Name: modified laparoscopic anatomic hepatectomy: two-surgeon technique combined with the simple extracorporeal pringle maneuver
Uploaded: 2023-06-16T12:40:00
Description: Watch this Scientific Journal Video about Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver at JoVE.com

This work was supported by grants from the National Natural Science Foundation of China (No. 81971773).

This protocol and surgery video demonstration obtained the patient&#39;s informed consent before surgery, and also obtained approval from The Fifth Affiliated Hospital of Sun Yat-sen University.
1. Preoperative preparation
<ol>
	<li>Perform laboratory tests, including blood routine examination, liver and renal function tests, tumor markers of the digestive system (alpha-fetoprotein, AFP; carcinoembryonic antigen, CEA), prothrombin time, international normalized ratio (INR), ...

<ol>
	<li>Vauthey, J. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+extended+hepatectomy+for+hepatobiliary+malignancy+justified.">Is extended hepatectomy for hepatobiliary malignancy justified.</a> Annals of Surgery. 239 (5), 722-730 (2004).</li><li>Shang, H. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+clinical+efficacy+and+complications+between+laparoscopic+partial+and+open+partial+hepatectomy+for+liver+carcinoma:+a+meta-analysis.">Comparison of clinical efficacy and complications between laparoscopic partial and open partial hepatectomy for liver carcinoma: a meta-analysis.</a> Journal of Laparoendoscopic &amp; Advanced Surgical Techniques. Part A. 29 (2), 225-232 (2019).</li><li>Belli, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+liver+resection+for+hepatocellular+carcinoma+in+patients+with+histologically+proven+cirrhosis:+short-+and+middle-term+results.">Laparoscopic versus open liver resection for hepatocellular carcinoma in patients with histologically proven cirrhosis: short- and middle-term results.</a> Surgical Endoscopy. 21 (11), 2004-2011 (2007).</li><li>Cucchetti, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comprehensive+meta-regression+analysis+on+outcome+of+anatomic+resection+versus+nonanatomic+resection+for+hepatocellular+carcinoma.">A comprehensive meta-regression analysis on outcome of anatomic resection versus nonanatomic resection for hepatocellular carcinoma.</a> Annals of Surgical Oncology. 19 (12), 3697-3705 (2012).</li><li>Moris, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anatomic+versus+non-anatomic+resection+for+hepatocellular+carcinoma:+A+systematic+review+and+meta-analysis.">Anatomic versus non-anatomic resection for hepatocellular carcinoma: A systematic review and meta-analysis.</a> European Journal of Surgical Oncology. 44 (7), 927-938 (2018).</li><li>Ciria, R., Cherqui, D., Geller, D. A., Briceno, J., Wakabayashi, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+short-term+benefits+of+laparoscopic+liver+resection:+9000+cases+and+climbing.">Comparative short-term benefits of laparoscopic liver resection: 9000 cases and climbing.</a> Annals of Surgery. 263 (4), 761-777 (2016).</li><li>Eeson, G., Karanicolas, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hemostasis+and+hepatic+surgery.">Hemostasis and hepatic surgery.</a> The Surgical Clinics of North America. 96 (2), 219-228 (2016).</li><li>Dagher, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=International+experience+for+laparoscopic+major+liver+resection.">International experience for laparoscopic major liver resection.</a> Journal of Hepato-Biliary-Pancreatic Sciences. 21 (10), 732-736 (2014).</li><li>Cauchy, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Risk+factors+and+consequences+of+conversion+in+laparoscopic+major+liver+resection.">Risk factors and consequences of conversion in laparoscopic major liver resection.</a> The British Journal of Surgery. 102 (7), 785-795 (2015).</li><li>Jones, R. M., Moulton, C. E., Hardy, K. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Central+venous+pressure+and+its+effect+on+blood+loss+during+liver+resection.">Central venous pressure and its effect on blood loss during liver resection.</a> The British Journal of Surgery. 85 (8), 1058-1060 (1998).</li><li>Liu, T. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Application+of+controlled+low+central+venous+pressure+during+hepatectomy:+A+systematic+review+and+meta-analysis.">Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis.</a> Journal of Clinical Anesthesia. 75, 110467 (2021).</li><li>Honda, G., Ome, Y., Yoshida, N., Kawamoto, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+to+dissect+the+liver+parenchyma:+Excavation+with+cavitron+ultrasonic+surgical+aspirator.">How to dissect the liver parenchyma: Excavation with cavitron ultrasonic surgical aspirator.</a> Journal of Hepato-Biliary-Pancreatic Sciences. 27 (11), 907-912 (2020).</li><li>Poon, R. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+techniques+of+liver+transection.">Current techniques of liver transection.</a> HPB. 9 (3), 166-173 (2007).</li><li>Nitta, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopy-assisted+major+liver+resections+employing+a+hanging+technique:+the+original+procedure.">Laparoscopy-assisted major liver resections employing a hanging technique: the original procedure.</a> Annals of Surgery. 251 (3), 450-453 (2010).</li><li>Imamura, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pringle's+maneuver+in+living+donors.">Pringle's maneuver in living donors.</a> Lancet. 360 (9350), 2049-2050 (2002).</li><li>Cai, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+novel+simple+intra-corporeal+Pringle+maneuver+for+laparoscopic+hemihepatectomy:+how+we+do+it.">A novel simple intra-corporeal Pringle maneuver for laparoscopic hemihepatectomy: how we do it.</a> Surgical Endoscopy. 34 (6), 2807-2813 (2020).</li><li>Yamamoto, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+simple+technique+for+hepatic+parenchymal+resection+using+a+Cavitron+Ultrasonic+Surgical+Aspirator+and+bipolar+cautery+equipped+with+a+channel+for+water+dripping.">New simple technique for hepatic parenchymal resection using a Cavitron Ultrasonic Surgical Aspirator and bipolar cautery equipped with a channel for water dripping.</a> World Journal of Surgery. 23 (10), 1032-1037 (1999).</li><li>Palavecino, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Two-surgeon+technique+of+parenchymal+transection+contributes+to+reduced+transfusion+rate+in+patients+undergoing+major+hepatectomy:+analysis+of+1,557+consecutive+liver+resections.">Two-surgeon technique of parenchymal transection contributes to reduced transfusion rate in patients undergoing major hepatectomy: analysis of 1,557 consecutive liver resections.</a> Surgery. 147 (1), 40-48 (2010).</li><li>Pringle, J. 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V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Notes+on+the+arrest+of+hepatic+hemorrhage+due+to+trauma.">Notes on the arrest of hepatic hemorrhage due to trauma.</a> Annals of Surgery. 48 (4), 541-549 (1908).</li><li>Rotellar, F., Pardo, F., Bueno, A., Mart&#237;-Cruchaga, P., Zozaya, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Extracorporeal+tourniquet+method+for+intermittent+hepatic+pedicle+clamping+during+laparoscopic+liver+surgery:+an+easy,+cheap,+and+effective+technique.">Extracorporeal tourniquet method for intermittent hepatic pedicle clamping during laparoscopic liver surgery: an easy, cheap, and effective technique.</a> Langenbeck's Archives of Surgery. 397 (3), 481-485 (2012).</li><li>Piardi, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+Pringle+maneuver:+how+we+do+it.">Laparoscopic Pringle maneuver: how we do it.</a> Hepatobiliary Surgery and Nutrition. 5 (4), 345-349 (2016).</li><li>Aloia, T. A., Zorzi, D., Abdalla, E. K., Vauthey, J. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Two-surgeon+technique+for+hepatic+parenchymal+transection+of+the+noncirrhotic+liver+using+saline-linked+cautery+and+ultrasonic+dissection.">Two-surgeon technique for hepatic parenchymal transection of the noncirrhotic liver using saline-linked cautery and ultrasonic dissection.</a> Annals of Surgery. 242 (2), 172-177 (2005).</li><li>Fujikawa, T., Kajiwara, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Modified+two-surgeon+technique+for+laparoscopic+liver+resection.">Modified two-surgeon technique for laparoscopic liver resection.</a> Cureus. 14 (3), e23528 (2022).</li><li>Kasai, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+major+hepatectomy:+a+systematic+review+and+meta-analysis+of+individual+patient+data.">Laparoscopic versus open major hepatectomy: a systematic review and meta-analysis of individual patient data.</a> Surgery. 163 (5), 985-995 (2018).</li><li>Wei Chieh, A. 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The protocol details a modified LAH performed in our center using the CUSA-ultrasonic dissector-extracorporeal Pringle maneuver technique. In this modified combination technique, we used both the simple extracorporeal Pringle maneuver and a low CVP technique to control and minimize intraoperative bleeding. The primary and secondary surgeons concurrently used a laparoscopic CUSA and ultrasonic dissector, respectively, during parenchymal transection and hemostasis to acquire precise and expeditious hepatectomy.
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The safety of hepatectomy has significantly improved in recent decades1, and with the rapid advancements in diagnostic imaging, energy devices, and surgical techniques, laparoscopic hepatectomy has become a widely performed procedure that yields favorable clinical outcomes2,3. Studies have demonstrated that anatomical hepatectomy yields superior outcomes compared to nonanatomic resection in patients with hepatocellular carcinoma4,5. Consequently, laparoscopic anatomic hepatectomy (LAH) has gained popularity worldwide6. However, intraoperative hemorrhage remains the primary concern during liver resection procedures-in laparoscopic and open surgeries involving both anatomic and nonanatomic resection7. Besides, intraoperative hemorrhage is the primary cause for conversion from laparoscopic surgery to open surgery during parenchymal transection8,9. To effectively control and minimize intraoperative bleeding, it is widely recommended to maintain the central venous pressure (CVP) below 5 cmH2O in patients undergoing hepatectomy10,11. Additionally, various instruments, such as a cavitron ultrasonic surgical aspirator (CUSA) and an ultrasonic dissector have been utilized12,13, and numerous liver resection techniques, including the liver hanging maneuver14, Pringle maneuver15,16, and the &#34;two-surgeon technique&#34;17,18, have also been documented.
The Pringle maneuver, first reported in 190819, represents the most straightforward technique for hepatic inflow occlusion and is currently readily achievable during laparoscopic hepatectomy with high efficacy20,21.
The two-surgeon technique, proposed as an alternative to the traditional single-surgeon approach, was initially employed in open liver resections17. This method blurs the division of labor between primary and secondary surgeons, with both participating concurrently during parenchymal transection, as well as hemostasis using different energy instruments. Studies have shown that this technique can reduce operation time and intraoperative complications18,22. Takahisa et al. provided us with some recommendations for performing the two-surgeon laparoscopic technique23, but different centers may select different devices to transect the liver parenchymal tissue, and there remains a lack of evidence to demonstrate which mode of the two-surgeon technique yields superior patient outcomes.
The CUSA, a commonly used device in liver resection, employs ultrasonic energy to fragment and aspirate parenchymal tissue, thereby allowing for precision transection with minimal damage to blood vessels and bile ducts13. Another frequently used tool is the ultrasonic dissector, which utilizes the vibrations of two blades to disrupt hydrogen bonds and effectively cut liver parenchyma while coagulating small vessels &#8804;3 mm in diameter13.
In July 2020, our center implemented the two-surgeon technique for the first time. One surgeon used a CUSA while the other used an ultrasonic dissector. This was combined with a simple extracorporeal Pringle maneuver and low CVP technique to treat a 54-year-old female patient who had been experiencing liver mass and an increased serum alpha-fetoprotein (AFP) level of 104 ng/mL for 1 week. Magnetic resonance imaging (MRI) (Figure 1A,B) indicated a tumor measuring about 2 cm in size located in the S5 and S8 segments, which was considered the primary hepatocellular carcinoma. This article presents the protocol of our center&#39;s experience with the CUSA-ultrasonic dissector-extracorporeal Pringle maneuver technique.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>1.0 absorbable suture</td>
			<td>Ethicon Inc</td>
			<td>SN2210023642</td>
			<td>Sterile, radiation sterilization, disposable</td>
		</tr>
		<tr>
			<td>1.0 non-absorbable suture</td>
			<td>Ethicon Inc</td>
			<td>SF1AN</td>
			<td>Sterile, radiation sterilization, disposable</td>
		</tr>
		<tr>
			<td>10-mm trocar</td>
			<td>Hangzhou Optoelectronic Equipment Medical Co., LTD</td>
			<td>121-01715</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>12-mm trocar</td>
			<td>Hangzhou Optoelectronic Equipment Medical Co., LTD</td>
			<td>121-01715</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>5-mm trocar</td>
			<td>Hangzhou Optoelectronic Equipment Medical Co., LTD</td>
			<td>121-01715</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>7.0 non-absorbable suture</td>
			<td>Ethicon Inc</td>
			<td>SF7AN</td>
			<td>Sterile, radiation sterilization, disposable</td>
		</tr>
		<tr>
			<td>Aspirator</td>
			<td>Hangzhou Kangji Medical Instrument Co., LTD</td>
			<td>20172080644</td>
			<td>Sterile,dry heat sterilized, reusable</td>
		</tr>
		<tr>
			<td>Cordless Ultrasonic dissector</td>
			<td>Covidien llc</td>
			<td>SCD396</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>CUSA</td>
			<td>INTEGRA</td>
			<td>HDA1902805IE</td>
			<td>Sterile,dry heat sterilized, reusable</td>
		</tr>
		<tr>
			<td>Electric coagulation hook</td>
			<td>Zhejiang Shuyou Instrument Equipment Co., LTD</td>
			<td>IIIA-D003-SG842</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Endo-GIA stapler</td>
			<td>Jiangsu Guanchuang Medical Technology Co., LTD</td>
			<td>GCJQB-160</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Endoscopic specimen bag</td>
			<td>Qingdao Huaren Medical Product Co., LTD</td>
			<td>20192060113</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Hem-o-lok</td>
			<td>Zhejiang Wedu Medical Instrument Co., LTD</td>
			<td>JY1004-2012003</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Laparoscopic ultrasound</td>
			<td>BK medical</td>
			<td>flex Focus 800</td>
			<td>Sterile,dry heat sterilized, reusable</td>
		</tr>
		<tr>
			<td>Lumir device (modified Pringle maneuver)</td>
			<td>Shanghai Chester Medical Technology Co., LTD</td>
			<td>016651477</td>
			<td>Sterile,dry heat sterilized, reusable</td>
		</tr>
		<tr>
			<td>Surgicel(absorbable hemostat)</td>
			<td>Ethicon Inc</td>
			<td>LAB0011179V3</td>
			<td>Sterile, radiation sterilization, disposable</td>
		</tr>
		<tr>
			<td>Veress needle</td>
			<td>Hangzhou Kangji Medical Instrument Co., LTD</td>
			<td>20172080644</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
	</tbody>
</table>

modified laparoscopic anatomic hepatectomy: two-surgeon technique combined with the simple extracorporeal pringle maneuver

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to the anatomical characteristics of the liver, with intraoperative hemorrhage being a primary concern. Intraoperative blood loss is the leading cause of conversion to open surgery; therefore, effective management of bleeding and hemostasis is crucial for a successful LAH.
The two-surgeon technique is proposed as an alternative to the traditional single-surgeon approach, with potential benefits in reducing intraoperative bleeding during laparoscopic hepatectomy. However, there remains a lack of evidence to determine which mode of the two-surgeon technique yields superior patient outcomes. Besides, to our knowledge, the LAH technique, which involves the use of a cavitron ultrasonic surgical aspirator (CUSA) by the primary surgeon while an ultrasonic dissector by the second surgeon, has been rarely reported before.
Herein, we present a modified, two-surgeon LAH technique, wherein one surgeon employs a CUSA while the other uses an ultrasonic dissector. This technique is combined with a simple extracorporeal Pringle maneuver and low central venous pressure (CVP) approach. In this modified technique, the primary and secondary surgeons utilize a laparoscopic CUSA and an ultrasonic dissectorconcurrently to achieve precise and expeditious hepatectomy. A simple extracorporeal Pringle maneuver, combined with the maintenance of low CVP, is employed to regulate the hepatic inflow and outflow in order to minimize intraoperative bleeding. This approach facilitates the attainment of a dry and clean operative field, which allows for the precise ligation and dissection of blood vessels and bile ducts. The modified LAH procedure is simpler and safer due to its effective control over bleeding as well as the seamless transition between the roles of primary and secondary surgeons. It holds great promise for future clinical applications.

This 54-year-old female patient underwent a successful total laparoscopic anatomic hepatectomy (S5 + S8v) using the CUSA-ultrasonic dissector-extracorporeal Pringle maneuver technique, resulting in favorable perioperative outcomes. During the operation, a total of four extracorporeal Pringle maneuvers were performed to control and minimize intraoperative bleeding. The operation lasted approximately 145 min, with an estimated blood loss of 150 mL. The patient made a rapid recovery, being d...

Watch this Scientific Journal Video about Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver at JoVE.com

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Here, we present a protocol to perform a modified laparoscopic anatomic hepatectomy using improved techniques and instruments.

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to ...

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Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In ...

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore ...

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may ...

A Modified Technique for Arteriovenous Fistula Construction in Rabbits

Juxta-anastomotic stenosis is a challenging problem that often causes non-maturation and decreases the patency of an arteriovenous fistula (AVF). Injury ...