Methods of Venous Hemostasis for the Standardization of Total Laparoscopic Hepatectomy

Mitsuo Miyazawa, MD FACS, Masayasu Aikawa, MD, Katsuya Okada, MD, Kojun Okamoto, MD, Yasuko Toshimitsu, MD, Shigeki Yamaguchi, MD, Isamu Koyama, MD. Saitama Medical University International Medical Center

In order to standardize total laparoscopic hepatectomy, it is necessary to establish a method for controlling venous hemorrhage, which impairs treatment and is the most common intra-operative complication. We investigated what types of techniques were useful in controlling hemorrhage during total laparoscopic hepatectomies conducted at our hospital.
[Methods] Total laparoscopic hepatectomy was conducted on 42 patients between January 2008 and May 2011 at Saitama Medical University International Medical Center, Department of Gastrointestinal Surgery. Our subjects comprised 9 of these patients whose intra-operative hemorrhage volume was 100 ml or more (3 cases [5 nodules] of hepatocellular carcinoma, 3 cases [8 nodules] of hepatic metastasis, 1 case of intrahepatic cholangiocarcinoma, 1 case of hepatic hemangioma, and 1 case of other hepatic tumor). We investigated the cause of hemorrhaging, useful hemostatic methods and clinicopathological features of the tumors.
[Results] None of the patients who underwent total laparoscopic hepatectomies during this period required conversion to laparotomy because of hemorrhaging. Increased hemorrhaging was observed in tumors localized to the S6, S7 peripheries, tumors with large diameter and, in one case, multiple nodules.
[Conclusions and Discussion] During total laparoscopic hepatectomy, it is difficult to conduct hemostasis on hemorrhaging in tumors, localized in S6, S7 peripheries because of the limited insertion angle for instruments used in hemostasis. Monopolar soft coagulation (under irrigation) was useful when there was a small amount of venous hemorrhaging (and the hole in the vein could be located). Bipolar soft coagulation with BiClamp was useful when the vein was narrow (a narrow vein had been torn). When difficulties are encountered with monopolar soft coagulation and bipolar soft coagulation, temporary pressure hemostasis using gauze and dissecting the area around the site of hemorrhaging before carefully examining the site and conducting hemostasis with clips and BiClamp was found to ensure no increased hemorrhaging.
 

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