Name: application of hemostatic devices in laparoscopic hepatectomy
Uploaded: 2022-04-19T13:00:00
Description: Watch this Scientific Journal Video about Application of Hemostatic Devices in Laparoscopic Hepatectomy at JoVE.com

This work was supported by grants from the Science and Technology Project of Guangzhou City (202102010090).

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 &#34;Application of simple and easy Hemostatic Devices in Laparoscopic Hepatectomy&#34; (acceptance No.: 2022-hg-ks-02) was approved by the clinical research and application ethics committee of the Second Affiliated Hospital of Guangzhou Medica...

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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&#39;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 intraoperat...

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&#39;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% (&#60;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.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>HARMONIC ACE Ultrasonic Surgical Devices</td>
			<td>Ethicon Endo-Surgery,LLC</td>
			<td>HAR36</td>
			<td></td>
		</tr>
		<tr>
			<td>Hem-o-lock</td>
			<td>Teleflex Medical</td>
			<td>544233</td>
			<td></td>
		</tr>
		<tr>
			<td>Monopole Electrocoagulation</td>
			<td>KANGJI MEDICAL</td>
			<td>/</td>
			<td></td>
		</tr>
		<tr>
			<td>single lumen ureter</td>
			<td>WELL LEAD MEDICAL CO.,LTD.</td>
			<td>12F</td>
			<td></td>
		</tr>
	</tbody>
</table>

application of hemostatic devices in laparoscopic hepatectomy

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.

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 8th day after the operation. The carcinoembryonic antigen (CEA) level post operation decreased to 110.64 &#181;g/L from the pre-operation level of 1058.69 &#181;g/L (Figure 12). Two months after the operation, the patient returned to the hospital to continue chemothe...

Watch this Scientific Journal Video about Application of Hemostatic Devices in Laparoscopic Hepatectomy at JoVE.com

Application of Hemostatic Devices in Laparoscopic Hepatectomy

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.

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. ...

The main advantage of this technique is that the hemostatic device is simple and easy to obtain and can be carried out in basic hospitals. This set of hemostatic equipment can be further applied to laparoscopic hepatectomy and other systems. It is highly recommended to have a certain basis of laparoscopic surgery, especially skilled use of a harmonic scalpel to apply this set of hemostatic devices in laparoscopic hepatectomy.Begin by applying direct puncture to establish pneumoperitoneum in laparoscopy. Place a 10 millimeter trocar in each observation hole in the subumbilical area, right mid-clavicular line under the costal margin and ventral midline. Then place a five millimeter trocar in the right anterior auxiliary line and the ventral midline.Assemble the hemostatic devices starting from the harmonic scalpel, monopole electrocoagulation, and single lumen catheter to be innovatively used in liver parenchyma tissue resection. To perform a Pringle maneuver, occlude the first porta hepatis intermittently by using a single lumen catheter. Clamp the lumen catheter with a hemostatic clip for 15 minutes followed by releasing it for five minutes using the harmonic scalpel to cut off the clip and take the clip out to restore blood supply to the first porta hepatis.Separate the hepatic pedicles supplying the tumor. Resect and divide them one by one with a harmonic scalpel. Observe the ischemia line on the liver surface, which becomes visible after the resection of the hepatic pedicles.Use the hook to mark it. Resect the liver parenchyma tissue using the harmonic scalpel while clamping and crushing the liver gradually. Observe the internal hepatic artery, vein, and bile duct.Resect and divide these pipeline structures. Once bleeding appears, coagulate the bleeding spots on the liver dissection surface immediately using point to point monopole electrocoagulation. Use the right posterior hepatic pedicle as a signpost for intrahepatic parenchyma tissue resection.Reserve the main posterior hepatic pedicle and dissect the branch of pedicles supplying the tumor. 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.The operation was completed within 2.5 hours. The intraoperative bleeding volume was 100 milliliters without the blood transfusion and no short-term complications were observed. The carcinoembryonic antigen level post-operation decreased to 110.64 micrograms per liter from the pre-operation level of 1058.69 micrograms per liter.The chemotherapy treatment was resumed two months after the operation, according to the tumor pathology results. The postoperative CT examination was compared with the preoperative CT and no signs of tumor regrowth were observed. The most important step in the surgical process is the use of the harmonic scalpel.A good amount of skill is required to avoid damage to vital structures.

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