Our study found that our two-handed technique combining HS and LPMOD in LHH had significantly reduced intraoperative blood loss and shortened operative time than using LPMOD only did. Our findings indicated the two-handed technique of combining HS and LPMOD was safer and more effective in LHH which benefits more to patients, including quicker physical recovery and better prognosis, than LPMOD only was. Synergistic combinations of the advantages of different hepatectomy tools instead of individual hepatectomy technique per se not only optimize the surgical procedures but also improve the safety and effectiveness of challenging hemihepatectomy through reducing intraoperative blood loss and shortening operative time which substantively increase the survival rate with better prognosis of patients with liver diseases, especially cancer patients.
In 2005, Aloia T et al. [13] first reported a two-surgeon technique, the primary surgeon and the secondary surgeon used two instruments to finish parenchyma division and hemostasis during the hepatectomy. Using the ultrasonic dissection (UD) device, the primary surgeon directed the dissection from the patient’ left side. Simultaneously, the secondary surgeon operated the saline linked cautery (SLC) device from the patient’ right side. Aloia TA showed that the use of the two-surgeon technique with UD plus SLC in hepatic resection resulted in shorter operative time and a reduction in the duration of hepatoduodenal ligament occlusion, while the postoperative liver function and complications rate were similar to that of using UD alone group. Mitsuhisa Takatsuki [14] claimed that the blood loss and donor complications in living donor hepatectomies significantly reduced when using the two-surgeon technique with Cavitron Ultrasonic Surgical Aspirator (CUSA) and SLC, while the early graft function and postoperative recipient survival didn’t present significant difference between the two groups. This finding was most likely owing to two factors: a) less time being required for exchanging surgical instruments for dissection and coagulation leading to the acceleration of operation process; b) the active participation of two surgeons during the parenchyma transection promoting the efficiency (rather than one active surgeon cutting and coagulating with an assistant retracting and suctioning) [15].
Accurate hemostasis is the key to successfully accomplish laparoscopic liver resection, and this requires a tacit cooperation between the primary surgeon and assistants. Recent years, more and more scholars have used the two-surgeon technique to optimize the surgical procedure of LHH, and have found that it can notably increase the efficiency of liver transection, shorten the operative time and reduce intraoperative blood loss [13-15]. But it is known more difficult to set up a great cooperation between the two surgeons in LHH if it is an open surgery. The learning curve is steep and the assistant needs long time training.
Inspired by the two-surgeon technique, our well-practiced surgeon team started applying our two-handed technique, which combined LPMOD and HS to complete laparoscopic liver parenchyma transection. The primary surgeon stood on the left side of the patient, and conducted HS by the left hand and LPMOD by the right hand. Alternated operation of two hands was performed to cut and crash the liver parenchyma in different parts of the transection plane. The two-handed technique is equivalent to a small operation team but accidental hemorrhage can be managed more accurately and quickly by the primary surgeon’s two hands than two different surgeons. The instructions for the two-handed operation are issued by the primary surgeon, which is more precise and does not lead to any misunderstanding which may occur between two surgeons when using the two-surgeon technique. The advantages of two-handed technique can be fully utilized by the surgeon during the operation without any exchanging or passing instruments frequently beween two surgeons, which speeds up the surgical process and optimizes the operation. The application of the two-handed technique has no strict requirements for the operator's surgical position. The authors routinely stand on the left-hand side of the patient whether performing a left or right hepatectomy. In order to better master the two-handed technique, surgeons are required to train the weak hand to adapt HS operation manner. For example, if someone’s the right hand is dominant, the left hand is required to have some practices in order to cooperate with the right hand during the surgery. Surgeons are required to spend some time training the coordinated cooperation between the two hands. Emphasis on the training of the primary surgeon’s two-handed technique doesn’t mean that assistant surgeons can be ignored. Assistant surgeons play a critical role in the field of vision exposure and assist the primary surgeon’s operation.
To our knowledge, this is the first study to have evaluated the safety and effectiveness of the two-handed technique of combining HS and LPMOD together for parenchyma transection in LHH. With similar baseline demographics and tumor characteristics, the two-handed technique significantly reduced blood loss and shortened operative time compared with the control group of having LPMOD only. The requirement of blood transfusion, conversion to laparotomy, as well as the length of postoperative hospital stay and resection margin were comparable between the two groups. Furthermore, there was no perioperative hospital mortality in both groups. The postoperative liver function parameters increased dramatically after surgery, but no significant differences were observed between the two groups.
This study found that the intraoperative blood loss was significantly reduced in the two-handed technique group compared with the LPMOD only group. Hemorrhage during laparoscopic hemihepatectomy is mainly due to damage of the hepatic vein or branches inside the liver parenchyma [16]. Our two-handed technique can manage accidental hemorrhage without delay because this technique combines the superiority of small vessels seal function of HS and liver parenchyma hemostasis function of LPMOD. It has been shown that massive blood loss is related to an increased risk of death and recurrence after radical resection since serious intraoperative bleeding may facilitate tumor hematogenous spread, which could result in the recurrent tumor [17, 18]. Combined with other techniques or devices, intraoperative blood loss can be significantly reduced. Low CVP anesthesia during hepatectomy is also essential to decrease the bleeding amount [19].
This study revealed that the operation time was significantly shorter in the two-handed technique group than that in the LPMOD only group. This can be explained by the fact that in the LPMOD only group, dissection of the vessels during liver parenchyma transection requires a supplementary procedure (cut by harmonic scalpel after clipping on the remnant side) to control bleeding at the cutting plane, which cost extra time, but in the two-handed technique group, HS can seal and occlude the small vessel simultaneously when LPMOD exposes the duct. Therefore, the use of LPMOD combined with HS would shorten the operation time by saving the time needed to switch tool to ligate vessels at the cutting plane.
There was no difference in the mean peak level of postoperative liver function measured by ALT, AST, TBIL and PT between the two groups. The complication of bile leakage during hemihepatectomy may be affected by the tools chosen for parenchyma transection. In the two-handed technique group, bile leakage occurred in 3 patients (6.4%) who were followed to be treated by long-time drainage without other invasive intervention. The incidence of bile leakage was comparable between the two groups (6.4% in the HS + LPMOD vs. 8.5% in the LPMOD only group) after PSM.
Besides, there was no perioperative death in both groups. Therefore, our data suggested that the two surgical techniques are both suitable to perform safe and efficient LHH with a similar complication profile and comparable short-term outcomes but the two-handed technique is better considering less intraoperative blood loss and shorter surgery time.
There are some limitations in this study. Firstly, this is a case-control study that is a retrospective study, so some selection bias might be concerned but it is minimized by applying PSM in the analyses and or controlled by that the study is nested in a prospectively collected database. Secondly, only patients having LHH were included in this study which results may not be generalized to other types of liver resection such as wedge resection and anatomical segmentectomy that were excluded in this study. Thirdly, surgeons are required to take some time to get trained and practiced if they want to use this technique. Up to date, we used this two-handed technique mostly in LHH. Future studies are needed to test the safety and effectiveness of the two-handed technique in other types of liver resection.
This study has some strength. This two-handed technique has extensively been tested in 98 patients, not a small sample size, with different liver diseases including cancers, benign tumors, liver cirrhosis, and others in more than two years. In addition, our findings are adjusted for some confounding factors including critical clinical and demographic factors since our study design is a case-control study design. That the study is nested in a prospectively collected database and using PSM in the analyses help control and or at least minimize potential biases from collected risk factors. Therefore, our results are valid and this two-handed technique can be used for other patient populations around the world.
In conclusion, this study shows the new two-handed technique combining HS and LPMOD is safer and more effective in LHH which benefits more to patients than other individual laparoscopic hepatectomy technique. Although no single instrument is available to effectively complete the division and hemostasis during laparoscopic liver parenchyma transection, we can combine the strengths of different hepatic transection instruments together to create a new technique like our two-handed technique. Our two-handed technique in LHH can synergize the advantages of different hepatectomy tools, improve hepatic transection efficiency, optimize surgical procedures, reduce intraoperative blood loss, and shorten operative time. We strongly recommend the application of this technique in other laparoscopic hepatectomy institutions.