed to avoid injury to a major structure. We usually open the jaws of the mosquito clamp to approximately 0.5 to 1.0 cm. The liver parenchyma is crushed little by little to expose the tougher vessels and bile ducts. Very little bleeding is encountered as there is very little avulsion of vessels. The self-assembled saline-linked diathermy comprises a commonly used diathermy and a transfusion tube. This idea originates from the TissueLink, an instrument designed for liver parenchymal transaction,[17]which is much more costly. Our saline-linked diathermy is very easy to assemble and it is extremely cost-effective. This simple device shares the same advantages of the TissueLink to seal the exposed small-vessels <3 mm while at the same time it prevents charring and escar formation by cooling the diathermy tip with a flow of saline. We tie or suture any vessels >3 mm in size. The intrahepatic vessels and bile duct can be exposed clearly for the clear operative field without bleeding.

The clamp-crushing technique for liver transection has been used in many centers for several decades because of its easy-availability and simplicity. Patrlj et al[11]recently reported a "postcoagulation technique" for liver parenchymal transection by the combined use of blunt-clamp dissection and LigaSure ligation. In this technique, a Kelly clamp is used to crush the liver parenchyma to expose the underlying vessels while the LigaSure is then directed along the tracts created by the Kelly clamp to seal and divide the vessels. The authors concluded that the combined use of the clamp-crushing method with the LigaSure device allowed identification of intraparenchymal vessels followed by sealing. The "postcoagulation technique" has the obvious advantage over "precoagulation" which may injure major blood and biliary vessels before they are exposed and visualized.[17]Our method is a kind of "postcoagulation technique", but it is extremely cheap to set up and it prevents excessive bleeding during transaction.[18]The blood loss in one case was 1100 mL, which was due to the spontaneous rupture of the tumor preoperatively.

In conclusion, our technique using the mosquito clamp-crushing combined with a self-assembled salinelinked diathermy has the advantages of reducing blood loss, exposing intrahepatic vessels clearly and being simple, cheap and effective. The material for the set up are easily available in any operating theatre.

Contributors:XF proposed the study and contributed to first draft. LWY contributed to revision of the draft. All authors were involved in the procedure. BP is the guarantor.

Funding:This work was supported by a grant from the National S&T Major Project (2008ZX10002-005).

Ethical approval:Not needed.

Competing interest:No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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(Hepatobiliary Pancreat Dis Int 2012;11:442-445)

February 10, 2012

Accepted after revision June 6, 2012

Author Affiliations: Institute of Hepatobiliary Surgery, Southwest Hospital, Southwest Cancer Center, Third Military Medical University, Chongqing 400038, China (Xia F, Lau WY, Ma KS and Bie P); Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China (Lau WY)

Ping Bie, MD, PhD, Institute of Hepatobiliary Surgery, Southwest Hospital, Southwest Cancer Center, Third Military Medical University, Chongqing 400038, China (Tel: 86-23-68754168; Fax: 86-23-65317637; Email: bieping@medmail.com.cn)

? 2012, Hepatobiliary Pancreat Dis Int. All rights reserved.

10.1016/S1499-3872(12)60206-9