Hepatic Surgery Using the Ligasure Vessel Sealing System

Abstract

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 intraabdominal 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.

Exploring new technologies to facilitate laparoscopic surgery: creating intestinal anastomoses without sutures or staples, using a radio-frequency-energy-driven bipolar fusion device

“…Interestingly, these advantages are almost exclusively achieved by using it as a dissecting tool to take down the intestinal mesentery, even though the presence of collagen in many other tissues renders this technology potentially suitable for numerous other applications. Experience in other organs is currently limited to a few clinical and experimental studies that have investigated the possibility of sealing and transecting collagen-containing tissues, such as the cystic duct [12], ureter [4], lung parenchyma [11,14], liver [7,10], hemorrhoids [1,9], and appendix [20]. The present study differs fundamentally from these studies since the LigaSure was not applied for its dissecting properties but for its possible reconstructive capacities, the creation of intestinal anastomoses.…”

The Aim of Technology During Liver Resection — A Strategy to Minimize Blood Loss During Liver Surgery

“…Furthermore the use of Ligasure System is not correlated with an increase of the rate of postoperative bile leaks and in some study bile leakage was nihill [76]- [127] and that proves his effectiveness in obliterate also bile vessel. D: after the application the coagulated tissue often sticks to the instrument's jaws causing new bleeding when the device is moved away; BVSD seems to be less effective in presence of cirrhosis for two reasons: first the portal hypertension correlated with cirrhosis causes thinning of the dilate portal vein's walls and makes their obliteration less effective; second cirrhosis makes crushing technique difficult and the hepatic tissue between the blades may disperse the power applied causing vessel to bleed [128]; moreover it seems to be ineffective in cystopericystectomy [77] (even if some surgeons sustain his effectiveness in this surgery [78]). Ligasure vessels sealing system has been widely use during liver transection in a "blind" way [70]- [71], achieving parenchymal fracture and vessel sealing in the same time without identìfication of tiny vasculatures and bile ducts.…”

“…BVSD is capable to obliterate the lumen of veins and arteries up to 7 mm in diameter by the fusion of elastin and collagen proteins of the vessel walls; that makes BVSB the only safe and real alternative to sutures and clips for sealing vessel [68], [69], [70]. A: BVSD coagulates sealing vessels up to 7 mm in diameter with minimal charring, thermal spread or smoke, it's capable to reduce blood loss and the need for vessel occlusion techniques if compared to traditional techniques [8], [71], [72], A recently published randomized controlled trial demonstrated that the use of Ligasure in combination with a clamp crushing technique resulted in lower blood loss and faster transaction speed in minor liver resections compared with the conventional technique of electric cautery or ligature for controlling vessels in the transection plane [73]. Otherwise a more recent randomized trial from the same team was not able to show a real difference between the traditional techniques and the Ligasure vessel sealing system [74].…”

“…Bleeding has to be considered a major concern for the hepatic surgeon because of several reasons. At first it is certainly the major intraoperative surgical complication and cause of death and historically one of the major postoperative complication together with bile leaks and hepatic failure [5], [6], [7], [8], [9].…”

Techniques for Liver Resection

“…This has been employed for liver transection with proven effectiveness 54,55 . The liver tissue can be crushed between the blades of the device and then coagulation energy is applied to seal the vessels.…”