Laparoscopic hepatic left lateral lobectomy using a combination of the harmonic scapel and the Aquamantys bipolar sealer: a case report

Abstract

Introduction: 

There are so many tools and energy devices, used in liver parenchymal transection and hemostasis. No consensus statement is achieved on what kind of tools or energy devices are more efficient or reliable.

Patient Concerns: 

A 40-year-old man presenting with epigastric discomfort was detected with a 6-cm sized mass at segment II/III with enhancement in the arterial phase with washout in the portal site or a delayed phase.

Diagnosis: 

The clinical diagnosis was hepatocellular carcinoma.

Interventions: 

We herein used a promising new tool, the Aquamantys bipolar sealer, combined with harmonic scalpel in liver parenchymal transection and hemostasis, and take laparoscopic left lateral lobectomy, for example.

Outcomes: 

When we used the Aquamantys bipolar sealer to coagulate and push parenchymal apart gently, the vessels were exposed spontaneously.

Conclusion: 

The coagulative and hemostatic effect was quite better than the previous tools. It is simple and practicable, and will help us to shorten the learning curve of laparoscopic hepatectomy.

Laparoscopic hepatectomy (LH) has been proven to be safe and effective, and is widely used around the world. It can shorten the operation time with less blood loss, reduce the complication rate, and shorten the duration of hospital stay compared with open surgery¹. Moreover LH often serves as a first-line treatment for malignancy confined to the left lateral lobe of liver. There are so many tools and energy devices, used in liver parenchymal transection and hemostasis, such as cavitron ultrasonic surgical aspirator, Habib-4X, harmonic scalpel, Ligasure, and Tissue-Link^2,3. No consensus statement is achieved on what kind of tools or energy devices are more efficient or reliable. The fundamental skills and experience cannot be replaced in spite of advances in technology. We herein report a promising new tool, the Aquamantys bipolar sealer (Medtronic Advanced Energy LLC, Rochester, NH) (Fig. 1), combined with harmonic scalpel in liver parenchymal transection and hemostasis, and take laparoscopic left lateral lobectomy, for example. This report is performed following the SCARE 2018 criteria⁴.

Figure 1: Side view of Aquamantys bipolar sealer (figure is not drawn to scale).

Clinical summary

A 40-year-old man presenting with epigastric discomfort was referred to our hospital for investigation. There was neither systemic illness, nor a history of abdominal surgery and substance abuse. HBs-Ag, HBe-Ab, and HBc-Ab were positive, while HCV-Ab was negative. Her liver function was fine, with a Child-pugh score A, and the preoperative indocyanine green (ICG) retention rate at 15 minutes was 3.8%. Preoperative levels of AFP and CA19-9 were 8581  ng/mL and 0.6 U/mL. Computed tomography scan showed a 6-cm sized mass at segment II/III with enhancement in the arterial phase with washout in the portal site or a delayed phase (Fig. 2). The clinical diagnosis was hepatocellular carcinoma.

Figure 2: Computed tomography image. A, A 6-cm sized mass at segment II/III with enhancement in the arterial phase. B, The enhancement washout in the portal phase.

Operative technique

The patient was placed in a supine position, with his legs apart, in the reversed Trendelenburg position. Three 12-mm trocars and two 5-mm trocars were used (Fig. 3). The principal steps of this procedure included division of the round ligament and falciform ligament, mark out the dissection line using the harmonic scapel, exposure of porta hepatis, dissection, and division the portal pedicles. Intraparenchymal dissection and division of the segment III and II pedicles, endovascular GIA stapler was used to control and divide the left hepatic vein, division of the coronary ligaments and finally removal of the specimen. The parenchymal transection was performed by using a combination of the harmonic scapel and the Aquamantys Bipolar Sealer. We usually coagulated for a few seconds and then push gently from side to side by using the Aquamantys Bipolar Sealer for soft liver parenchymal. When we felt tough liver pedicles beneath the parenchymal, we also used it to coagulate and push the surrounding parenchymal in order to expose the pedicles, then we used the Hemolock clips to ligate the vessels and cut them by using the harmonic scapel or scissor. Hemostasis could also be achieved by Aquamantys Bipolar Sealer. No pringle maneuver was performed in this procedure. This operation lasted 110 minutes with blood loss about 50 mL. The patient was discharged 5 days after surgery without postoperative complications.

Figure 3: Trocar positions. Three 12-mm trocar and two 5-mm trocar were used. Extend the middle trocar hole to take out the specimen (dashed line).

Conclusions

The tools and energy devices used in liver transection can be divided into 2 categories: the blind transaction using Endo-GIA, Habib-4X, and clamp-crush, which need not give priority to expose vessels clean before dissection, and the sharp transaction using cavitron ultrasonic surgical aspirator, harmonic scalpel, Ligasure, and bipolar coagulator, which need to expose vessels, and then clip or ligate them^2,3. In the present video, Supplemental Digital Content 1 (https://links.lww.com/IJSGH/A1) we used a promising new tool, the Aquamantys bipolar sealer, for laparoscopic left lateral lobectomy. When we used it to coagulate and push parenchymal apart gently, the vessels were exposed spontaneously. Subsequently, we can easily congeal or use clips to ligate them. The coagulative and hemostatic effect was quite better than the previous tools. It is simple and practicable, and will help us to shorten the learning curve of LH.

Ethical approval

Informed written consent was obtained from the patient for publication of this case report and accompanying images.

Sources of funding

This work was supported by grants from the Guangdong Medical Research Project (No.A2018247), Guangzhou Health and Family Planning Technology Project (No.20191A011096) awarded to Y.G.

Author contribution

Y.G., Y.L., and Y.T. performed the surgery together. All drafts of the reports were written by Y.G. and Y.T. All authors read and approved the final paper.

Conflict of interest disclosures

The authors declare that they have no financial conflict of interest with regard to the content of this report.

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Guarantor

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