Advancement in liver laparoscopic resection - development of a new surgical device

Liver resection is the standard treatment for any liver lesion. Laparoscopic liver resection is associated with lower intra-operative blood loss and fewer complications than open resection. Access to the posterior part of the right liver lobe is very uncomfortable and difficult for surgeons due the anatomic position, especially when employing laparoscopic surgery. Based on these experiences, a new laparoscopic device was developed that is capable of bending its long axis and allowing the application of radiofrequency energy in areas that were not technically accessible. The device is equipped with four telescopic needle electrodes that cause tissue coagulation after the delivery of radiofrequency energy. Ex vivo testing was performed in 2012 and 2014 at the University Hospital, Ostrava, on a porcine liver tissue. The main goal of this testing was to verify if the newly proposed electrode layout was suitable for sufficient tissue coagulation and creating a safety zone around lesions. During the ex vivo testing, the material of needle electrodes was improved to achieve the lowest possibility of adhesion. The power supply was adjusted from 20 to 120 W and the ablation time, which varied from 10 to 110 s, was monitored. Subsequently, optimal power delivery and time for coagulation was determined. This experimental study demonstrated the feasibility and safety of the newly developed device. Based on the ex vivo testing, LARA-K1 can create a safety zone of coagulation. For further assessment of the new device, an in vivo study should be performed.

Ressecção hepática robótica: relato de experiência pioneira na América Latina / First robotic-assisted laparoscopic liver resection in Latin America

Graças ao melhor conhecimento da anatomia segmentar do fígado e desenvolvimento de novas técnicas, houve aumento no número de indicações de hepatectomias. O desenvolvimento da cirurgia minimamente invasiva ocorreu paralelamente e o aumento da experiência, aliado ao desenvolvimento de novos instrumentais, resultaram no crescimento exponencial das ressecções hepáticas videolaparoscópicas. A abordagem laparoscópica pode tornar viável a ressecção hepática em pacientes cirróticos com hipertensão portal que não tolerariam este mesmo procedimento por via laparotômica. A cirurgia robótica surgiu nos últimos anos como a última fronteira de desenvolvimento técnico aplicado à videocirurgia. O presente trabalho descreve a experiência pioneira de ressecção hepática totalmente com o uso de robótica na América Latina, em paciente com carcinoma hepatocelular e cirrose hepática. A hepatectomia laparoscópica com o uso do sistema robótico Da Vinci permite refinamentos técnicos graças à visualização tridimensional do campo cirúrgico e utilização de instrumentais precisos e com grande amplitude de movimentação que simulam os movimentos da mão humana.

The surgical robotic system is superior to traditional laparoscopy in regards to 3-dimensional images and better instrumentations. Robotic surgery for hepatic resection has not yet been extensively reported. The aim of this paper is to report the first known case of liver resection with use of a computer-assisted, or robotic, surgical device in Latin America. A 72-year-old male with cryptogenic liver cirrhosis and hepatocellular carcinoma was referred for surgical treatment. Preoperative clinical evaluation and laboratory data disclosed a Child-Pugh class A patient. Magnetic resonance imaging showed a 2.2 cm tumor in segment 5. Liver size was decreased and there were signs of portal hypertension, such as splenomegaly and enlarged portal vein collaterals. Preoperative upper digestive endoscopy disclosed esophageal varices. Five trocars were used. Liver transection was achieved with harmonic scalpel and bipolar forceps. Hemostasis of raw surface areas was accomplished with interrupted stitches. Operative time was 120 minutes. Blood loss was minimal and the patient did not receive transfusion. The recovery was uneventful and patient was discharged on the 3rd postoperative day without ascites formation. Laparoscopic hepatic resection can safely be performed. The laparoscopic approach may enable liver resection in patients with cirrhosis and evidence of liver failure that would contraindicate open surgery probably because it precludes the transection of major abdominal collaterals. The Da Vinci robotic system allowed for technical refinements of laparoscopic liver resection due to 3-dimensional visualization of the operative field and instruments with wrist-type end-effectors.

Evaluación hepática con TC multidetector. Angiotomografía, determinación volumétrica y hepatectomía virtual / Liver evaluation with multidetector CT. Angiotomography, volume determination and virtual hepatectomy

Objetivo: mostrar una nueva técnica de evaluación prequirúrgica del hígado utilizando tomografía computada multidetector (TCMD), determinando la utilidad de las reconstrucciones angiográficas, la volumetría hepática y la hepatectomía virtual, en correlación con los hallazgos quirúrgicos. Métodos: veinte pacientes con tumores hepáticos primarios o secundarios fueron evaluados con TCMD y luego operados. Las TC se efectuaron con técnica de doble fase (arterial y venosa) con un tomógrafo de 4 filas de detectores (Mx8000; Philips Medical Systems) luego de la inyección de 120ml de contraste endovenoso con una bomba inyectora. La adquisición se realizó con una colimación de 4x2.5mm. Las imágenes se evaluaron en conjunto con los cirujanos. Se calcularon los volúmenes hepáticos, se realizaron reconstrucciones vasculares y se efectuó la hepatectomía virtual. Se determinó la correlación del volumen de hígado a resecar establecido por la hepatectomía virtual y el de la pieza quirúrgica mediante el método de Bland y Altman. Resultados: la hepatectomía virtual permitió planificar y realizar en todos los pacientes la cirugía en un solo tiempo quirúrgico. No se produjeron complicaciones. El coeficiente de correlación fue 0.83 (IC 95%: -132.08- 159.78). Conclusiones: la hepatectomía virtual prequirúrgica es una nueva herramienta diagnóstica de la TCMD que, junto con las reconstrucciones vasculares, es útil para determinar la técnica quirúrgica a realizar en cada paciente y para estimar si el volumen hepático remanente será suficiente para evitar el desarrollo de una insuficiencia hepática post-quirúrgica.

Aim: to show a new technique of presurgical liver tumor evaluation using multidetector computed tomography (MDCT), determining the usefulness of angiographic reconstructions, presurgical virtual hepatectomy and 3D liver volume determination, in correlation with surgery findings. Methods: twenty patients with primary or secondary liver tumors were evaluated with MDCT and then operated on. Dualphase CT was performed in all patients on a 4-row multidetector CT scanner (Mx8000; Philips Medical Systems) after mechanical injection of 120ml of iodinated contrast medium. Scanning was performed using a detector configuration of 4x2.5mm. Images were sent to a workstation and they were analysed with the surgeons. The 3D volumes of each lesion, of the total liver and of the segments to be resected were calculated. Vascular reconstructions and virtual hepatectomy were also performed. Correlation of the liver volume between MDCT and surgery was calculated using the Bland and Altman method. Results: virtual liver segmentation allowed to perform the surgery in 100 % of the patients in one time and there were no complications. The correlation coefficient was 0.83 (CI 95%: -132.08, 159.78). Conclusions: presurgical liver hepatectomy is a new application tool of MDCT. The angiographic findings and the volume determination are useful to determine the surgical technique for each patient and this information allows the surgeons to know if the remnant liver will be enough for the patients to avoid a post-surgical liver insufficiency.