Techniques of Parenchyma Transection in Hepatology
Today, liver resection can be performed by different transection devices with or without inflow occlusion to prevent bleeding. The concomitant use of low central venous pressure (CVP) anaesthesia further minimizes blood loss by preventing retrograde bleeding from the hepatic veins. The most popular devices facilitating bloodless transection include:
Ultrasonic Surgical Aspirator
The ultrasonic surgical aspirator is a dissecting tool that has found application in different fields of surgery for about a decade. Its utilisation in the field of hepatology enables the ablation of endometriosis by laparoscopy and allows surgical therapy on an outpatient basis in most cases.
Through laparoscopy the vibrating tip of the tool is brought into contact with the patients liver tissue and fragments the cells. The operative time is about 2 hours and there is conceivably less tissue damage caused by this technique than the amount of tissue damage resulting from the use of a scalpel or laser. Another advantage of the system might be its selective dissection. Since the rate fragmentation is proportionate to the water content of the cells, soft, fleshy tissues with high-water content are fragmented readily, whereas blood vessels, ureters and connective tissue skeletonized remain intact.
The ultrasonic surgical aspirator is used commonly in open liver and biliary surgery. There is now a prototype instrument for laparoscopic cholecystectomy.
Water Jet Dissector
The water jet dissector is a new technique for Parenchyma Transection using the energy of a pressurized water jet with varying pressure to separate cells from tissue, differentiating between soft liver parenchyma and blood vessels, thus minimizing the blood loss and operation time.
The dissecting sealer uses saline enhanced radiofrequency energy to cut and coagulate human tissue.
Radio-frequency energy from a standard electrosurgical generator is delivered to tissue through a conductive fluid, usually saline. The saline becomes the electrode and couples the energy to tissue, thus increasing contact area and keeping the surface cool (~100°C or below). This technique manages the heat flow and resulting tissue temperature, shrinks the collagen, closes the vessels, and stops the bleeding.
Controlled temperature delivery produces a permanent seal through the shrinking of the collagen and the tissue turns a light tan color. No smoke or eschar are created and perforations are eliminated.
Clamp Crushing Technique under Inflow Occlusion
Parenchyma transection under routine inflow occlusion has been performed with finger fracture technique (digitoclasy), where liver parenchyma was crushed between the thumb and one finger isolating vessels and bile ducts, which can then be ligated and divided. This technique was subsequently improved through the use of surgical instruments such as small Kelly or Péan clamps (clamp crushing) for blunt transection.
In a study, the clamp crushing technique was the most efficient device in terms of resection time, blood loss, and blood transfusion frequency compared with CUSA, Hydrojet, and dissecting sealer, and proved to be also the most cost-efficient device with a cost-saving potential of 600 € to 2400 € per case.
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