Liver resection using heat coagulative dessication

1. Liver Resection Using Heat Coagulative Desiccation - preliminary experience with 30 operated patients Prof. M. Milićević MD, Ph D., FACS and P. Bulaji ć MD . The First Surgical Clinic, University of Belgrade Clinical Center IASG Meeting, Buc h arest 2003.

4. The crucial issue is: Can a simple technique achieve minimal blood loss and safe, tissue sparing liver, parenchyma transsection even in non-anatomical planes ?

6. 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.

8. Radionics Cool-tip ™ RF System Coagulative necrosis – tissue dessication 100° C 50° C Denatura tion of collagen Thermal lesion starts 60° C 70° C 80° C 90° C Cool Tip minimal goal Temp. RF induced ionic agitation produces heat

12. CAN RF BE USED FOR LIVER RESECTION AND NOT ONLY FOR TUMOR ABLATION – THAT IS THE QUESTION?

13. “ ZERO BLOOD LOSS” HEPATECTOMY The Nagy Habib RF hepate ctomy

14. How does RF work on liver tissue ? Current Diameter of coagulation 3 x 1 cm tumor = 20 min. 3 x 1 cm liver = 40 sec.

15. THE ORIGINAL “NAGY HABIB OPERATION” THE TWO CIRCLE TECHNIQUE

17. The first patient operated by the “Habib technique” Liver cut at right angle

18. The second patient operated by the “Habib technique” Liver cut at right angle

20. Patient No. 3 horizontally placed needle V IV

21. Patient No. 3 IVb VIII VI II i III

23. Patient No. 4 part V i VI seg. 150 g

24. Patient No. 4 postoperative view

26. Patient No. 5 OP. modification : cooling of the bile ducts

27. Patient No. 5 Main tumor 550 g. Vitality of seg. V ?

28. Patient No. 5 Diaphragm resected – Pleural space not entered Seg. V and VI preserved

29. Microscopic analysis of the resected liver (HE stain)

30. THE SEQUENTIAL CONTINUOUS COAGULATE-CUT TECHNIQUE min. blood loss liver transection technique without occlusion 2.8 kg (the CUSA like technique)

31. 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 Coulombs Maximal delivered current = 1735.89 mA

32. The sequential continuous coagulate-cut technique - the CUSA like technique -

33. The sequential continuous coagulate-cut technique - resection close to the liver hilum -

34. 3,8 kg The sequential continuous coagulate-cut technique - massive tumor right hepatectomy -

35. The sequential continuous coagulate-cut technique - minimal blood-loss liver transection -

36. Atypical liver resection (rf technique)

37. The sequential continuous coagulate-cut technique - how close to vital liver structures with RF needle - res. IVa, VHM VCI VHM GB ped

38. Re-resection 9 months after right hepatectomy minimal liver tissue damage

39. rf resected area 11 months after operation

40. rf resected area following sequential continuous coagulate-cut technique HE 40x – cell shrinkage, granular hyperesonophylic cytoplasm small dark picnotic nucleus – desication evident

41. SOLITARY NECROTIC LIVER NODULE rf resection in rare entity K. Iwase et al, J Hepato-Biliary- Pancreatic Surgery, 9;1 (120-124), 2002 untill today only 22 cases published

42. OPERATED PATIENTS 01.1 2 .2001 – 01.11.200 2 38 pts. – 40 operations (18 to 76 yrs . – mod. 60) liver lesion pts. operated CRC metastases 20 liver primary Ca 9 recurrent liver abscess 1 actynomicosis 1 ovarii Ca meetastasis 1 hydatid cyst 2 GB cancer 2 Giant liver haemangioma Pulmonary metastasis unknown primary solitary necrotic liver nodule 1 1 1 1 t o t a l 40

43. type of liver resection 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

44. * reoperated † died ( 3 pts. -7.5%) Morbidity and mortality Type of complication No. pts. sequestrated desiccated tissue * pleural empyema † op. site infection wound dehiscience* thrombosis of portal vein enteralna fistula* † pseudomembranous colitis † 2 2 1 1 1 1 1 U k u p n o 9

45. BLOOD TRANSUSION ? NO TRANSFUSION 26 pts. 65.0 % TRANSFUSION 1 4 pts. 3 5.0 % 12 of 1 4 pts. (8 5 %) avg . preop. Hb 9.33 g/L - difficult adhaesiolysis - resection of other organs AVERAGE TRANSFUSION 457.27 mL ( min 240 – max. 1160 ) BLOOD LOSS NOT RELATED TO PROCEDURE ON LIVER

46. instead of a conclusion for those who doubt RF coagulation works …. Transsegment al rese ction of s p l een – no additional hemostasis ... Scintigraphy 2 months po. HE stain