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Liver Resection Using Heat Coagulative Desiccation- preliminary experience with 30 operated patients
Prof. M. Milićević MD, Ph D., FACS and P. Bulajić MD.
The First Surgical Clinic,University of Belgrade Clinical Center
IASG Meeting, Bucharest 2003.
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The facts …
Surgical resection remains the gold standard in dealing with liver tumors …
Results of liver resection have improved over the last decade …
Liver resection remains a formidable surgical procedure …
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The facts …
• Intraoperative blood loss remains a major concern for surgeons operating on the liver: it is associated with a higher rate of postoperative complications and shorter long-term survival
Bismuth H.: Ann Surg 1989; 210:13-19.
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The crucial issue is:
Can a simple technique achieve minimal blood loss and safe, tissue sparing liver, parenchyma transsection
even in non-anatomical planes ?
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The objective ?
To asses a new technique using radiofrequency energy (RF) to coagulate liver resection margins and
perform practically bloodless liver resection …
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The effect of monopolar diathermy …
Cushing H, Bovie WT. Electro-surgery as an aid to the removal of intracranial tumors. Surg Gynecol Obstet 1928;47:751-784.
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Cool-tip™RF Generator
Cool-tip™RF Peristaltic Perfusion Pump
Cool-tip™RF Electrode Needles
Generator output: 0 -200 Watts, 2000 mA, 480 KHz
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Radionics Radionics
Cool-tip Cool-tip™™RF SystemRF System Coagulative necrosis – tissue dessication
100° C
50° CDenaturation of collagenThermal lesion starts
60° C
70° C
80° C
90° C
Cool Tip minimal goal Temp.
RF induced ionic agitationproduces heat
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What RF assisted technique are we talking about ?
High frequency alternating current is used to achieve clearly demarcated coagulative dessication of liver tissue
The direction of the current is from the non-insulated tip of the electrode into liver tissue
Ions in liver tissue follow the direction of the current (ionic agitation) and the resulting friction produces heat
Source of the heat is not the electrode – it is the tissue itself close to the electrode
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The advantage of RF generated heat coagulative dessication:
No tissue boiling No tissue cavitation No tissue charring Tissue dessication is not self-limiting High energy for short periods
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Traditional RF(Ø : + 1 - 1.5 cm) - 15 min.
Cooled RF(Ø : 3 cm) - 15 min.
Cooltip™RF MethodCooltip™RF Method
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CAN RF BE USED FOR LIVER RESECTION AND NOT ONLY FOR TUMOR ABLATION – THAT IS
THE QUESTION?
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“ZERO BLOOD LOSS” HEPATECTOMYThe Nagy Habib RF hepatectomy
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How does RF work on liver tissue ?
Current
Diameter of
coagulation3 x 1 cm tumor = 20 min.3 x 1 cm liver = 40 sec.
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THE ORIGINAL “NAGY HABIB OPERATION”
THE TWO CIRCLE TECHNIQUE
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first patient done bythe “Habib technique”
– 67 yrs.– 7 m. after APR (Miles) op.– metastasis VI i VII seg.– pre. op. perfused
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The first patient operated by the “Habib technique”
Liver cut at right angle
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The second patient operated by the “Habib technique”
Liver cut at right angle
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The third patient operated by the “Habib technique”
– 71 yrs.– 9 mon. after right
hemicolectomy– Multiple metastases– in seg. II i III– in seg. IVa– In seg. V
II i III
IV
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Patient No. 3
horizontally placed needle
V
IV
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Patient No. 3
IVb
VIII
VI
II i III
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Patient No. 4
– 69 yrs.– 18 mon. l. hemicolectomy– Multiple hepatic mets– in seg. II i III– in seg. V i VI
250 g
II i III seg.
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Patient No. 4
part V i VI seg.
150 g
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Patient No. 4 postoperative view
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Patient No. 5
– 68 yrs.– Primary liver tumor– Liver micronod.
fibrosis– Tu in VI seg.– Tu in VII i VIII– Infiltration of
diaphragm– No lymph nodes
IV
VI
VII
VIIIInfl. Diaphrgm.
lig.
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Patient No. 5
OP. modification: cooling of the bile ducts
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Patient No. 5
Main tumor 550 g.Vitality of seg. V ?
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Patient No. 5
Diaphragm resected –Pleural space not entered
Seg. V and VIpreserved
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Microscopic analysis of the resected liver(HE stain)
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THE SEQUENTIAL CONTINUOUS COAGULATE-CUT TECHNIQUE
min. blood loss liver transection technique without occlusion
2.8 kg
(the CUSA like technique)
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Modification of the operative technique Computer monitoring of output parameters
( average - last 24 patients )
Total emission time = 41.08 min.Total current integral = 1892.39 CoulombsMaximal delivered current = 1735.89 mA
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The sequential continuous coagulate-cut technique- the CUSA like technique -
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The sequential continuous coagulate-cut technique- resection close to the liver hilum -
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The sequential continuous coagulate-cut technique- massive tumor right hepatectomy -
3,8 kg
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The sequential continuous coagulate-cut technique- minimal blood-loss liver transection -
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Atypical liver resection (rf technique)
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The sequential continuous coagulate-cut technique
- how close to vital liver structures with RF needle -
res. IVa, VHM
VCI
VHM
GB
ped
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Re-resection 9 months after right hepatectomyminimal liver tissue damage
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rf resected area 11 months after operation
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rf resected area following sequential continuous coagulate-cut technique
HE 40x – cell shrinkage, granular hyperesonophylic cytoplasm small dark picnotic nucleus – desication evident
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SOLITARY NECROTIC LIVER NODULErf resection in rare entity
K. Iwase et al, J Hepato-Biliary- Pancreatic Surgery, 9;1 (120-124), 2002untill today only 22 cases published
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liver lesion pts. operatedCRC metastases 20
liver primary Ca 9
recurrent liver abscess 1
actynomicosis 1
ovarii Ca meetastasis 1
hydatid cyst 2
GB cancer 2
Giant liver haemangiomaPulmonary metastasisunknown primarysolitary necrotic liver nodule
1111
t o t a l 40
OPERATED PATIENTS01.12.2001 – 01.11.2002
38 pts. – 40 operations (18 to 76 yrs. – mod. 60)
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TYPE HEPATECTOMY (20%) NO. PTS.
right 5
left 3
TOTAL 8
TYPE OF RESECTION NO. PTS
three segments
two segments
two segments + subsegmen.
segmentectomy + subsegmen.
segmentectomy
sub-segmentectomy
metastasectomy
TOTAL
3
7 ( 3 leve)
6
6
1
6
3
32
type of liver resection
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Type of complication No. pts.
sequestrated desiccated tissue *pleural empyema †
op. site infection
wound dehiscience*
thrombosis of portal veinenteralna fistula* †pseudomembranous colitis †
2
2
1
1
1
1
1
U k u p n o 9
* reoperated
† died ( 3 pts. -7.5%)
Morbidity and mortality
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BLOOD TRANSUSION ?
NO TRANSFUSION 26 pts. 65.0%TRANSFUSION 14 pts. 35.0%
12 of 14 pts. (85%) avg. preop. Hb 9.33 g/L - difficult adhaesiolysis - resection of other organsAVERAGE TRANSFUSION 457.27 mL (min 240 – max. 1160)
BLOOD LOSS NOT RELATED TO PROCEDURE ON LIVER
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instead of a conclusion for those who doubt RF coagulation works ….
Transsegmental resection of spleen – no additional hemostasis ...
Scintigraphy 2 months po.HE stain