Scraping Hepatectomy Using Ultrasonic Scalpel for Complex Liver Segment Resection.

Abstract

In recent years, laparoscopic anatomical liver resection (LALR) has gained recognition for its efficacy and safety.^1,2 However, segments VII and VIII remain challenging due to their deep location and proximity to major vessels.³ Inadvertent manipulation can easily cause serious complications including massive bleeding and CO₂ gas embolism. Therefore, we propose an innovative ultrasonic scalpel scraping technique for hepatic vessel skeletonization in LALR. A male patient was admitted with hepatic mass. Three-dimensional liver modeling showed the tumor located in segment VIII without major vessel invasion. The liver parenchyma dissecting-first ventral approach was used. Inflow occlusion was managed by an intermittent Pringle maneuver using a Foley catheter. Initially, liver parenchyma transection was attempted without inflow occlusion, but as the transverse plane deepened and the skeletal process of the middle hepatic vein(MHV), right hepatic vein(RHV), and VIII Glisson segment progressed, the Pringle maneuver was applied to enhance safety and visibility. During parenchymal dissection, the ultrasonic scalpel remained in a continuously activated state, scraping back and forth between the liver parenchyma and the surface of blood vessels (Fig. 1). The activated working surface maintained close liver contact throughout. Small vessels and bile ducts were directly coagulated and sealed by ultrasonic energy, avoiding injury to deep structures. During vessel skeletonization, the ultrasonic scalpel was positioned at 15-30° angles, gently separating parenchyma covering vessels through scraping rather than clamping. This method avoided vessel damage from tissue clamping. Even brief adventitial contact caused no vascular injury. During this process, small venous branches of the MHV and RHV were sometimes severed, producing small holes in venous walls. Most were immediately sealed by ultrasonic energy, while persistent oozing was controlled with bipolar coagulation. A small portion needed to be treated with Hem-o-Lock clips or 5-0/6-0 Prolene sutures. Fig. 1 Demonstration of ultrasonic scalpel scraping technology RESULTS: A total of six cycles of inflow occlusion were performed using the Pringle maneuver, with a cumulative clamping time of 90 min. Operative time was 280 min and blood loss was 100 ml. Histopathological diagnosis was moderately differentiated intrahepatic cholangiocarcinoma. No postoperative complications occurred and the patient was discharged 7 days after surgery. The continuously activated ultrasonic scalpel scraping technique in LALR not only achieves rapid vessel skeletonization, but also ensures vessel integrity.