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Hemorrhage control for laparoscopic hepatectomy: technical details and predictive factors for intraoperative blood loss

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Abstract

Background

Controlling bleeding during laparoscopic hepatectomy (LH) is technically demanding, but reportedly associated with less estimated blood loss (EBL) than open surgery. The present study aimed to describe and evaluate hemorrhage control techniques during LH and identify predictors of high intraoperative EBL.

Methods

The data of 438 consecutive patients undergoing LH between 1995 and 2012 were reviewed. Bleeding control was facilitated by the proper use of hemostatic devices and surgical maneuvers unique to LH and by preserving intra-abdominal pressure. EBL was evaluated among three groups of 146 patients in each group: 1995–2006 (group A), 2006–2009 (group B), and 2009–2012 (group C). We also sought factors that predicted EBL ≥800 mL.

Results

Mean EBL decreased overtime from groups A to C: group A, 378 ± 619 mL; group B, 293 ± 391 mL; groups C, 257 ± 366 mL; P = 0.127. Transfusion rate was 6.7 % in group A, 5.5 % in group B, and 4.8 % in group C (P = 0.743). Hypertension (odds ratio (OR) 2.82, 95 % confidence interval CI 1.37–5.78; P = 0.006), preoperative chemotherapy (OR 2.55, 95 % CI 1.26–5.31; P = 0.009), resection of posterosuperior segments (OR 3.73, 95 % CI 1.33–12.17; P = 0.012), and major hepatectomy (OR 4.21, 95 % CI 1.64–13.02; P < 0.001) independently predicted high EBL.

Conclusions

Improvements in bleeding control techniques over time have reduced EBL during LH. The use of these techniques and an understanding of the predictive factors for high EBL will help surgeons improve outcomes after LH.

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Abbreviations

LH:

Laparoscopic hepatectomy

OH:

Open hepatectomy

SD:

Standard deviation

EBL:

Estimated blood loss

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Acknowledgments

The authors thank Dr. Nobutaka Tanaka, Dr. Yukihiro Nomura, and Dr. Motoki Nagai at Asahi General Hospital for helping with acquisition of data and providing useful insights.

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Authors and Affiliations

  1. Department of Digestive Diseases, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014, Paris, France

    Yoshikuni Kawaguchi, Takeo Nomi, David Fuks, Frederic Mal & Brice Gayet

  2. Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

    Yoshikuni Kawaguchi & Norihiro Kokudo

  3. Department of Surgery, Asahi General Hospital, Chiba, Japan

    Yoshikuni Kawaguchi

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  1. Yoshikuni Kawaguchi
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Correspondence to Yoshikuni Kawaguchi or Brice Gayet.

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Disclosures

Yoshikuni Kawaguchi, Takeo Nomi, David Fuks, Frederic Mal, Norihiro Kokudo, and Brice Gayet have no conflict of interest or financial ties to disclose.

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Supplementary video 1

Inflow occlusion technique (Pringle maneuver). A tape is placed around the hepatoduodenal ligament, along which a tube is introduced to allow occlusion of hepatic inflow. Parenchymal transection close to the surface does not cause bleeding without applying the Pringle maneuver as in this case. The tube is repositioned when it interferes with the transection. The inflow occlusion technique is performed to address persistent bleeding deep within the liver, after which parenchymal transection is subsequently performed using standard techniques on the cut surface. (MPG 61220 kb)

Supplementary video 2

Removal of bipolar forceps while continuing to apply current. Bipolar forceps are used for bleeding control. The postcoagulation tissue is removed with the tips as the forceps are withdrawn, causing re-bleeding at the same point on removal. To avoid re-bleeding under these circumstances, bipolar forceps should be removed from the point of bleeding with the current still applied. (MPG 37272 kb)

Supplementary video 3

Replacement of bipolar forceps. Bipolar forceps are replaced with a clean set to prevent inefficient coagulation and adherence to the liver parenchyma due to excessive burnt tissue on the tips after coagulation. (MPG 17586 kb)

Supplementary video 4

Preservation of intra-abdominal pressure. Bleeding is first controlled by compression with forceps. Subsequently, a suction catheter is used cautiously so as not to decrease the intra-abdominal pressure while accommodating bipolar coagulation. (MPG 16208 kb)

Supplementary video 5

Bipolar coagulation with simultaneous compression of the liver parenchyma. During bleeding control using bipolar coagulation, the liver parenchyma is compressed by a suction catheter to reduce hepatic venous pressure with interest and optimize contact between the device tips and the bleeding point. (MPG 9108 kb)

Supplementary video 6

Bipolar coagulation and placement of fibrillar oxidized cellulose. Whenever bleeding persists after an attempt at bleeding control with bipolar coagulation, a small amount of fibrillar oxidized cellulose is placed on the point of subsequent oozing, providing short-term local compression. (MPG 22612 kb)

Supplementary video 7

Bleeding of peripheral portal pedicle. Massive bleeding is encountered from the stump of a peripheral portal pedicle during transection of the liver. Such massive bleeding can be controlled by a combination of the techniques previously described, including compression of the liver parenchyma by forceps and preservation of the intra-abdominal pressure. (MPG 36558 kb)

Supplementary video 8

Bleeding directly from the hepatic vein: instantaneous (single shot) bipolar coagulation. Bleeding from small holes on the hepatic vein is controlled using instantaneous (single shot) coagulation with bipolar forceps. (MPG 13522 kb)

Supplementary video 9

Introduction of a gauze through a hand-assisted system at the beginning of the procedure. A gauze is introduced through a hand-assisted system before parenchymal transection if there is judged to be a high risk of massive bleeding. The gauze is placed on the bleeding point using the surgeon’s hand when bleeding control is difficult. The point of bleeding was controlled 5 minutes after manual compression with the gauze. Subsequent transection was performed with the gauze still on the cut surface to suppress oozing. (MPG 55348 kb)

Supplementary video 10

Conversion to an open approach. During extended left lateral sectionectomy including segment 4a, bleeding is encountered when parenchymal transection is performed on the liver surface, where risk of bleeding is generally considered to be lower than that deep within the liver. Bleeding control has been attempted laparoscopically, but conversion to an open approach is needed due to persistent bleeding from the parenchyma close to the surface. (MPG 43238 kb)

Supplementary video 11

Bleeding control using a monopolar electrode with saline irrigation. Bleeding from the hepatic vein and the cut surface of the liver is controlled using a monopolar electrode with saline irrigation. This device delivers less intense coagulation to the cut surface while avoiding carbonization of the tissue. (MPG 23088 kb)

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Kawaguchi, Y., Nomi, T., Fuks, D. et al. Hemorrhage control for laparoscopic hepatectomy: technical details and predictive factors for intraoperative blood loss. Surg Endosc 30, 2543–2551 (2016). https://doi.org/10.1007/s00464-015-4520-3

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