Ramanathan M Seshadri, MD, David J Niemeyer, MD, Ryan Z Swan, MD, David Sindram, MD, PhD, David A Iannitti, MD, John B Martinie, MD. Carolinas Medical Center.
Introduction: Minimally Invasive Hepatobiliary Surgery has become standard of care in many well established tertiary care facilities across the country and the world. Early recovery, shorter hospital stay with comparable outcomes has made this technique very popular amongst surgeons and patients. However, the risk involved in the surgery remains the same; hemorrhage being the most common and significant complication. It increases the morbidity and mortality of the procedure and is associated with a higher risk of tumor recurrence.
There are several electrosurgery devices which are routinely used in liver surgery. The Tissue Link was one of the earlier iterations of using monopolar energy with saline coupled radiofrequency to control hemorrhage. Subsequently the Aquamantys® system using bipolar energy was introduced for open solid organ surgery. Our aim was to test the use of a novel laparoscopic bipolar sealer in conjunction with the Aquamantys® system in laparoscopic hepatobiliary procedures from a feasibility and safety perspective.
Methods: A prospective observational study was performed at our tertiary care facility. 20 patients (8M/12F) were recruited for the study after obtaining informed consent. Pertinent data including dissection time, vessel diameter, reliability, tissue response, steam production, blood loss, thermal spread, desiccation, sealing time, intraoperative and postoperative complications were recorded and managed using a HIPPA compliant web application – REDCap (Research Electronic Data Capture)
Results: The mean age of the patients undergoing the procedure was 62 years. There were 7 robot assisted partial hepatectomies, 10 laparoscopic hepatectomies (both involving resection > 2 segments); 2 laparoscopic cholecystectomies and 1 lap marsupialization of hepatic cyst performed. The laparoscopic Aquamantys® device was used for transection of liver parenchyma and cautery of the cut surface of liver or gallbladder fossa (per case) to achieve hemostasis. A successful seal was achieved in all cases with a maximal thermal spread of 2mm. Amongst the major hepatectomies (> 2 segments); the average time to obtain an adequate seal was 6 min and average blood loss was 320cc. Supplementary hemostatics (fibrin sealants) were used in 5 patients (20%). Steam production was noted while the device was active and required periodic venting via the laparoscopic ports but did not cause a delay in overall procedure time. There were no intraoperative complications. 5 patients had postoperative complications unrelated to the device (pleural effusion, ileus, tachycardia, urinary retention). All patients had a follow-up visit 2 weeks following discharge from the hospital and had no device related complications such as post-operative bleeding, bile leak, adjacent soft tissue injury, skin burns.
Conclusion: The laparoscopic Aquamantys® device provides adequate hemostasis minimizing blood loss and decreasing the need for secondary hemostatics. It can be safely used in minimally invasive hepato-biliary surgery.