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Energy devices and liver adjuncts .pptx
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- 2. History • Dr. WilliamT. Bovie in the 1920s- spark gap generator was used to build the first electrosurgery tool, commonly known as RF knife or ‘Bovie’ • 1950’s- first bipolar unit built by Dr. Leonard Malis, wherein two electrodes were used for gripping and manipulating the tissue
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- 4. Electrosurgery • Electro cautery-(Thermal probe) -Electrically heated wire contacting tissue -No transfer of electricity -Direct current • Electro-surgery -AC is applied to the tissue -Current passes through patient -Cut, coagulate, dessicate and fulgurate
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- 8. Crest Factor (Coagwithout cut)
- 9. Other definitions • Dessication -Destruction of cells by dehydration - If continued- lateral thermal spread • Fulguration - Non-contact effect - Ionisation of air formation of sparks effects from coagulation to carbonization depending on duration of current applied • Vaporization - Initial dessication short spark intracellular boiling cell expolosion steam release
- 11. Monopolar • Simple equipment-easy to use • Cheaper • Shorter operative times • Best for making skin incisions Disadvantages • Injury to patients through direct and capacitive coupling, insulation failure • Interference with pacemakers • Risk of OR fire • Smoke • Higher temperature at tip- longer cool down times • Large thermal spread (development of biliary strictures post lap cholecystectomy) Advantages
- 12. Complications • Grounding failures •Alternate site injuries • Demodulated currents • Insulation failure • Tissue injury at distal site • Sparking • Direct coupling • Capacitive coupling • Surgical glove injury • Explosion
- 14. Caution • Lowest settingas feasible • Pacemaker/ Defibrillator/ Conductive prosthesis • Tip to be cleaned to avoid impedance/resistance- spark and flames • Wipe alcohol rubs off the abdominal wall prior to use - risk of fires
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- 16. Bipolar Advantages Disadvantages • Passageof current through operated tissue • Smaller thermal spread • Good coaptive sealing • Equal peak temperatures on different tissues • Available in many forms- scissors, forceps • Longer operative time than monopolar • Not effective for small blood vessels • Thermal spread dependent on power setting and user’s skill • Smoke
- 17. Adaptive tissue technology •Computer controlled tissue feedback response systems • Based on characteristic of tissue in jaws of instrument • Tissue impedance/ temperature based • Continuously adjust current and voltage generated by unit • Pulsed electrical transfer
- 18. Devices with adaptivetissue technology available under the following names
- 19. Advanced Bipolar (Ligasure) •Radio-frequency-energy-driven bipolar fusion device • Differences -Uses pressure and energy based collagen sealing (Impedance feedback- 3333 times/sec) -Electrical energy – pulsatile allowing tissue cooling and minimizing lateral spread -Self built retractable cutting blade -Seals upto 7 mm vessel diameter
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- 22. Ultrasonic electrosurgical devices •Principle- Piezoelectric effect • Electrical energy Mechanical energy • Ultrasonic vibrations of piezoelectric crystals (23 KHz in CUSA and 55 KHz in Harmonic Scalpel) • Transmitted to the tip of instrument Thermal energy • Tissue transection with hemostasis
- 23. Ultrasonic generator • 2settings MAX- • Mechanical energy delivered greatest –rapid tissue transection • Less lateral thermal spread, poor hemostatic potential MIN- • Low mechanical energy – ideal for vessel sealing • Increased risk of lateral thermal spread
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- 25. Ultrasonic energy Advantages • Usuallyleast thermal spread • No smoke • Best for small vessels upto 2 mm • Best quality seals at lower power levels • Lesser operative time • No charring- better visualized planes Disadvantages • High blade temperatures- damage after switching off • Temperature inversely proportional to tissue thickness • High power settings- significant thermal spread(25.7 mm)and peak temp • No sealing effect for vessels more than 2 mm
- 26. CUSA • Cavitational ultrasonicaspirating device • Cavitational fragmentation- cells disrupted • Ultrasonic aspirator- fragments cells and aspirates cellular debris and water • Vibrates at 23,000 Hz • Collagen rich tissues intact- vessels, nerves and lymphatics
- 27. Thunderbeat • Single devicesimultaneously delivers -Ultrasonically generated frictional heat energy (like Harmonic) -Electrically generated advanced bipolar energy (like Bipolar) • Higher bursting pressure and highly reduced thermal spread, no blade required for cutting
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- 30. Lasers • First used-1979 • Today relegated to gynecological procedures mostly; cosmetic and eye surgeries; used in lap cholecystectomy • Generate heat by a concentrated light beam • Most commercial – infra red to UV frequencies
- 31. Lasers • Photo- thermalprocess- destroys tumors • Photo- chemical process- non thermal mechanisms -Low irradiance- induces chemical reactions causing inactivity -High irradiance- ‘photo plasmal’ process • Contact or non contact type
- 32. Lasers Advantages • Wide usagein gynaecological procedures because of precise control of affected depth of tissue • Less scarring Disadvantages • Very expensive • Risk of fire • Increased operative time • Air embolism • Precision vs efficiency • Laser lap cholecystectomy- Hepatic artery injury
- 33. Argon Beam Coagulation •First reported use in head and neck surgery (1989) • Directed beam of Argon aids conduction of radiofrequency to tissue by ionization • Non contact method • Caution - Flow rate should be low to prevent gas embolism - Direct contact to be avoided • No significant benefit over other techniques Bobbio A, Ampollini L, Internullo E, Caporale D, Cattelani L, Bettati S, et al. Thoracoscopic parietal pleural argon beam coagulation versus pleural abrasion in the treatment of primary spontaneous pneumothorax. European Journal of Cardio-thoracic Surgery. 2006;29(1):6–8.
- 34. Argon Beam Coagulation Advantages •Good hemostasis- faster coagulation times; (diffuse ooze on liver cut surface) • Blows away blood and debris- uniform coagulated surface • Less smoke • Constant thermal spread (2-3 mm) Disadvantages • Air embolism- fatal • Not used for cutting • Use of electricity- risk of interference with surgical equipment
- 35. Radio Frequency Energy •3 kHz- 300 MHz frequency • Lowest frequency Electromagnetic wave- longer time to generate heat • 2 modes- laparoscopic usage; percutaneous treatment via needle insertion into organ • Uniform heating of larger tissues but lack of precision • Interference with cardiac activity
- 36. Radio Frequency Energy •Novel commercial device- -Gyrus Plasma Trissector- bipolar RF system -Reduces sticking, seals large vessels , secure dissecting of tissue -Ligasure
- 37. Summary • Thermal damage- Monopolar >>> Ultrasonic energy • Seal strength - dependent on blood vessel size - Ultrasonic for small vessels - Electrosurgery for larger vessels • Least Operative time – Harmonic scalpel • ABC- most effective for hemostasis ; risk of air embolism • Lasers- limited application; high cost
- 38. Familiarity with energysource - less chances of inadvertent injuries
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- 40. Introduction • Liver resectionis the most effective treatment of HCC and Colorectal liver metastases • No. of resections have increased • Major hepatectomies • Knowledge and use of adjuncts- decreased morbidity & mortality
- 41. Anatomic Knowledge AnestheticTechniques Vascular Control + Transection Techniques Imaging Progress in Hepatic Surgery
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- 43. CT & MRI •Hepatic & biliary anatomy • Better surgical planning • Decreased postop complications • Volumetric CT: Future Liver Remnant
- 44. IOUS • Better definitionof relationship of tumour to surrounding structures • Changes surgical Strategy in over 40% of cases • CT scans had a sensitivity of 72.8% overall, but decreases to 34.6% for tumours less than 1cm. • Sensitivity: 98% • Parker GA, Lawrence W Jr, Florsley JS et al. Intraoperative ultrasound of the liver affects operative decision making. Annals of Surgery l989;209:569-577 • Shukla PJ, Pandey D, Rao PP, Shrinkhande SV, Thakur MH, Arya S, Ramani S, Mehta S, Mohandas KM. Impact of intra-operative ultrasonography in liver surgery. Indian J oumal of Gastroenterology 2005; 24(2):62-65
- 45. ICG • Tumor identification •ICG (0.5 mg/kg body weight) is administered intravenously, usually within two weeks before surgery • Detect biliary congestion caused by tumor invasion, micrometastases from pancreatic cancer, and extrahepatic spread of HCC
- 46. ICG • Liver segmentation •Injection of 0.25−2.5 mg/mL ICG into the portal veins or by intravenous injection of 2.5 mg ICG following closure of the proximal portal pedicle toward hepatic regions to be removed • ICG administration –at least 15 minutes prior • ICG stays upto 6 hours into extrahepatic bile duct
- 47. ICG • Liver segmentation •Injection of 0.25−2.5 mg/mL ICG into the portal veins or by intravenous injection of 2.5 mg ICG following closure of the proximal portal pedicle toward hepatic regions to be removed • ICG administration -upto 6 hours into extrahepatic bile duct
- 48. Intraop cholangiogram • Cholangiographycatheter/ IFT advanced into cystic duct and fixed using a silk suture • Five to ten ml of contrast(meglumine diatrizoate)injected into biliary tree • Distal common bile duct occluded • Describe the anatomical variation occurring in intrahepatic bile ducts • Bile duct leakages on liver surface determined digitally in the form of contrast extravasation
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- 51. Anesthetic techniques Low CVP <5mm Hg Vasodilators Diuretics Urine output: 25 ml/ hr Systolic BP >90
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- 53. Blood loss • Post-operativemorbidity: 23- 46% • Mortality: 4- 5% • Intra-operative haemorrhage: 700 -1200 ml • Rate of perioperative transfusions Immunosuppression Increased infection & recurrence* • *Stephenson KR, Steinberg SM, Hughes KS, Vetto JT, Sugarbaker PH, Chang AE. Perioperative blood trasfusions are associated with decreased time to recurrence and decreased survival after resection for colorectal liver metastases. Annals of Surgery 1988; 208: 679-687 • *Fujimoto J, Okamoto E, Yamanaka N et al: Adverse Effect of Perioperative Blood Transfusions on Survival after hepatic Resection for Hepatocellular Carcinoma. Hepato- Gastroenterlogy 1997; 44:1390-1396
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- 56. Vascular Control • Principle:To limit the blood flow through liver Strategies Inflow control Total vascular occlusion
- 57. Inflow Control Pringle Maneuvre Intermittent Pringle Maneuvre CPMwith Preconditioning Half Pringle Maneuvre Segmental Vascular Clamping
- 58. Pringle Maneuvre • Portaltriad of hepatoduodenal ligament • No hemodynamic effect • No special anaesthetic requirement • Back-bleeding from hepatic veins • Reperfusion injury A. Band placed around ligament B. ligament occluded C. Ligament clamped
- 59. Intermittent Pringle Maneuvre •Clamping: Unclamping = 20:5 or 5:1 • *Belghiti J, Noun R, Malafosse R, Jagot P, Sauvanet A, Pierangeli F, et al. Continuous versus intermittent portal triad clamping for liver resection: a controlled study. Ann Surg 1999; 229: 369-75 Well tolerated in cirrhosis Prolonged duration of ischemia Blood loss is similar Increased blood loss during reperfusion Transection time is prolonged Advantages Disadvantages
- 60. Ischemic Preconditioning • 10min ischemia 10 min reperfusion CPM • Protects against reperfusion injury* • Beneficial in young pt requiring prolonged inflow occlusion/ steatotic liver *Clavien PA, Yadav S, Sindram D, Bentley RC. Protective effects of ischaemic precon‐ ditioning for liver resection performed under inflow occlusion in humans. Ann Surg 2000; 232: 155-62 *Clavien PA, Selzner M, Rudiger HA, Graf R, Kadry Z, Rousson V, Jochum W. A prospective randomized study in 100 consecutive patients undergoing major liver resection with versus without ischemic preconditioning. Ann Surg 2003; 238: 843-52
- 61. Half Pringle Maneuvre(Hemihepatic Clamping) • Clamping of portal v. and hepatic a. to right or left liver • Clear demarcation • No ischemia of unaffected lobe • No visceral congestion • Bleeding from unoccluded lobe *Makuuchi M, Mori T, Gunven P, Yamazaki S, Hasegawa H. Safety of hemihepatic vascular occlusion during resection of the liver. Surg Gynecol Obstet 1987; 164: 155-8.
- 62. Segmental Vascular Clamping •Shimamura et al • Hepatic a. & portal v. of affected segment • Balloon catheter in portal v. using Cholangiogram needle • Allows limited anatomical resection • Identifies boundaries of segment • Decreased blood loss *Castaing D, Garden OJ, Bismuth H. Segmental liver resection using ultrasound-guided selective portal venous occlusion. Ann Surg 1989; 210: 20-23.
- 63. Total Vascular Exclusion •Huguet et al • Isolates liver and retrohepatic vena cava from rest of the systemic circulation • Large tumors close to or infiltrating IVC • No advantage over vascular occlusion *Huguet C, Addario-Chieco P, Gavelli A, Arrigo E, Harb J, Clement RR. Technique of hepatic vascular exclusion for extensive liver resection. Am J Surg 1992; 163: 602-05.
- 64. Complete mobilization of Liver PringleManeuvre Infrahepatic IVC Control Suprahepatic IVC Control
- 65. Infrahepatic VC prepared for2-3 cm Right adrenal vein ligated A finger is passed under the cava from the right to the left right angle is passed under the infrahepatic vena cava Mobilize the retrohepatic and suprahepatic vena cava up to the diaphragm. Pass a finger behind the vena cava and cauterizing the connective tissue. There are no venous branches in this area. Curved clamp is placed from left to right as high as possible
- 66. • Significant hemodynamicchanges* • Marked decrease in venous return • 80% increase in systemic vascular resistance • 50% increase in heart rate • 40-60% decrease in cardiac output • Decreases • Hemorrhage • Air embolism from injury to IVC or hepatic veins • Increased postop complications than PM *Eyraud D, Richard O, Borie DC, Schaup B, Carayon A, Vezinet C, et al. Hemodynamic and hormonal responses to the sudden interruption of caval flow: Insights from a prospective study of hepatic vascular exclusion during major liver resections. Anesth Analg 2002; 95: 1173-8.
- 67. Total Vascular Exclusionwith Preservation of Caval Flow • Elias et al • For patients who should have classical vascular exclusion but cannot tolerate vena cava clamping • Hepatic veins are dissected and looped • Inflow occlusion hepatic vein occlusion • No interruption of caval flow • Continuous or intermittent • More demanding technique • Avoids the haemodynamic drawbacks of TVE *Elias D, Dube P, Bonvalot S, Debanne B, Plaud B, Lasser P. Intermittent complete vascular exclusion of the liver during hepatectomy: Technique and indications. Hepatogastroenterology 1998; 45: 389-95.
- 68. Mobilise Right & Leftlobes Pringle Maneuvre Exposure & clamping of Right Hepatic Vein Exposure & Clamping of Left & Midlle hepatic veins
- 70. No hemodynamic changes Canbe done intermittently No need for retrocaval dissection Better tolerated in diseased liver Less splanchnic congestion Technically demanding Cant be used in tumors involving IVC Advantages Disadvantages
- 71. Ischemia Time Method NormalLiver Cirrhotic Liver Continuous Inflow Occlusion 60 30 Intermittent PM 120 60 Total Vascular Exclusion 60 30 Ischemic Preconditioning 75 ?
- 72. Comparison of DifferentOcclusion Techniques
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- 75. Surgical Techniques Transection • Fingerfracture • Clamp/ Crush • Ligasure • Harmonic Scalpel • Hydrojet • CUSA Hemostasis • Electrocoagulation • Clips • Sutures • Staplers • Ligasure • Gyrus
- 76. Finger Fracture • Describedin1896 by William Keen • Resection can be completed in 15 min • Friable liver tissue is crushed b/w fingers isolating vessels and bile ducts • Insecurity of introducing fingers and looking for structures
- 77. Clamp Crush Technique •Described in 1970 by Lin • Crush the tissue using Kelly clamp • Vessels and bile ducts are visualised and controlled • Difficult in cirrhosis
- 78. • Rents arecreated on glisson capsule 2- 3 cm apart • Clamp is introduced and liver crushed • Structures appear as white cords bridges • Clamp is released • Portal v, hepatic a and duct anteriorly and hepatic vein posteriorly ligated
- 79. CUSA (Cavitron UltrasonicSurgical Aspirator) • Titanium tip • Oscillates at 23 kHz • Saline irrigation system Continuous cooling of device • Continuous suction
- 80. Accurate surgical control Bettervisualization Non anatomic resection Deeper dissection Selective dissection No hemostasis Less useful in cirrhosis Advantages Disadvantages
- 81. Helix Hydrojet • Atthe tip of the nozzle, the water jet reaches hypersonic speeds at up to 20000 bar pressure, with which even steel panels can be cut very precisely, effortlessly and without any heat development • High-pressure liquid jet with pressures of between 10 and 150 bar and a jet diameter of 0.12 mm. • Equipped with suction • Allows vascular and bile duct structures to be rinsed out of the parenchyma
- 82. Precision Smooth cut surface Cirrhoticliver No hemostasis Seeding Infection to users Advantages Disadvantages
- 83. Harmonic Scalpel •Simultaneously cuts &coagulates •Vessels upto 3 mm •No smoke •Cirrhotic Bile leak* Risk of shearing Advantages Disadvantages *Kim J, Ahamad SA, Lowy AM et al: Increased biliary fistulas after liver resection with the Harmonic Scalpel. The American Surgeon 2003; 69(9):815-819
- 84. Harmonic Focus • Fusiontechnique • Crushing by nonactivated HS • Precision & depth of crushing adjusted by modulating blade pressure • Vessels upto 5 mm coagulated under vision without changing blades • Reduces bile leak
- 85. TMFB (Tissuelink Monopolar FloatingBall) • Based on RF • Continuous saline supply to tip cooling & conduction of RF • Coagulates vessels upto 3 mm • No char/ coagulum/ smoke • Cheap • Easy to use
- 86. Bipolar Vessel SealingDevice (Ligasure ) • RF based • Fragmentation by clamp crush • Instant Response Technology No smoke/ charring Seals vessels upto 7 mm Coagulum sticks to tissues Not useful in cirrhosis Advantages Disadvantages
- 87. Gyrus Plasmakinetic PulsedBipolar Coagulation Device Clamp crush No smoke/ charring Seals vessels upto 7 mm Cirrhosis Less data Advantages Disadvantages
- 88. Aquamantis System • Transcollationtechnology- simultaneous delivery of RF & saline • Keeps temp < 100 degrees Seals upto 6 mm No smoke/ charring Cirrhotic liver Inadequate data Constant suctioning Advantages Disadvantages
- 89. Coolinside • Simultaneous coagulation(RF) & cutting (cold knife) • Precoagulation Difficulty in identifying vessels • 5 mm coagulated area Limiting in cirrhosis
- 90. Staplers Faster Controlling hepatic v. Failsto seal small bile ducts Expensive Misfiring Inadequate margins near vitals structures Advantages Disadvantages
- 91. Habib’s Technique (BloodlessHepatectomy Technique) • Cooled tip RF probe of 3 cm exposed tip to coagulate liver resection margins. • 2 cm-wide coagulative necrosis zone is created by multiple applications of the probes division of the parenchyma with a surgical scalpel • Both the remnant liver and the removed specimen have on the margin of resection a portion of necrotic coagulated liver l cm thick.
- 92. Non anatomic resections Repeatedresections Hemostasis by RF use only (coagulates large vessels) No need for occlusive techniques (eg. Knots, clips, glue) Simple Cirrhotic Loss of 1 cm of normal parenchyma Increased abdominal abscess Cant be applied near vena cava and hilum (RF less effective) Time consuming Advantages Disadvantages
- 93. Chang’s Needle Technique •18 cm needle & no. 1 silk • Overlapping interlocking mattress sutures • Transection by scissors or cautery • No other occlusion technique • Cheap • Cant be used in lesions close to IVC
- 94. • The needlepenetrates the entire depth of the liver parenchyma from the liver surface and catches one end of no. 1 silk thread from below , then penetrates again, 3–5 cm away from the previous point of insertion, to catch the other end of the thread. • A secure tie can subsequently be made to block all vascular flows within this area
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- 96. Comparison of Transectiontechniques • Bipolar – least blood loss and shorter operative time, followed by stapler and Tissue Link • Harmonic Scalpel- lower complications than Hydrojet and clamp crushing A systematic review and network meta analysis of parenchymal transection techniques during hepatectomy: an appraisal of current RCTs; September 2019; HPB
- 97. Comparison of Transectiontechniques A systematic review and network meta analysis of parenchymal transection techniques during hepatectomy: an appraisal of current RCTs; September 2019; HPB
- 98. Transection techniques ina nutshell • Clamp crushing -low-cost technique; requires substantial experience • CUSA -currently the standard liver transection technique • Low blood loss with a well-established safety record • Main disadvantage- slow transection Poon RT. Current techniques of liver transection. HPB (Oxford). 2007;9(3):166-73.
- 99. Transection techniques ina nutshell Newer instruments - Harmonic Scalpel, Ligasure and TissueLink Dissector • Enhance the capability of hemostasis and allow faster transection • Lack the preciseness of CUSA in dissection of major hepatic veins • Associated with increased risk of bile leak • Wedge or segmental resection (particularly useful in laparoscopic liver resection) • Combination with CUSA - sealing of vessels, increases the cost substantially • RFA-assisted transection- probably the most speedy technique Poon RT. Current techniques of liver transection. HPB (Oxford). 2007;9(3):166-73.
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Editor's Notes
- #22 Better hemostasis, longer jaw, less thermal spread, 360 degree rotation
- #44 Indocyanine Green Clearance Test 14%: Resection 15-20%: PVE >20%: No resection
- #46 Segment 8 – crlm rim fluorescent lesion
- #47 Seg 6 with icg+ indigo carmine
- #60 Reperfusion endothelial cells first and then apoptosis of hepatocytes Analysed by AST and ALT levels post resection
- #61 Caspase 3 and 8 activity decreased. AST and ALT levels decreased. Morphological features suggestive of hepatocyte and endothelial ce;lls apoptosis not found on electron microscopy in murine model. Liver tissue measured for atp levels.
- #63 22g chiba needle 5 ml isotonic saline in balloon Occlusion upto 60 min
- #79 2-3 times Caution so that tubular structures wont tear
- #81 Fragmentation, suction & irrigation simultaneously Tumour close to vital structures
- #99 Cusa, rfds, hydrojet, sharp dissection, clamp crush