Energy devices and liver adjuncts .pptx

.........

1. Energy Devices Dr. Tanvi Jain

2. History  Dr. William T. Bovie in the 1920s- spark gap generator was used to build the first electrosurgery tool, commonly known as RF knife or ‘ Bovie ’ 1950’s - first bipolar unit built by Dr. Leonard Malis , wherein two electrodes were used for gripping and manipulating the tissue

3. Temperature determined tissue changes

4. Electrosurgery Electro cautery- (Thermal probe) -Electrically heated wire contacting tissue -No transfer of electricity -Direct current Electro-surgery -AC is applied to the tissue -Current passes through patient -Cut, coagulate, dessicate and fulgurate

5. Monopolar

6. Crest Factor ( Coag without cut)

7. Other definitions Dessication Destruction of cells by dehydration - If continued- lateral thermal spread Fulguration - Non-contact effect - Ionisation of air  formation of sparks  effects from coagulation to carbonization depending on duration of current applied Vaporization - Initial dessication  short spark  intracellular boiling  cell expolosion  steam release

8. Monopolar Simple equipment- easy to use Cheaper Shorter operative times Best for making skin incisions Disadvantages Injury to patients through direct and capacitive coupling, insulation failure Interference with pacemakers Risk of OR fire Smoke Higher temperature at tip- longer cool down times Large thermal spread (development of biliary strictures post lap cholecystectomy) Advantages

9. Complications Grounding failures Alternate site injuries Demodulated currents Insulation failure Tissue injury at distal site Sparking Direct coupling Capacitive coupling Surgical glove injury Explosion

10. Caution Lowest setting as feasible Pacemaker/ Defibrillator/ Conductive prosthesis Tip to be cleaned to avoid impedance/resistance- spark and flames Wipe alcohol rubs off the abdominal wall prior to use - risk of fires

11. Bipolar

12. Bipolar Advantages Disadvantages Passage of current through operated tissue Smaller thermal spread Good coaptive sealing Equal peak temperatures on different tissues Available in many forms- scissors, forceps Longer operative time than monopolar Not effective for small blood vessels Thermal spread dependent on power setting and user’s skill Smoke

13. Adaptive tissue technology Computer controlled tissue feedback response systems Based on characteristic of tissue in jaws of instrument Tissue impedance/ temperature based Continuously adjust current and voltage generated by unit Pulsed electrical transfer

14. Devices with adaptive tissue technology available under the following names

15. Advanced Bipolar ( Ligasure )  Radio-frequency-energy-driven bipolar fusion device Differences -Uses pressure and energy based collagen sealing (Impedance feedback- 3333 times/sec) -Electrical energy – pulsatile allowing tissue cooling and minimizing lateral spread -Self built retractable cutting blade -Seals upto 7 mm vessel diameter

16. Ligasure

17. Enseal

18. Ultrasonic electrosurgical devices Principle- Piezoelectric effect Electrical energy  Mechanical energy Ultrasonic vibrations of piezoelectric crystals (23 KHz in CUSA and 55 KHz in Harmonic Scalpel) Transmitted to the tip of instrument Thermal energy Tissue transection with hemostasis

19. Ultrasonic generator 2 settings MAX- Mechanical energy delivered greatest –rapid tissue transection Less lateral thermal spread, poor hemostatic potential MIN- Low mechanical energy – ideal for vessel sealing Increased risk of lateral thermal spread

20. Harmonic scalpel

21. Ultrasonic energy Advantages Usually least thermal spread No smoke Best for small vessels upto 2 mm Best quality seals at lower power levels Lesser operative time No charring- better visualized planes Disadvantages High blade temperatures- damage after switching off Temperature inversely proportional to tissue thickness High power settings- significant thermal spread(25.7 mm)and peak temp No sealing effect for vessels more than 2 mm

22. CUSA Cavitational ultrasonic aspirating device Cavitational fragmentation- cells disrupted Ultrasonic aspirator- fragments cells and aspirates cellular debris and water Vibrates at 23,000 Hz Collagen rich tissues intact- vessels, nerves and lymphatics

23. Thunderbeat Single device simultaneously delivers -Ultrasonically generated frictional heat energy (like Harmonic) -Electrically generated advanced bipolar energy (like Bipolar) Higher bursting pressure and highly reduced thermal spread, no blade required for cutting

24. Thunderbeat

25. Device comparison

26. Lasers First used- 1979 Today relegated to gynecological procedures mostly; cosmetic and eye surgeries; used in lap cholecystectomy Generate heat by a concentrated light beam Most commercial – infra red to UV frequencies

27. Lasers Photo- thermal process- destroys tumors Photo- chemical process- non thermal mechanisms -Low irradiance- induces chemical reactions causing inactivity -High irradiance- ‘photo plasmal ’ process Contact or non contact type

28. Lasers Advantages Wide usage in gynaecological procedures because of precise control of affected depth of tissue Less scarring Disadvantages Very expensive Risk of fire Increased operative time Air embolism Precision vs efficiency Laser lap cholecystectomy- Hepatic artery injury

29. Argon Beam Coagulation First reported use in head and neck surgery (1989) Directed beam of Argon aids conduction of radiofrequency to tissue by ionization Non contact method Caution - Flow rate should be low to prevent gas embolism - Direct contact to be avoided No significant benefit over other techniques Bobbio A, Ampollini L, Internullo E, Caporale D, Cattelani L, Bettati S, et al. Thoracoscopic parietal pleural argon beam coagulation versus pleural abrasion in the treatment of primary spontaneous pneumothorax.  European Journal of Cardio-thoracic Surgery.  2006;29(1):6–8.

30. Argon Beam Coagulation Advantages Good hemostasis- faster coagulation times; (diffuse ooze on liver cut surface) Blows away blood and debris- uniform coagulated surface Less smoke Constant thermal spread (2-3 mm) Disadvantages Air embolism- fatal Not used for cutting Use of electricity- risk of interference with surgical equipment

31. Radio Frequency Energy 3 kHz- 300 MHz frequency Lowest frequency Electromagnetic wave- longer time to generate heat 2 modes- laparoscopic usage; percutaneous treatment via needle insertion into organ Uniform heating of larger tissues but lack of precision Interference with cardiac activity

32. Radio Frequency Energy Novel commercial device- -Gyrus Plasma Trissector - bipolar RF system -Reduces sticking, seals large vessels , secure dissecting of tissue - Ligasure

33. Summary Thermal damage - Monopolar >>> Ultrasonic energy Seal strength - dependent on blood vessel size - Ultrasonic for small vessels - Electrosurgery for larger vessels Least Operative time – Harmonic scalpel ABC- most effective for hemostasis ; risk of air embolism Lasers- limited application; high cost

34. Familiarity with energy source - less chances of inadvertent injuries

35. Adjuncts in Hepatic Resection

36. Introduction Liver resection is the most effective treatment of HCC and Colorectal liver metastases No. of resections have increased Major hepatectomies Knowledge and use of adjuncts- decreased morbidity & mortality

37. Imaging

38. CT & MRI Hepatic & biliary anatomy Better surgical planning Decreased postop complications Volumetric CT: Future Liver Remnant

39. IOUS Better definition of relationship of tumour to surrounding structures Changes surgical Strategy in over 40% of cases CT scans had a sensitivity of 72.8% overall, but decreases to 34.6% for tumours less than 1cm. Sensitivity: 98% Parker GA, Lawrence W Jr, Florsley JS et al. Intraoperative ultrasound of the liver affects operative decision making. Annals of Surgery l989;209:569-577 Shukla PJ, Pandey D, Rao PP, Shrinkhande SV, Thakur MH, Arya S, Ramani S, Mehta S, Mohandas KM. Impact of intra-operative ultrasonography in liver surgery. Indian J oumal of Gastroenterology 2005; 24(2):62-65

40. ICG Tumor identification ICG (0.5 mg/kg body weight) is administered intravenously, usually within two weeks before surgery Detect biliary congestion caused by tumor invasion, micrometastases from pancreatic cancer, and extrahepatic spread of HCC

41. ICG Liver segmentation I njection of 0.25−2.5 mg/mL ICG into the portal veins or by intravenous injection of 2.5 mg ICG following closure of the proximal portal pedicle toward hepatic regions to be removed ICG administration –at least 15 minutes prior ICG stays upto 6 hours into extrahepatic bile duct

42. ICG Liver segmentation I njection of 0.25−2.5 mg/mL ICG into the portal veins or by intravenous injection of 2.5 mg ICG following closure of the proximal portal pedicle toward hepatic regions to be removed ICG administration - upto 6 hours into extrahepatic bile duct

43. Intraop cholangiogram C holangiography catheter/ IFT advanced into cystic duct and fixed using a silk suture Five to ten ml of contrast(meglumine diatrizoate)injected into biliary tree D istal common bile duct occluded D escribe the anatomical variation occurring in intrahepatic bile ducts Bile duct leakages on liver surface determined digitally in the form of contrast extravasation

44. Exposure Thompson’s retractor

45. Anaesthesia

46. Role of Surgeon

47. B lood loss Post-operative morbidity: 23- 46% Mortality: 4- 5% Intra-operative haemorrhage: 700 -1200 ml Rate of perioperative transfusions  Immunosuppression  Increased infection & recurrence* *Stephenson KR, Steinberg SM, Hughes KS, Vetto JT, Sugarbaker PH, Chang AE. Perioperative blood trasfusions are associated with decreased time to recurrence and decreased survival after resection for colorectal liver metastases. Annals of Surgery 1988; 208: 679-687 *Fujimoto J, Okamoto E, Yamanaka N et al: Adverse Effect of Perioperative Blood Transfusions on Survival after hepatic Resection for Hepatocellular Carcinoma. Hepato- Gastroenterlogy 1997; 44:1390-1396

48. Vascular Occlusion Techniques

49. Vascular Control Principle: To limit the blood flow through liver

50. Pringle Maneuvre Portal triad of hepatoduodenal ligament No hemodynamic effect No special anaesthetic requirement Back-bleeding from hepatic veins Reperfusion injury A. Band placed around ligament B. ligament occluded C. Ligament clamped

51. Intermittent Pringle Maneuvre Clamping: Unclamping = 20:5 or 5:1 *Belghiti J, Noun R, Malafosse R, Jagot P, Sauvanet A, Pierangeli F, et al. Continuous versus intermittent portal triad clamping for liver resection: a controlled study. Ann Surg 1999; 229: 369-75

52. Ischemic Preconditioning 10 min ischemia  10 min reperfusion  CPM Protects against reperfusion injury* Beneficial in young pt requiring prolonged inflow occlusion/ steatotic liver *Clavien PA, Yadav S, Sindram D, Bentley RC. Protective effects of ischaemic precon‐ ditioning for liver resection performed under inflow occlusion in humans. Ann Surg 2000; 232: 155-62 *Clavien PA, Selzner M, Rudiger HA, Graf R, Kadry Z, Rousson V, Jochum W. A prospective randomized study in 100 consecutive patients undergoing major liver resection with versus without ischemic preconditioning. Ann Surg 2003; 238: 843-52

53. Half Pringle Maneuvre ( Hemihepatic Clamping) Clamping of portal v. and hepatic a. to right or left liver Clear demarcation No ischemia of unaffected lobe No visceral congestion Bleeding from unoccluded lobe *Makuuchi M, Mori T, Gunven P, Yamazaki S, Hasegawa H. Safety of hemihepatic vascular occlusion during resection of the liver. Surg Gynecol Obstet 1987; 164: 155-8.

54. Segmental Vascular Clamping Shimamura et al Hepatic a. & portal v. of affected segment Balloon catheter in portal v. using Cholangiogram needle Allows limited anatomical resection Identifies boundaries of segment Decreased blood loss *Castaing D, Garden OJ, Bismuth H. Segmental liver resection using ultrasound-guided selective portal venous occlusion. Ann Surg 1989; 210: 20-23.

55. Total Vascular Exclusion Huguet et al Isolates liver and retrohepatic vena cava from rest of the systemic circulation Large tumors close to or infiltrating IVC No advantage over vascular occlusion *Huguet C, Addario-Chieco P, Gavelli A, Arrigo E, Harb J, Clement RR. Technique of hepatic vascular exclusion for extensive liver resection. Am J Surg 1992; 163: 602-05.

56. Significant hemodynamic changes* Marked decrease in venous return 80% increase in systemic vascular resistance 50% increase in heart rate 40-60% decrease in cardiac output Decreases Hemorrhage Air embolism from injury to IVC or hepatic veins Increased postop complications than PM *Eyraud D, Richard O, Borie DC, Schaup B, Carayon A, Vezinet C, et al. Hemodynamic and hormonal responses to the sudden interruption of caval flow: Insights from a prospective study of hepatic vascular exclusion during major liver resections. Anesth Analg 2002; 95: 1173-8.

57. Total Vascular Exclusion with Preservation of Caval Flow Elias et al For patients who should have classical vascular exclusion but cannot tolerate vena cava clamping Hepatic veins are dissected and looped Inflow occlusion  hepatic vein occlusion No interr uption of caval flow Continuous or intermittent More demanding technique Avoids the haemodynamic drawbacks of TVE *Elias D, Dube P, Bonvalot S, Debanne B, Plaud B, Lasser P. Intermittent complete vascular exclusion of the liver during hepatectomy: Technique and indications. Hepatogastroenterology 1998; 45: 389-95.

58. Ischemia Time Method Normal Liver Cirrhotic Liver Continuous Inflow Occlusion 60 30 Intermittent PM 120 60 Total Vascular Exclusion 60 30 Ischemic Preconditioning 75 ?

59. Comparison of Different Occlusion Techniques

60. Liver Transection Techniques

61. Surgical Techniques

62. Finger Fracture Described in1896 by William Keen Resection can be completed in 15 min Friable liver tissue is crushed b/w fingers isolating vessels and bile ducts Insecurity of introducing fingers and looking for structures

63. Clamp Crush Technique Described in 1970 by Lin Crush the tissue using Kelly clamp Vessels and bile ducts are visualised and controlled Difficult in cirrhosis

64. Rents are created on glisson capsule 2-3 cm apart Clamp is introduced and liver crushed Structures appear as white cords bridges Clamp is released Portal v, hepatic a and duct anteriorly and hepatic vein posteriorly ligated

65. CUSA (Cavitron Ultrasonic Surgical Aspirator) Titanium tip Oscillates at 23 kHz Saline irrigation system  Continuous cooling of device Continuous suction

66. Helix Hydrojet At the tip of the nozzle, the water jet reaches hypersonic speeds at up to 20000 bar pressure, with which even steel panels can be cut very precisely, effortlessly and without any heat development High-pressure liquid jet with pressures of between 10 and 150 bar and a jet diameter of 0.12 mm. Equipped with suction Allows vascular and bile duct structures to be rinsed out of the parenchyma

67. Harmonic Scalpel *Kim J, Ahamad SA, Lowy AM et al: Increased biliary fistulas after liver resection with the Harmonic Scalpel. The American Surgeon 2003; 69(9):815-819

68. Harmonic Focus Fusion technique Crushing by nonactivated HS Precision & depth of crushing adjusted by modulating blade pressure Vessels upto 5 mm coagulated under vision without changing blades Reduces bile leak

69. TMFB (Tissuelink Monopolar Floating Ball) Based on RF Continuous saline supply to tip  cooling & conduction of RF Coagulates vessels upto 3 mm No char/ coagulum/ smoke Cheap Easy to use

70. Bipolar Vessel Sealing Device ( Ligasure ) RF based Fragmentation by clamp crush Instant Response Technology

71. Gyrus Plasmakinetic Pulsed Bipolar Coagulation Devic e

72. Aquamantis System Transcollation technology- simultaneous delivery of RF & saline Keeps temp < 100 degrees

73. Coolinside Simultaneous coagulation (RF) & cutting (cold knife) Precoagulation  Difficulty in identifying vessels 5 mm coagulated area  L imiting in cirrhosis

74. Staplers

75. Habib’s Technique (Bloodless Hepatectomy Technique) Cooled tip RF probe of 3 cm exposed tip to coagulate liver resection margins. 2 cm-wide coagulative necrosis zone is created by multiple applications of the probes  division of the parenchyma with a surgical scalpel Both the remnant liver and the removed specimen have on the margin of resection a portion of necrotic coagulated liver l cm thick.

76. Chang’s Needle Technique 18 cm needle & no. 1 silk Overlapping interlocking mattress sutures Transection by scissors or cautery No other occlusion technique Cheap Cant be used in lesions close to IVC

77. The needle penetrates the entire depth of the liver parenchyma from the liver surface and catches one end of no. 1 silk thread from below , then penetrates again, 3–5 cm away from the previous point of insertion, to catch the other end of the thread. A secure tie can subsequently be made to block all vascular flows within this area

78. Haemostatic Technique

79. Comparison of Transection techniques Bipolar – least blood loss and shorter operative time, followed by stapler and Tissue Link Harmonic Scalpel- lower complications than Hydrojet and clamp crushing A systematic review and network meta analysis of parenchymal transection techniques during hepatectomy: an appraisal of current RCTs; September 2019; HPB

80. Comparison of Transection techniques A systematic review and network meta analysis of parenchymal transection techniques during hepatectomy: an appraisal of current RCTs; September 2019; HPB

81. Techniques For Parenchymal Transection. MetaAnalysis. Cochrane 2009 *KS Gurusamy, V Pamecha, D Sharma, BR Davidson. Techniques for liver parenchymal transection in liver resection. Cochrane Library Copyright © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd. Rahbari NN, Koch M, Schmidt T, Motschall E, Bruckner T, Weidmann K, Mehrabi A, Büchler MW, Weitz J. Meta-analysis of the clamp-crushing technique for transection of the parenchyma in elective hepatic resection: back to where we started? Ann Surg Oncol 2009;16:630-639

82. Transection techniques in a nutshell Clamp crushing -low-cost technique; requires substantial experience CUSA -currently the standard liver transection technique Low blood loss with a well-established safety record Main disadvantage- slow transection Poon RT. Current techniques of liver transection. HPB (Oxford). 2007;9(3):166-73.

83. Transection techniques in a nutshell Newer instruments - Harmonic Scalpel, Ligasure and TissueLink Dissector Enhance the capability of hemostasis and allow faster transection Lack the preciseness of CUSA in dissection of major hepatic veins Associated with increased risk of bile leak Wedge or segmental resection (particularly useful in laparoscopic liver resection) C ombination with CUSA - sealing of vessels, increases the cost substantially RFA-assisted transection- probably the most speedy technique Poon RT. Current techniques of liver transection. HPB (Oxford). 2007;9(3):166-73.

84. Topical agents

85. Supportive management

86. Conclusion

87. Thank you