ročník 11,2003 č.4
Kongres

Bloodless liver resection technique

Milicevic, M.

The First Surgical Clinic, Institute for Digestive Diseases,
University Clinical Center of Belgrade,
Serbia and Montenegro

Liver surgery developed rapidly during the past fifty years, when practically every major abdominal operations were already routine practice in surgical departments worldwide. Better understanding of liver anatomy, physiology and hepatic cell biology coupled with intraoperative ultrasound facilitated the performance of anatomical liver resections and resulted in the development of many surgical techniques. The mortality and morbidity associated with major liver resection significantly decreased in HPB centers of excellence and patients were offered safe and efficient surgery.
Nevertheless, liver surgery still remains a complex surgical procedure in general surgical units, especially in developing countries, requiring well trained, experienced and skilled surgeons as well as significant resources. Intraoperative blood loss remains a major concern for surgeons operating on the liver since it is associated with a significantly higher rate of postoperative complications and shorter long-term survival (1).
Many different surgical techniques have developed during the past half century to reduce intraoperative blood loss and allow safer liver resections. Intraoperative blood loss can be decreased by performing operations in hypotensive anesthesia, using Pringl's maneuver, partial or total vascular occlusion. Division of liver parenchyma can be done by simple procedures like cutting with a scalpel or crushing the tissue with fingers or clamps or using sophisticated forms of mechanical energy like ultrasonic dissectors, harmonic scalpel, compressive bipolar diathermy, floating ball devices and hydroscissors. All these procedures are less efficient in cirrhotic livers and when doing non-anatomical resections (2-5).
A new technique using radiofrequency (RF) energy to coagulate liver resection margins and perform tissue sparing bloodless liver resection is described.

The technique

Under general anesthesia a modified right subcostal (J) incision was made. The peritoneal cavity was examined for evidence of extrahepatic disease. Intra-abdominal adhesions and the falciform ligament were divided. The liver was then mobilized according to the size and site of lesion to be resected, avoiding unnecessary liver mobilization. An intraoperative ultrasound was always performed.
The tumor was bimanually palpated and intraoperative ultrasound repeated in order to determine the accurate position and extent of the tumor. The upper and lower surface of the liver was marked with diathermy in order to provide a roadmap for the resection. It is important to clearly mark the path of the resection line, since after RF is used the parenchyma becomes desiccated and hardened rendering further palpation and intraoperative ultrasound useless in determining the tumor edge.
Coagulative desiccation is produced using the 1 or 3cm water cooled-tip single RF probe and a 500-kHz Generator (Radionics Europe, Model RFG-3D, N.V., Wettdren, Belgium). The generator is capable of producing 100 W of power and allows measurements of the generator output, tissue impedance and electrode tip temperature. The probe contains a 1 or 3cm exposed electrode, a thermocouple on the tip to monitor temperature and impedance and two coaxial cannulae through which chilled (around 4-10oC) sterile distilled water is forced by a rotary pump during RF energy application. Cooling of the tip prevents tissue boiling and cavitation immediately adjacent to the electrode. The RS232 port of the Radionics generator is connected to a notebook computer running a specially designed software for the authors that monitors RF emission time (min), total delivered current (Coulombs) and maximal delivered current (mA). Since the RF generator was used for coagulating normal liver tissue, instead of tumor tissue for which it was designed, the authors felt that exact monitoring of relevant output parameters and their registration was needed in order to enhance patient safety.
The principle and procedure of liver resection using RF energy was described in detail by Weber and Habib (6). The procedure that we use is based on the same principal that it takes less than a minute to coagulate and desiccate a centimeter wide and three centimeters long cylinder of normal tissue instead of the 20 minutes it takes for the same effect in tumor tissue. The electrode is used in a different manner. Instead of sticking the electrode into the liver parenchyma and retracting it during coagulation, we prefer to use the probe in a similar way that the CUSA hand piece is used. The needle is initially placed 2 to 3mm beneath the surface of the liver along the marked lines and as coagulative desiccation progresses up to the surface, the coagulated area is cut with a scalpel. The resection advances from the surface into the depth of the liver and from the anterior to the posterior aspect of the liver. This is what we call a "sequential coagulate-cut technique". Extent of coagulation depends on the energy, exposure time and contact surface of the needle as well as the vicinity of large blood vessels (the heat sink effect). The cut surface is constantly sprayed with sterile saline to facilitate conductivity. Pedicles and veins can be coagulated or ligated, depending on their diameter and the preference of the surgeon. Coagulation can be done from inside the resection margins to stop any potential point of bleeding. Working with the electrode close to important structures is not a problem providing direct contact and prolonged exposure are avoided. The Pringle maneuver was not applied in our series. A drain is placed at the site of the resection. The abdomen is subsequently closed in layers.
In all patients, biochemical liver function tests were monitored before and after resection within the first 24 hours.

Patients and results

Liver resection was done for different indications (Table No. 1). During a period ranging from 01.12.2001 to 01.09.2003 a total of 54 patients underwent 60 operations. The youngest patient was 18 years old and the oldest 78 years old (mod 60 years).

Indication for resection Pts. operated
CRC metastases 36
liver primary Ca 11
hydatid cyst 2
GB cancer 2
lung cancer metastases 2
recurrent liver abscess 1
liver actinomycosis 1
metastases from Ca of the ovary 1
giant liver haemangioma 1
solitary necrotic liver nodule 1
cystadenoma of the liver 1
unknown primary 1
Total 60
Tab. No.1 - Operated patients

There were 8 (13.33%) formal liver resections, 5 (8.3%) right hepatectomies and 3 (5.3%) left hepatectomies. The types of liver resections are presented on table No. 2. It is not always easy to determine the number of engaged segments since the resections are mostly atypical and frequently non adjacent segments are resected. Four patients were re-resected several months after the initial operation for new metastases while one patient was resected three times for recurring metastases.

Number of segments engaged in resection No. pts.
three segments 4
two segments (left) 7
two segments + subsegment 7
segmentectomy + subsegmentectomy 7
Segmentectomy 6
Subsegmentectomy 9
Metastasectomy 12
Total 52
Tab. No.2 - Type of liver resection

The morbidity and mortality is presented on table No. 3.

Type of complication No. pts.
sequestrated desiccated tissue* 2
pleural empyema† 2
surgical site infection 1
wound dehiscience* 1
portal vein thrombosis 1
recurrent enteral perforation*† 1
pseudomembraneous colitis† 1
biliary fistula 1
Total 10
Tab. No.3 - Morbidity and mortality
† died, * reoperated

One patient was re-operated for sequestrated desiccated tissue and one other patient for abdominal wound dehiscience. One patient died due to uncontrollable pulmonary complications. This was a young patient re-resected eight months after an operation for CRC liver metastases due to recurrence. During operation the extent of disease proved to be far greater that expected so the liver was re-resected, the right adrenal gland was removed, the right kidney was resected, a large part of the diaphragm (closed with a mesh) and the inferior portion of the right lung. The operation proved to be too extensive; the patient retained good liver function but developed recurrent pleural empyema and died from sepsis. The second patient that died was a 73 year old man who had a large liver tumor engaging the hepatic flexure of the colon. A liver resection was done together with extended right colectomy. Liver function was normal but on day seven the patient developed peritonitis and on re-operation a perforation of the jejunum was detected some 20 cm from the ligament of Treitz. The intestine was resected and anastomosed. On day 16 after the first operation the patient developed peritonitis again and was re-operated and another perforation of the jejunum some 35 cm from the ligament of Treitz was detected. The patients liver function remained stable but 6 days after the second re-operation he developed peritonitis again and was not re-operated. The third patient that died was 78 years old and he was resected for CRC liver metastases. In the early postoperative period this patient had anuria and oliguria and stable liver function. The kidney dysfunction was corrected but he developed uncontrollable sepsis and diarrhea in spite of intensive therapy. Autopsy revealed small sclerotic kidneys and pseudo-membraneous colitis. Liver function was not affected by the operation. The one patient that developed a bile like was a 45 year old patient in whom we did a right hepatectomy for multiple CRC metastases. He was re-operated for two metastatic nodules in the left liver one year after the first operation. During the second liver resection a the common hepatic duct and the left hepatic duct were infiltrated with tumor and had to be resected. Hepatico-jejuno Roux-en y anastomosis was done to a small caliber left hepatic duct and stented. A bile leak developed from the anastomosis verified by tubogram. The leak closed spontaneously and the patient was discharged with good liver function.
There was no substantial blood loss related to the liver resection. A total of 15 (25%) patients received blood transfusion. Twelve of the 15 patients (80%) had an average preoperative Hb value of 9.33 g/L and had a difficult adhaesyolisis and resection of other organs as well. Detailed analysis reveals that 10 patients received less than 310 ml of blood and it was not indicated by the operating surgeon but rather by the anesthetist who did not have a detailed knowledge of the RF resection procedure. Only 5 patients had acceptable indications for blood transfusion and received more than two units each. Blood loss in these patients was not related to the procedure on the liver. The last 15 patients in the series did not receive blood transfusion.

Discussion and conclusion

The concept of using RF generated heat to cause coagulative necrosis in liver tumors is not new and it is the basis for RF tumor ablation (7-11). The innovative step with this technique is that the coagulation of normal liver parenchyma is very fast and elevated temperature causes desiccation and colagen bonding resulting in a type of "weld" at the resection line. Since all small vascular and biliary branches are "welded", the tissue is uniformly desiccated, postoperative bleeding and bile fistula are not probable.
The main advantage of this procedure is that it makes atypical resection simple and bloodless. It is possible to do tissue sparing oncologically correct operations without inflow occlusion of the liver even at multiple sites in the liver. Unfortunately, it is difficult to classify these procedures as to what part of a segment or segments is resected, but since the tumor does not understand segmental anatomy, it might really be of no great importance. The sequential coagulate-cut procedure has several advantages: a. it is under direct vision that the RF energy is applied and vital structures can be avoided, b. vital structures can be ligated in order to save time and keep RF emission time as short as possible, c. resection can be extended to include devitalized liver parenchyma, d. the margin of desiccated parenchyma left on the resected liver surface is minimal (several millimeters), e. identification of pedicles and temporary clamping is possible, f. it is possible to use this procedure on cirrhotic livers and g. if the tip of the electrode is carefully manipulated working around the VCI and portal vein is not a threat.
Further studies are needed to evaluate the true value of RF live resection.

References

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Address for correspondence:

Miroslav Milicevic, MD, Ph D., FACS
The First Surgical Clinic, Institute for Digestive Diseases,
University Clinical Center of Belgrade,
Belgrade, Serbia and Montenegro