Abstract
How to Reduce Blood Loss and Morbidities in Laparoscopic Liver Resection
Dr Ho-Seong Han
Professor and Chairman, Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
The laparoscopic liver resection is being performed only in limited centers, even over 20 years of history of laparoscopic surgery. The major obstacles to wide application of this procedure are technical difficulty, potential risk of gas embolism, difficulty in controlling hemorrhage, and insufficient development of the instrument. Furthermore, the laparoscopic liver resection requires the surgeon to have experiences in both open liver surgery and laparoscopic procedure. The requirements of highest skill hinder the wide application of this procedure. In this session, the technique to reduce the blood loss and morbidities will be discussed.
Liver resection is accompanied with huge bleeding even in open surgery. As with open surgery, meticulous procedure is crucial to reducing the bleeding amount. If the amount of blood loss is high, the morbidities also accordingly increase. The procedure, which is prone to massive bleeding is during parenchymal transection. There are several equipments for parenchymal transection. The ultrasonic shears and Liga-sure are good equipment for fast transection with proper coagulation of the parenchyme of the liver. Although they are very useful during superficial transection of liver parenchyme, these devices have limitation in controlling larger diameter vessels. If they fail to control the vessels, the result of massive bleeding is formidable. We have used CUSA, designed for laparoscopy, for parenchymal transection. The large vessels and bile duct can be isolated by CUSA, then they can be safely controlled with endo-clip or endo-GIA. Endo_GIA is also useful for severing the large diameter vessels and bile ducts. Pringle maneuver can be used in laparoscopic setting as open surgery. Although lowering of the CVP is usually used in open surgery, its use should be cautiously balanced due to the risk of gas embolism. If the amount of blood loss exceed over 1 L, open conversion and meticulous hemostasis are necessary
Morbidities occur less frequently in laparoscopic resection than open surgery. Although gas embolism has never been reported in the literature on laparoscopic liver resection, we should be aware of this catastrophic complication during the procedure. If the hemodynamic status of the patient suddenly deteriorates, we must consider the possibilities of gas embolism, The Argon beam coagulator or any device, which increases intraperitoneal pressure, should not be used during parenchymal transection of the liver.
Although the laparoscopic liver resection requires high skilled technique, meticulous techniques and the standardization of the procedure will make this procedure as attractive option for liver resection.
