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.

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 …

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.

The crucial issue is:

Can a simple technique achieve minimal blood loss and safe, tissue sparing liver, parenchyma transsection

even in non-anatomical planes ?

The objective ?

To asses a new technique using radiofrequency energy (RF) to coagulate liver resection margins and

perform practically bloodless liver resection …

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.

Cool-tip™RF Generator

Cool-tip™RF Peristaltic Perfusion Pump

Cool-tip™RF Electrode Needles

Generator output: 0 -200 Watts, 2000 mA, 480 KHz

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

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

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

Traditional RF(Ø : + 1 - 1.5 cm) - 15 min.

Cooled RF(Ø : 3 cm) - 15 min.

Cooltip™RF MethodCooltip™RF Method

CAN RF BE USED FOR LIVER RESECTION AND NOT ONLY FOR TUMOR ABLATION – THAT IS

THE QUESTION?

“ZERO BLOOD LOSS” HEPATECTOMYThe Nagy Habib RF hepatectomy

How does RF work on liver tissue ?

Current

Diameter of

coagulation3 x 1 cm tumor = 20 min.3 x 1 cm liver = 40 sec.

THE ORIGINAL “NAGY HABIB OPERATION”

THE TWO CIRCLE TECHNIQUE

first patient done bythe “Habib technique”

– 67 yrs.– 7 m. after APR (Miles) op.– metastasis VI i VII seg.– pre. op. perfused

The first patient operated by the “Habib technique”

Liver cut at right angle

The second patient operated by the “Habib technique”

Liver cut at right angle

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

Patient No. 3

horizontally placed needle

V

IV

Patient No. 3

IVb

VIII

VI

II i III

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.

Patient No. 4

part V i VI seg.

150 g

Patient No. 4 postoperative view

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.

Patient No. 5

OP. modification: cooling of the bile ducts

Patient No. 5

Main tumor 550 g.Vitality of seg. V ?

Patient No. 5

Diaphragm resected –Pleural space not entered

Seg. V and VIpreserved

Microscopic analysis of the resected liver(HE stain)

THE SEQUENTIAL CONTINUOUS COAGULATE-CUT TECHNIQUE

min. blood loss liver transection technique without occlusion

2.8 kg

(the CUSA like technique)

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

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

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

The sequential continuous coagulate-cut technique- massive tumor right hepatectomy -

3,8 kg

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

Atypical liver resection (rf technique)

The sequential continuous coagulate-cut technique

- how close to vital liver structures with RF needle -

res. IVa, VHM

VCI

VHM

GB

ped

Re-resection 9 months after right hepatectomyminimal liver tissue damage

rf resected area 11 months after operation

rf resected area following sequential continuous coagulate-cut technique

HE 40x – cell shrinkage, granular hyperesonophylic cytoplasm small dark picnotic nucleus – desication evident

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

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)

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

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

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

instead of a conclusion for those who doubt RF coagulation works ….

Transsegmental resection of spleen – no additional hemostasis ...

Scintigraphy 2 months po.HE stain