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Technical Aspects of Laparoscopic Liver Resection. An Experimental Study
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Various techniques are used to transect the liver. With increase in laparoscopic liver resections (LLR), it is of even more interest to develop surgical techniques to minimize bleeding and the risk for gas embolism during transection. Instrument like argon enhanced coagulator provides good hemostasis but increases the danger of gas embolism. The CO2 pneumoperitoneum that is routinely used in most types of laparoscopic surgery can be modified by the use of different gas pressure. It can be assumed that different pressure influences bleeding but also the risk for gas embolism.

In presented porcine studies, three instrumental combinations have been studied. In study I sixteen piglets were randomized to LLR with either the cavitron ultrasonic aspirator (CUSA™) in combination with vessels sealing system (Ligasure™) or with CUSA™ and ultrascision scissors (Autosonix™), with the endpoints of intra-operative bleeding and gas embolism.  In study IV sixteen piglets were randomized to LLR either with staple device (Endo-GIA™) or the Ligasure™ - CUSA™ combination with same primary endpoints and additionally secondary endpoints of effect on gas-exchange, systemic- and pulmonary hemodynamic.

Focusing on intra-abdominal pressure (IAP) in study II, sixteen piglets were randomized to LLR with an IAP of either 8 or 16 mmHg.  Primary endpoints were bleeding and gas embolism and secondary endpoints, effect on gas-exchange, systemic- and pulmonary hemodynamic.

In study III effect of argon gas was tested during LLR. Sixteen piglets were randomized to either argon pneumoperitoneum or CO2 pneumoperitoneum. Primary endpoints were effect on gas-exchange, systemic- and pulmonary hemodynamic.

In presented studies, we tested efficacy and safety of different techniques for LLR. CUSA™ can be used in combination with either Ligasure™ or Autosonix™. However, Ligasure™ reduces the amount of bleeding. The recent introduction of staplers seems promising with a further reduction in bleeding, gas embolism, and operating time. The IAP influences both the amount of bleeding as well as gas embolism. It seems reasonable to use a higher IAP to decrease bleeding with caution and with close monitoring for gas embolism. Argon gas embolism gives more extensive effect on gas-exchange and hemodynamic and should probably be avoided in this type of surgery.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. , 104 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 756
Keyword [en]
Gas embolism, laparoscopy, liver resection, pneumoperitoneum, carbon dioxide, argon, bleeding, stapling device
National Category
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-171735ISBN: 978-91-554-8321-0 (print)OAI: oai:DiVA.org:uu-171735DiVA: diva2:512252
Public defence
2012-05-11, Enghoffsalen, Akademiska Sjukhuset, entrance 50, ground floor, Uppsala, 13:00 (Norwegian)
Opponent
Supervisors
Available from: 2012-04-20 Created: 2012-03-26 Last updated: 2012-08-01Bibliographically approved
List of papers
1. Laparoscopic left lobe liver resection in a porcine model: a study of the efficacy and safety of different surgical techniques
Open this publication in new window or tab >>Laparoscopic left lobe liver resection in a porcine model: a study of the efficacy and safety of different surgical techniques
2009 (English)In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 23, no 5, 1038-1042 p.Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: Laparoscopic liver surgery is evolving and the best technique for dividing the liver parenchyma is currently under debate. The aim of this study was to study different techniques during a full laparoscopic lobe resection, and determine the efficacy and risks of bleeding and gas embolism. METHODS: Sixteen pigs were randomized to two groups: group US underwent an operation with Ultracision shears (AutoSonix) and ultrasonic dissector (CUSA) and group VS with a vessel sealing system (Ligasure) and ultrasonic dissector. A left lobe resection was performed. Transesophageal endoscopic echocardiography (TEE) was used to detect gas emboli in the right side of the heart and pulmonary artery. The operations and TEE were recorded for later assessment. RESULTS: Compared with group VS, group US exhibited significantly more intraoperative bleeding (p = 0.02), a trend towards a longer operation time (p = 0.08), and a trend towards more embolization for grade I emboli. In total, 10 of 15 animals had emboli during the operation. CONCLUSIONS: This study showed that a laparoscopic left lobe resection can be performed with a combination of AutoSonix and CUSA as well as with Ligasure and CUSA instrumentation. In our hands, less bleeding was incurred with Ligasure than with AutoSonix.

Keyword
Laparoscopic liver surgery, Liver resection, Carbon dioxide embolism, Bleeding
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-109411 (URN)10.1007/s00464-008-0115-6 (DOI)000265442900017 ()18814003 (PubMedID)
Available from: 2009-10-15 Created: 2009-10-15 Last updated: 2017-12-12Bibliographically approved
2. High intra-abdominal pressure during experimental laparoscopic liver resection reduces bleeding but increases the risk of gas embolism
Open this publication in new window or tab >>High intra-abdominal pressure during experimental laparoscopic liver resection reduces bleeding but increases the risk of gas embolism
2011 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 98, no 6, 845-852 p.Article in journal (Refereed) Published
Abstract [en]

Background: Various recommendations exist regarding intra-abdominal pressure (IAP) during laparoscopic liver resection. A high IAP may reduce bleeding but at the same time increase the risk of gas embolism. This study investigated the effects of two different IAPs during laparoscopic left liver lobe resection in piglets. Methods: Sixteen piglets underwent laparoscopic left liver lobe resection using carbon dioxide pneumoperitoneum of either 8 or 16 mmHg (8 per group). A combination of CUSA System 200 (TM) and LigaSure (TM) instruments was used for parenchymal division. During resection, a standard injury to the left liver vein was also created to increase the risk of bleeding and/or gas embolism during the operation. Heart rate, cardiac output, and arterial, pulmonary arterial, pulmonary capillary wedge and central venous pressures were measured. Arterial blood gases were monitored continuously. Transoesophageal echocardiography was video recorded to detect and quantify gas embolism within the right cardiac ventricle. The duration of operation and bleeding were noted. Results: High IAP resulted in reduced bleeding (P = 0.016), but gas embolism occurred more frequently (P = 0.001) than with low IAP. Gas embolism disturbed gas exchange, with an increase in arterial pressure of carbon dioxide, and a decrease in arterial partial pressure of oxygen and pH. These effects were sustained for at least 30 min after surgery. Conclusion: High IAP reduces the amount of bleeding but increases the risk of gas embolism. Monitoring for gas embolism is therefore indicated if a high IAP is used during laparoscopic liver resection.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-154346 (URN)10.1002/bjs.7457 (DOI)000290519300077 ()21523699 (PubMedID)
Available from: 2011-05-31 Created: 2011-05-31 Last updated: 2017-12-11Bibliographically approved
3. Is there a difference between carbon dioxide and argon gas embolisms in laparoscopic liver resection?
Open this publication in new window or tab >>Is there a difference between carbon dioxide and argon gas embolisms in laparoscopic liver resection?
2012 (English)Article in journal (Other academic) Submitted
Abstract [en]

Background:

Several methods are available to control bleeding during laparoscopic liver resection (LLR).  One of these techniques, argon enhanced coagulation (AEC), could be hazardous because of the argon gas.  Argon gas has poorer solubility in blood than CO2.  Previous animal studies have shown the danger of gas embolism during LLR.  The aim of this study was to compare the effects of Argon gas embolism and CO2 embolism, with special emphasis on pulmonary circulation and gas exchange, during laparoscopic liver surgery.

Method:

Sixteen piglets underwent laparoscopic left lateral liver resection and were randomised to either CO2 or argon pneumoperitoneum, at 16 mmHg.  The pulmonary circulation of the animals was monitored with a pulmonary arterial catheter.  Paratrend® was used to continuously measure PaCO2, PaO2, and pH, and transoesophageal ultrasound was used to detect embolisms on the right side of the heart.

Results:

Equal amount of embolism were seen in both groups.  The mean pulmonary arterial pressure (MPAP) increased in the Argon-group (P=0.050) as did the pulmonary vascular resistance (PVR) (P=0.015) compared with the CO2-group, correlating with the amount of embolism.  The gas exchange was then affected with an decrease in PaO2 and increase in PaCO2 , resulting  in acidosis.

Conclusion:

Argon gas embolism has more effects on pulmonary circulation and gas exchange than CO2.  If used, great care should be taken with argon gas and the patient should be carefully monitored during LLR.

Keyword
gas embolism, laparoscopy, liver surgery, pneumoperitoneum, argon.
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-171729 (URN)
Available from: 2012-03-26 Created: 2012-03-26 Last updated: 2015-06-08Bibliographically approved
4. Faster and safer resection with a stapler device: randomised, controlled trial of laparoscopic liver resection in a porcine model
Open this publication in new window or tab >>Faster and safer resection with a stapler device: randomised, controlled trial of laparoscopic liver resection in a porcine model
Show others...
(English)Article in journal (Other academic) Submitted
Abstract [en]

Introduction. Many surgeons use stapling during liver resection. The stapler has the potential to close all luminal structures in the liver tissue and thus result in minimal bleeding, reduced danger of gas embolism, and a faster surgery.

Material. Sixteen piglets where randomised into two groups receiving either laparoscopic liver resection with a vessel sealing system and an ultrasonic dissector (group-L) or with stapling (group-S). Pneumoperitoneum at 16 mmHg pressure was used. Gas embolism was detected with transesophageal ultrasound and intra-operative bleeding estimated. Monitoring of gas exchange with continuous recording of PaCO2, PaO2, end-tidal CO2, and pH was used. Invasive monitoring of systemic and pulmonary circulation was performed.

Results. Stapling resulted in less bleeding (P = 0.026), less gas embolism (P = 0.001), and a shorter operating time (P = 0.004).

Conclusion. In this animal model, stapling of the liver parenchyma led to a faster and safer resection compared to the use of a vessel sealing system and an ultrasonic dissector.

Keyword
Pneumoperitoneum, laparoscopy, liver surgery, stapling device, gas embolism, bleeding
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-171731 (URN)
Available from: 2012-03-27 Created: 2012-03-26 Last updated: 2012-08-01Bibliographically approved

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