What kind of energy devices should be used for laparoscopic liver resection? Recommendations from a systematic review

Abstract

Transection methods and hemostasis achievement have an impact on blood loss, and consequently on outcome and survival. However, no consensus exists on parenchymal transection or hemostasis techniques in laparoscopic liver resection (LLR). The aim of this review is to clarify the role of energy devices (ED) in LLR. ED is a generator of mechanic or electric energy transfer to an operating tool, used for transection, sealing or both. Searches were performed in PubMed, PubMed Central, Cochrane, Embase, Google Scholar in human or animal experimental models. Each study quality was graded following the GRADE system. From 1996 to 2014, 30 studies were found: five comparative, one prospective, two case-control, and 16 case series and some case reports, with level of evidence ranging from Moderate to Very Low. Since 2012, the Research and Development of new tools raised quicker than clinical studies could follow. The two main techniques emerged are blind transection versus sharp dissection: due to the low quality and heterogeneity of the studies, no firm conclusion can be drawn, but meticulous dissection of vessels usually never leads to vascular damage. As a matter of fact, ED, though efficient and reliable, cannot replace the basic skills of hepatic surgery: sharp dissection, vascular control and elective sealing.

Evolution and revolution of laparoscopic liver resection in Japan

“…These expert technical recommendations will never be confirmed by level 1 evidence, but still need to be shared so that beginners can benefit from expert guidance. Another major achievement of the consensus conferences is the publication activities related to the conferences and the systematic reviews prepared to develop recommendations before the Morioka Consensus Conference 46, 67, 84, 118, 119, 120, 121, 122. We hope that all these publications will contribute to the safe uptake of LLR.…”

Systematic reviews from the 2nd International Consensus Conference on Laparoscopic Liver Resection

“…In this issue, primary authors of several CQs [3][4][5][6][7][8] present their systematic reviews that were prepared to create recommendations before the ICCLLR (Figs 1,2). A comprehensive literature review was performed and analysis was done using multiple case series, case-control studies, reviews, and metaanalyses published over the last several years.…”

“…[6] CQ14 What kind of energy devices should be used for LLR? [3] CQ15 What is the best approach to the hilar structures (individual or Glissonian approach)? CQ16 Is anatomical resection preferable for LLR?…”

From Louisville to Morioka: where is now MILS?

“…These are technical recommendations from experts that will never be proved by level 1 evidence and still need to be shared so that the beginners can benefit from the expert learning curve. Another major achievement of the ICCLLR is publications of related activity to the ICCLLR [3][4][5][6][7] and the systematic reviews that were prepared to create recommendations before the ICCLLR [8][9][10][11][12][13][14]. A couple of more manuscripts are now under review to be published.…”

“…During this 3-day conference, we extensively discussed how to improve the quality of LLR. Improving quality includes how to use energy devices [9], how to perform parenchymal transection [13], how to avoid bleeding [14], and how to perform parenchyma sparing anatomical resection. Complications in liver resection mainly consist of these three factors as shown in Table 4.…”