Application of Hemostatic Devices in Laparoscopic Hepatectomy

Summary

High-grade hemostatic devices are essential for laparoscopic hepatectomy. However, these devices are not generalized in basic medical organizations. Therefore, a suite of simple and easy hemostatic devices is shown in this article, which can make the laparoscopic hepatectomy easier to perform.

Abstract

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. Despite its non-invasive aspect, bleeding and bile leakage occur in liver parenchyma tissue resection during the operation or in the post-operation period, indicating the requirement for high-grade hemostatic devices, such as ultrasonic surgical aspiration, bipolar electrocoagulation, etc. The lack of availability of these high-grade hemostatic devices prevents laparoscopic hepatectomy from becoming a generalized procedure in basic medical organizations. In view of the situation mentioned above, a suite of simple and easy hemostatic devices is developed in this protocol, which includes a harmonic scalpel, monopole electrocoagulation, and a single lumen catheter, to innovatively perform liver parenchyma tissue resection. First of all, the porta hepatis or hepatic pedicle is occluded intermittently by a single lumen catheter, followed by clamping for 15 min and releasing for 5 min. Subsequently, using the harmonic scalpel, clamping and crushing of the liver are done to cut off the hepatic parenchyma tissue and to reveal the intrahepatic arteries, veins, and bile ducts. Lastly, the bleeding spots are coagulated by using monopole electrocoagulation at each spot. Intrahepatic pipeline structures are then visible by using these methods, which could stop bleeding easily, reduce the incidence rate of bile leakage, and improve the safety and feasibility of laparoscopic hepatectomy. Therefore, the simple and easy hemostatic devices shown here are suitable for conducting procedures in primary medical institutions.

Introduction

Hepatocellular carcinoma is one of the most common malignant tumors of the digestive system. According to the different primary sites, it can be divided into primary hepatocellular carcinoma and secondary liver cancer. Cells can metastasize from primary tumors from organs outside the liver into the liver in various ways, leading to carcinoma in the liver. It has been reported that more than 50% of metastatic cells in the liver come from colorectal cancer, while others are from breast, pancreas, lung, and stomach tumors, etc¹. In recent years, many treatments for secondary liver cancer are available, including systematic chemotherapy, interventional therapy, molecular targeted therapy, surgery, etc². However, radical resection is still the most effective treatment because it can completely remove the cancer³.

With the rapid development of laparoscopic technology, laparoscopic anatomical hepatectomy is gradually recognized by surgeons but is still not widely performed, especially in primary medical institutions. One of the reasons is the requirement for high-grade hemostatic devices. These are required to reduce the risks of bleeding and bile leakage during the operation process. Here, we present a set of simple and easy hemostatic equipment, including a single lumen catheter, harmonic scalpel, and monopole electrocoagulation, for performing laparoscopic hepatectomy. To do this, first the porta hepatis is occluded intermittently by using a single lumen catheter. Liver parenchyma tissue is then resected by using the harmonic scalpel. Bleeding spots are coagulated by monopole electrocoagulation point-to-point. This simple and easy hemostatic equipment uses a single lumen catheter to perform the pringle maneuver and utilizes the hemostasis of the harmonic scalpel and monopole electrocoagulation. The equipment can be found easily in hospitals, thereby providing added ease for performing laparoscopy or training. Thus, these simple and easy hemostatic devices are suitable for conducting procedures in primary medical institutions.

In this study, the patient was a 67-year-old male diagnosed with a moderately differentiated adenocarcinoma of the sigmoid colon metastasized in the liver. Radical resection of the sigmoid colon cancer was performed in January 2021. The pathological results were moderately differentiated adenocarcinoma with the TNM stage of pT4aN2aM1. FOLFOX chemotherapy was given four times after the operation. Following this, the patient's body condition was deemed suitable to perform laparoscopic anatomical hepatectomy to completely remove the lesion of liver metastases. The Child-Pugh grade of liver function was Grade A. For the liver reserve function test, R15 in the ICG clearance test was 1.6% (<10%). CT showed a 57 mm x 68 mm x 76 mm tumor across the dorsal part of S5 and ventral part of S6 of the liver; the three-dimensional reconstruction model is shown in Figure 1.

Protocol

The operation is routine and received ethics approval. The approvals are as follows: Approval for rapid review by the Clinical Research and Application Ethics Committee of the Second Affiliated Hospital of Guangzhou Medical University: The scientific research ethics review project "Application of simple and easy Hemostatic Devices in Laparoscopic Hepatectomy" (acceptance No.: 2022-hg-ks-02) was approved by the clinical research and application ethics committee of the Second Affiliated Hospital of Guangzhou Medical University. Its research contents and methods meet the medical ethics norms and requirements.

1. Preoperative preparation, operative position, and anesthesia

1. Ask the patient to consume a liquid diet 1 day before the surgical operation and then abstain from eating food and drinking water at least 8 h before the surgery.
2. Place the patient in a supine position and 30° reverse Trendelenburg position, tilted softly to the left. The principal surgeon operates from the patient's right side.
3. Perform endotracheal intubation and give general anesthesia. Judge the anesthetic effect according to the patient's post-anesthesia and intraoperative conditions, such as complete anesthesia block, no additional drugs during operation, and stable vital signs.

2. Surgical technique

1. Apply direct puncture to establish pneumoperitoneum in laparoscopy. Place five trocars in the following positions: observation hole in the sub-umbilical area 12 mm trocar, right anterior axillary line 5 mm trocar, right midclavicular line under the costal margin 10 mm trocar, ventral midline 10 mm and 5 mm trocar (see Figure 2).
2. Assemble the following hemostatic devices: harmonic scalpel, monopole electrocoagulation, and single lumen catheter, to be innovatively used in liver parenchyma tissue resection (see Figure 3).
3. Perform a Pringle maneuver. To do so, follow the steps below.
   1. Occlude the first porta hepatis intermittently by using a single lumen catheter. Clamp the lumen catheter with a hemostatic clip for 15 min, followed by releasing for 5 min.
   2. When required to release, use the harmonic scalpel to cut off the clip and take the clip out to restore blood supply to the first porta hepatis (see Figure 4).
4. Separate the hepatic pedicles supplying the tumor. Resect and divide them one by one with a harmonic scalpel (see Figure 5).
5. Observe the ischemia line on the liver surface, which becomes visible after the resection of the hepatic pedicles. Use the hook to mark this (see Figure 6).
6. Resect the liver parenchyma tissue using the harmonic scalpel with clamping and crushing of the liver little by little. Observe the internal hepatic artery, vein, and bile duct now visible. Resect and divide these pipeline structures (see Figure 7).
7. Once bleeding appears, coagulate the bleeding spots on the liver dissection surface immediately using point-to-point monopole electrocoagulation (see Figure 8).
8. Use the right posterior hepatic pedicle as a signpost for intrahepatic parenchyma tissue resection. Reserve the main posterior hepatic pedicle (PP) and dissect the branch of pedicles (PPa) supplying the tumor (see Figure 9).
9. To complete the operation, wash the liver surface so one can see if there are still bleeding spots. Stop the bleeding on the liver dissection surface and remove the tumor specimen from the abdominal cavity (see Figure 10).
   ​NOTE: The Paraffin pathology results of the tumor was metastatic adenocarcinoma, which is shown in Figure 11.

3. Postoperative nursing

1. Perform ECG monitoring after the operation. Calculate the total 24 h inflow and outflow and observe the urine volume.
   NOTE: The patient's total rehydration volume (antibiotic, amino acid, vitamin, electrolyte, etc.) was 1,750 mL 10.5 h after surgery (after surgery until 7:00 am the next day). The total liquid excretion of the patient at 10.5h after surgery was 1,900ml, including 1,700ml of urine and 200ml of drainage.
2. On the first day after the operation, give the patient a liquid diet and instruct the patient to turn over and exercise in bed, such as turning over, patting the back, moving the legs, and other exercises, which are mainly guided by the nurses.
3. On day 2 after the operation, assist the patient to get out of bed and carry out daily activities.
4. On day 3 after the operation, guide the patient to walk in the corridor and increase gradually the amount of activity in combination with the recovery of the patient's condition. Implement psychological intervention according to the patient's situation to improve the patient's bad mood.
5. Finally, according to the patient's drainage flow, remove the drainage tube. In this case, the drainage tube was removed on the 7^th day after the operation when the drainage flow was 50 mL.

Representative Results

The operation was completed within 2.5 h and the intraoperative bleeding volume was 100 mL without the blood transfusion. There were no short-term complications, and the patient was discharged from the hospital on the 8^th day after the operation. The carcinoembryonic antigen (CEA) level post operation decreased to 110.64 µg/L from the pre-operation level of 1058.69 µg/L (Figure 12). Two months after the operation, the patient returned to the hospital to continue chemotherapy treatment (chemotherapy regimen was mFOLFOX6). The chemotherapy regimen was performed according to the tumor pathology result, which is shown in Figure 11. The CT examination performed when the patient returned to the hospital for re-examination was compared with the CT examination performed before the operation. No signs of tumor regrowth were observed. For details, please see Figure 13.

Figure 1: The 3D digital imaging of the liver tumor. Please click here to view a larger version of this figure.

Figure 2: The trocar position is shown on the body surface. Please click here to view a larger version of this figure.

Figure 3: Hemostatic devices: single Lumen catheter, harmonic scalpel, and monopole electrocoagulation. Please click here to view a larger version of this figure.

Figure 4: Pringle maneuver completed by single lumen catheter. Please click here to view a larger version of this figure.

Figure 5: Ligation of the first hepatic pedicle of S5. Please click here to view a larger version of this figure.

Figure 6: Resection area marked by ischemia line. Please click here to view a larger version of this figure.

Figure 7: Resection of parenchyma tissue by harmonic scalpel. Please click here to view a larger version of this figure.

Figure 8: Monopole electrocoagulation for stopping the bleeding. Please click here to view a larger version of this figure.

Figure 9: Successful appearance of the right posterior hepatic pedicle. Please click here to view a larger version of this figure.

Figure 10: The liver dissection surface at the last stage of surgery. Please click here to view a larger version of this figure.

Figure 11: The tumor pathology results. Please click here to view a larger version of this figure.

Figure 12: Preoperative and postoperative carcinoembryonic antigen (CEA) levels. Please click here to view a larger version of this figure.

Figure 13: The CT examination performed when the patient returned to the hospital for re-examination compared with the CT examination performed before the operation. Please click here to view a larger version of this figure.

Discussion

Hepatectomy is one of the most important treatment methods for patients with primary liver cancer and secondary liver cancer. In 1991, Reich et al. applied laparoscopy to remove benign tumors of the liver and completed the world's first laparoscopic hepatectomy⁴. After years of rapid development and promotion, laparoscopic hepatectomy has become one of the mainstream methods to treat liver malignant tumors and has been widely carried out in recent years. With the advantages of less intraoperative bleeding, less postoperative pain, low incidence of postoperative complications, short hospital stays, etc., the feasibility and safety of this technique have been confirmed and have led to its extensive use in clinical practice⁵. Makuuchi et al.⁶ proposed anatomical hepatectomy according to the anatomical characteristics of the liver. Anatomical hepatectomy removes the tumor completely and preserves normal liver tissue, which avoids postoperative residual liver congestion and reduces the occurrence of biliary fistula. It is the best choice for hepatectomy in the treatment of liver cancer⁷. The main difference between anatomical hepatectomy and non-anatomical hepatectomy lies in the resection scope. Theoretically, anatomical hepatectomy based on the liver segment can better reduce the risk of recurrence, but the operation requirements are higher⁷. In recent years, with a better understanding of liver anatomy and the application of ultrasound and ICG fluorescence navigation technology in laparoscopic surgery, laparoscopic anatomical hepatectomy is now carried out in hospitals all over the world. Resection has been performed in various segments and even subsegments, including laparoscopic anatomical middle lobe hepatectomy, right posterior lobe hepatectomy, left lateral lobe hepatectomy, S7+8 hepatectomy, S8 dorsal segment hepatectomy, etc.^9,10,11. Liver metastases of the patient presented here showed a lesion located across parts S5 and S6. So, the solution was to trace the hepatic pedicle of S5 and S6, which was considered as a signpost intrahepatic parenchyma tissue resection. Meanwhile, a wide incisal margin (>1 cm) was made. The main posterior hepatic pedicle (PP) and anterior trunk (AT) were reserved, and the branch of pedicles supplying the tumor was dissected.

The advantages of laparoscopic anatomical liver resection have been gradually confirmed in recent years. The reason for the reduction of intraoperative bleeding is that the hepatic blood flow of the pre-resected liver is treated preferentially. This is conducive to the control of bleeding in the process of liver resection. Making an ischemic line helps to find a normal anatomical level and reduce bleeding¹². There are many methods to reduce bleeding during hepatectomy. On the one hand, low central venous pressure during hepatectomy can effectively reduce venous bleeding¹³. On the other hand, blocking the first hepatic portal (Pringle method) has a significant effect on reducing bleeding during hepatectomy. This method is simple, effective, and safe for patients with liver cirrhosis¹⁴. At the same time, the use of some advanced hemostatic devices during ultrasonic surgical aspiration and bipolar electrocoagulation plays a very important role in reducing intraoperative hemostasis, but these cannot be popularized in primary medical institutions because of their high price.

The key step of our operation is to use the Pringle method, followed by using the single lumen catheter to intermittently block the porta hepatis or hepatic pedicle, and then using the harmonic scalpel to crush the liver parenchyma tissue, bit by bit, along with coagulation of the bleeding point with the monopole electrocoagulation at the same time. This method can improve the safety and feasibility of laparoscopic anatomical hepatectomy. The hemostatic device is simple and easy, so it is more suitable for use and promotion in medical institutions with basic facilities.

Despite its simplicity and ease of use, the hemostatic device also has its limitations. For example, the hemostatic scalpel is not an advanced hemostatic equipment, and it is difficult to ensure sufficient hemostatic effect in complex hepatectomy. However, in the early stage of laparoscopic hepatectomy, we can use this set of equipment when the operation cannot be carried out due to the lack of advanced hemostatic equipment and then gradually accumulate experience and combine the use of advanced hemostatic equipment to carry out more difficult surgery.

Laparoscopic anatomical hepatectomy is a difficult operation, but we can use this simple device innovatively to reduce the incidence of bleeding and bile leakage and improve the safety and feasibility of laparoscopic anatomical hepatectomy.

Materials

Name	Company	Catalog Number	Comments
HARMONIC ACE Ultrasonic Surgical Devices	Ethicon Endo-Surgery,LLC	HAR36
Hem-o-lock	Teleflex Medical	544233
Monopole Electrocoagulation	KANGJI MEDICAL	/
single lumen ureter	WELL LEAD MEDICAL CO.,LTD.	12F