Liver Resection with a New Multiprobe Bipolar Radiofrequency Device

ORIGINAL ARTICLE Liver Resection With a New Multiprobe Bipolar Radiofrequency Device

Ahmet Ayav, MD, PhD; Long Jiao, MD, FRCS; Robert Dickinson, PhD; Joanna Nicholls, MSc; Miroslav Milicevic, MD; Ricardo Pellicci, MD; Philippe Bachellier, MD; Nagy Habib, ChM, FRCS

Hypothesis: Liver resection can be associated with Main Outcome Measures: Intraoperative blood loss, marked blood loss. A novel multiprobe bipolar radio- liver parenchyma transection time, and complications. frequency device (Habib 4X; RITA Medical Systems Inc, Fremont, California) has been developed to assist Results: There were 51 minor and 11 major hepatecto- in liver resection and to reduce intraoperative blood mies. Mean (SD) transection time was 39 (27) seconds loss. per square centimeter. Mean (SD) blood loss was 4.8 (5.6) mL per square centimeter. No patient required hepatic Design: Prospective study. inflow occlusion. One patient required blood transfusion. There were no deaths, and the morbidity rate was Setting: Tertiary referral unit. 18%. Mean (SD) hospital stay was 8 (3) days.

Patients: Sixty-two patients requiring liver resection be- Conclusions: This new bipolar radiofrequency device tween November 1, 2004, and February 28, 2006, pri- allows minor and major hepatectomies to be performed marily for metastatic cancer. with minimal blood loss, low blood transfusion require- ment, and reduced mortality and morbidity rates. Intervention: Liver resection with the radiofrequency device. Arch Surg. 2008;143(4):396-401

URGICAL RESECTION REMAINS hydrodissectors, LigaSure diathermy (Val- the most effective treatment leylab), and monopolar floating ball have for liver tumors, but it can still been developed to reduce blood loss dur- be associated with marked ing parenchymal transection.17-22 Radio- blood loss, which can affect frequency energy has been widely used in postoperative recovery and long-term sur- the field of liver tumors, especially for in S1-4 23 vival. Various intraoperative methods have situ ablation of the tumors. A technique been adopted by surgeons to minimize for liver resection has been described that blood loss, including hypotensive anesthe- uses a monopolar radiofrequency with a sia, hepatic pedicle clamping, and total vas- Cool-Tip needle (CT1200; Tyco Health- cular exclusion.5-8 These techniques in- care, Hants, England) and has been re- volve clamping of inflow vessels to reduce ported to reduce intraoperative blood loss bleeding during transection, which increases morbidity, mortality, and liver dys- See Invited Critique function, especially in patients with preex- isting chronic liver disease.9,10 Despite these at end of article maneuvers, intraoperative blood loss ranges from 250 to 900 mL during liver resection, and postoperative morbidity.24 However, with 7% to 56% of the procedures requir- 2 major drawbacks related to the use of ing intraoperative blood transfusion.4,11-16 radiofrequency have been recognized. The In recent years, to avoid complica- first is that it uses monopolar radiofre- Author Affiliations: tions related to pedicle clamping, tech- quency energy, which generates a cur- Hepatopancreaticobiliary Unit, niques for liver resection without clamp- rent that passes from the active electrode Division of Surgery, 4,5,15 Anaesthetics, and Intensive ing have been described. Devices such within the liver through the body to a Care, Hammersmith Hospital, as the CUSA ultrasonic surgical aspira- ground electrode on the skin surface; this Imperial College School of tion system (Valleylab, Boulder, Colo- carries risks of skin burn from the ground- Medicine, London, England. rado), harmonic scalpel, bipolar scissors, ing pad, myocardial infarction, myoglo-

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 binemia, and cardiac arrhythmias.25-28 As a result, the applied power must be curtailed to minimize such burns, hence increasing the heating time for each coagulation. The second drawback is that radiofrequency is time con- suming because, even if the individual coagulation of nontumoral liver is known to be quicker than that of fi- brotic tumors, many probe applications are required to obtain an avascular plane along the resection line, especially for major hepatectomies or when multiple tumorectomies are mandatory.29 To solve the problem, multiple electrode systems and bipolar devices have been designed, but to date none of them has been used to perform liver resection because they are actually used to ablate tumors.30 A new multiprobe bipolar radiofrequency device (Habib 4X; RITA Medical Systems Inc, Fremont, California) consisting of an array of needles arranged in a square has been devel- Figure 1. The Habib 4X multiprobe bipolar radiofrequency device (RITA Medical Systems Inc, Freemont, California), a handheld electrosurgical oped and used in our unit to assist in liver resection. The instrument consisting of a 2ϫ2 array of 4 needles spaced at the corners of a present study assessed the feasibility and safety of liver 6ϫ7-mm rectangle. There are 2 versions: 1 with long (120-mm) needles resection with this new device. (left) and 1 with short (60-mm) needles (right).

insulating the proximal portion of the electrodes with a polytef METHODS coating, leaving the distal portion uninsulated (Figure 1). The short-needle device has been designed to perform precise co- From November 1, 2004, to February 28, 2006, all patients who agulation of shallow tissues, especially for coagulating super- underwent liver resection with this new device at the Ham- ficial vessels that may be bleeding after resection. Pairs of needles mersmith Hospital were prospectively enrolled for the study. on the short (6-mm) side of the rectangle are connected to- The device has been approved by the New Medical Device and gether, and each pair is connected to 1 terminal of a bipolar Procedures Committee in England. All patients underwent care- radiofrequency generator (1500X; RITA Medical Systems Inc). ful preoperative assessment of their disease, including spiral computed tomography, magnetic resonance imaging, and/or SURGICAL PROCEDURE positron emission tomography. All cases were discussed at a multidisciplinary meeting, and patients were fully informed of With the patient under general anesthesia, without reduction the risks, benefits, and alternatives to hepatic resection. Pa- of central venous pressure, a modified right subcostal incision tient data were collected prospectively and included demo- is made. After exploration to exclude extrahepatic or perito- graphic details, nature and number of tumors, operative pro- neal disease, the liver is mobilized according to the size and cedure, operating time, results of preoperative and postoperative site of the lesion to be resected. Intraoperative ultrasonogra- liver function tests, perioperative complications, mortality rate, phy is always performed before liver resection to confirm the hospital stay, and outcome. Operative time was defined as the number, size, and location of the tumors, and to disclose any overall time of the surgical procedure measured from the start previously undetected lesions. It can also detect any aberrant to closure of the skin incision, while the resection time was de- or variant blood vessels or bile ducts that need to be preserved fined as the time from the start of radiofrequency to the comple- in cases of nonanatomic resection. Dissection of the hepatic tion of parenchymal transection. The overall blood loss was the pedicle is performed only for tumors located close to the hilus combination of the weight of the surgical swabs and the amount to facilitate separation of the tumor from hilar structures. For of blood in the suction system for the whole operation. Blood tumors close to hepatic veins, dissection is again performed first, loss during liver parenchyma transection was recorded in a simi- to separate the tumor from the veins with ligation of these ves- lar way. All resected specimens were measured to calculate the sels. Otherwise, the hepatic veins and/or pedicle vessels are co- resection surface to evaluate the resection time as well as the agulated with radiofrequency without dissection or ligation blood loss per square centimeter. beforehand. Once the tumor is localized by bimanual palpation and in- DESIGN OF THE RADIOFREQUENCY DEVICE traoperative ultrasonography, a line is made on the liver cap- sule with argon diathermy 1 cm away from the edge of the tu- The radiofrequency device we used is a handheld electrosur- mor. It is important to mark the resection line before starting gical instrument consisting of a 2ϫ2 array of 4 needles spaced the radiofrequency energy because the liver tissue hardens and at the corners of a 6ϫ7-mm rectangle. There are 2 versions: 1 induces image changes on intraoperative ultrasonography, which with long (120-mm) needles and 1 with short (60-mm) needles. can obscure the visualization of the tumor edge. The sealer is The needles act as radiofrequency electrodes and are made of then introduced into the liver parenchyma along this line, which stainless steel (Tomlinson Tube & Instrument Ltd, Warwick- represents the future resection line. Radiofrequency power is shire, England) with a polished titanium nitride nonstick coat- set at 125 W to allow adequate coagulation of liver paren- ing (Tecvac Ltd, Cambridgeshire, England; Integrated Surgi- chyma before its division. This will ensure sealing of small ves- cal Sciences Corp, Sedalia, Colorado) to facilitate insertion and sels. However, for larger vessels such as hepatic or portal vein removal from the liver tissue. The long device can reach distal or in case of bleeding after ablation with 125 W, the power is regions of the liver being treated by applying radiofrequency reduced to 75 W to ensure sealing of these vessels at the ex- energy at various depths. The volume heated by such long pense of time. A series of coagulations is made, repositioning needles would be too great for rapid heating, so the active por- the device at a mean (SD) distance of 10 (3) mm each time to tion of the needles is restricted to the most distal 40 mm by create a band of coagulation. At this stage, the liver paren-

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 away from the proper plane. To do this, a step-by-step approach is adopted, alternating application of radiofrequency with 12 mm division of coagulated liver parenchyma to maintain a stereo- 8-10 mm tactic plane by tactile feeling with 1 hand placed at the inferior surface of the liver along the future transection plane. The surface of the liver parenchyma left behind is homogeneous, with- Resection line out visible bile duct structures or blood vessels. Thus, no ties or clips are used to ensure biliary or blood vessel control, even for portal or hepatic veins. A 30F Robinson drain is usually placed at the site of resection before closing the abdomen. In Tumor the beginning of our experience, we used to monitor the tis- Remaining liver sue electrical impedance during heating, and the power was dis- abled when the impedance increased by 5 ⍀ from the quies- cent value. If the impedance increased by more than 5 ⍀,we noticed carbonization on the needles, which can cause tissue adhesion and bleeding when the device is removed from the liver. To avoid this, new generators (RITA 1500X; RITA Medi- Coagulated zone cal Systems Inc) are preprogrammed to switch the power off automatically when the impedance increases by 5 ⍀.

RESULTS Figure 2. Resection technique. The coagulated zone is obtained after 5 applications of the multiprobe device. The high-frequency current delivered between the electrodes causes ionic agitation, friction, and tissue heating. From November 1, 2004, to February 28, 2006, 62 con- The latter causes cellular dehydration, resulting in a coagulated zone located secutive patients underwent liver resection with the Habib in normal liver tissue surrounding the lesion to be resected. 4X multiprobe bipolar radiofrequency device. There were 52 first, 8 second, and 2 third hepatectomies. Clinical details of the patients are summarized in the Table. Most Table. Patient and Tumor Characteristics of the patients in this series (35 [56%]) had a solitary tumor in the liver. All of the procedures were completed Characteristic Finding as planned. Procedures undertaken were single segmen- Age, mean (SD), y 59 (12) tectomy or tumorectomy in 37 cases, multiple segmen- Sex, No. M/F 28/34 tectomies or tumorectomies in 9 cases, left lateral sec- Diagnosis, No. (%) tionectomy in 5 cases, left hepatectomy in 2 cases, and Metastases 51 (82) right hepatectomy in 9 cases. Five of the 9 patients who Colorectal 39 Neuroendocrine 3 underwent right hepatectomy had undergone previous Pancreas 2 embolization of the right branch of the portal vein be- Breast 2 cause of a small remnant liver (left lobe). Ovarian 2 The overall operative time (mean [SD]) was 157 (56) GIST 1 minutes (median, 150 minutes; range, 60-300 min- Sarcoma 1 utes). The mean (SD) parenchymal transection time was Melanoma 1 Hepatocellular carcinoma 6 (10) 43 (32) minutes (median, 30 minutes; range, 8-120 min- Cholangiocarcinoma 1 (2) utes). The mean (SD) parenchymal transection time per Gallbladder carcinoma 1 (2) square centimeter was 39 (27) seconds (median, 23 sec- Biliary cyst 1 (2) onds; range, 14-108 seconds). The mean (SD) overall in- Angioma 2 (3) traoperative blood loss was 267 (292) mL (median, 195 Tumor size, mean (SD), mm 44 (32) mL; range, 10-707 mL), and the mean (SD) blood loss No. of lesions, mean (SD) 2.0 (1.8) during parenchyma transection was 75 (60) mL (me- Abbreviation: GIST, gastrointestinal stromal tumor. dian, 50 mL; range, 10-200 mL). The mean (SD) blood loss per square centimeter was 4.8 (5.6) mL (median, 2.1 mL; range, 0.17-19.6 mL). No patient required hepatic chyma is divided with a scalpel. The liver parenchyma should inflow occlusion (Pringle maneuver) during the proce- be supported with fingers on both sides of the device to avoid dure. Only 1 patient underwent blood transfusion either pulling suddenly with force, which might lead to parenchy- during or after the operation, which entailed a third he- mal fracture and bleeding. The plane of division is situated be- patectomy for colorectal metastases; the overall blood loss tween the lines defined by the 2 electrodes (Figure 2). This was 707 mL and the patient received2Uofredblood technique allows a small amount of coagulated liver paren- cells. Most of the blood loss (650 mL) occurred during chyma to be left behind (less than 10 mm in depth), which is dissection to gain access to the liver rather than paren- enough to ensure sealing of blood vessels and bile ducts. For chymal transection. No patient received fresh frozen deeply placed tumors, the radiofrequency device can be applied first to the surface of the liver to open it with the scalpel plasma at any stage, and none was admitted to the in- to a depth of 3 or 4 cm; it is then reapplied to continue the re- tensive care unit postoperatively. No patients devel- section deeper into the liver. Because the liver is a global struc- oped grounding pad skin burn, myocardial infarction, ture with a third dimension, it is extremely important to re- myoglobinemia, or cardiac arrhythmia during or after the main oriented to the division line at all times to avoid wandering procedure. There were no deaths.

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 The postoperative course was uneventful in 51 pa- The monopolar (CoolTip) radiofrequency-assisted tients (82%). Morbidity occurred in 11 patients. Three liver resection previously reported produces a margin patients developed an intra-abdominal fluid collection of 1 to 2 cm, and some have expressed concern that diagnosed on computed tomography, of which only 1 necrotic tissue is left behind.33,34 With the multiprobe needed radiologic drainage; the other 2 were treated with bipolar radiofrequency device used in this study, the antibiotics alone without the need for drainage because plane of division is situated between the line defined of the very small size of the collection. In the case of ra- by the 2 electrodes (Figure 2), indicating that the diologic drainage, the collection was an abscess and not depth of necrotic tissue left behind is less than 10 mm, biliary fistulas. Eight patients developed a right pleural which is enough to ensure hemostasis and biliary con- effusion, which was diagnosed on systematic chest radi- trol. In this series, there was no postoperative bleeding ography. Six of these patients were treated with physio- or biliary fistula, which confirms the accuracy of the therapy alone and 2 with additional aspiration. Right pleu- sealer to close blood vessels and biliary ducts. In this ral effusion occurred after 3 right hepatectomies and 5 series, no additional ties or clips were applied on ves- segmentectomies of the upper part of the liver (ie, seg- sels along the resection line. All vessels, including the ment VII or VIII). No patient developed postoperative right hepatic vein in cases of right hepatectomy, were hemorrhage, biliary leak, or liver failure, and no patient coagulated with the device. For major hepatectomy required reoperation. Serum aspartate transaminase, ala- with this technique, there is no need for hilar or extra- nine transaminase, and bilirubin levels rose at postop- parenchymal dissection to control large pedicles erative day 1 and normalized between postoperative days because radiofrequency, when applied repeatedly at a 3 and 7. Findings on pathologic examination showed that power of 75 W, is adequate to seal off larger pedicles, the resection margin, which normally consisted of ap- including arterial, venous, and biliary structures. proximately 5 mm of coagulative zone owing to the re- Other groups using this method for liver resection section technique, was free of tumor in all cases. The mean have also reported this phenomenon.35 Furthermore, postoperative stay was 8 (3) days. we believe that the coagulated zone left in the resection margin may improve the clearance of this margin and may reduce the incidence of local recurrence.23,36 COMMENT In our own experience with liver resection with monopolar radiofrequency, we encountered 2 cases of To date, several multiple electrode systems and bipolar local recurrence in the resection margin among 156 radiofrequency devices have been designed, but none has patients.37 This low incidence needs to be confirmed been used for liver resection.30 To our knowledge, this is in a larger series with long-term follow-up. the first series in which bipolar radiofrequency energy has No major postoperative morbidity, such as hemor- been used to coagulate the liver parenchyma before tran- rhage, biliary fistulas, or liver failure, occurred in secting it with a simple knife and without additional ties patients undergoing liver resection with this device. or clips. Haghighi et al31 reported the use of a multineedle Minor complications, consisting of intra-abdominal probe to coagulate a line of liver parenchyma before resec- collections and right pleural effusion, occurred in a tion with an in-line radiofrequency ablation system. Even few patients. These complications were not directly if this system worked in a bipolar mode, the authors used related to the resection technique; they occur frequently radiofrequency primarily to prepare the transection plane. with conventional parenchymal transection tech- Transection was performed with an ultrasonic aspirator, niques.4,7,12,13,17,38 Postoperative liver function tests and the vessels were sealed with the use of diathermy or showed a significant increase in transaminase and bili- clips. In our experience, the radiofrequency field created rubin levels postoperatively at day 1, which normalized between the 4 electrodes causes ionic agitation, friction, and spontaneously between postoperative days 3 and 7. tissue heating, which led to occlusion of bile duct and blood Liver function changes have also been reported in vessels up to 7 mm in diameter. In the 9 cases of right he- patients undergoing liver resection with an ultrasonic patectomy, the right hepatic vein was sealed intraparen- dissector and/or monopolar floating ball without chymally after multiple applications of the probe with the pedicle clamping.7,15,21 These transient abnormalities are power set at 75 W. None of these patients had previous ex- most likely related to the zone of coagulative necrosis traparenchymal control or division of the right hepatic vein. left behind along the resection margin and are com- Furthermore, among these first 62 cases, no postopera- pletely different from the whole-liver ischemic damage tive hemorrhage or biliary fistula occurred, confirming the that is caused by hepatic inflow occlusion and can lead ability of the radiofrequency energy to seal vessels and bile to postoperative liver failure, especially in the case of ducts. underlying liver disease.5,7,9,11 In this study, the mean blood loss during parenchy- The rate of major hepatectomies was quite small mal transection was 75 mL, which is lower than in most in this series. We believe that the use of this major published series.1,4,11-16,32 We did not encounter ma- radiofrequency-assisted liver resection technique has jor bleeding during mobilization of the liver because with more than halved the number of right hepatectomies this radiofrequency technique there is no need for ex- compared with resections performed previously with tensive mobilization or dissection of the hepatic pedicle. conventional techniques. In our experience, the rate of However, in the case of a second or third hepatectomy, major hepatectomy dropped from 64% to 20% with bleeding can still occur during the liver mobilization the current technique, allowing us to safely perform phase, as seen in 1 of our patients. more minor and fewer major hepatectomies. Even

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 though segmental and nonanatomic resections are operative and long-term outcome in patients following hepatic resection for co- commonly classified as minor hepatectomies, they are lorectal metastases. Ann Surg. 2003;237(6):860-869. 4. Poon RT, Fan ST, Lo CM, et al. Improving perioperative outcome expands the often more challenging and technically demanding role of hepatectomy in management of benign and malignant hepatobiliary dis- and can cause more bleeding than classic lobar resec- eases: analysis of 1222 consecutive patients from a prospective database. Ann tion. This new device allows the liver surgeon to safely Surg. 2004;240(4):698-710. perform multiple tumorectomies with minimal blood 5. Man K, Fan ST, Ng IO, Lo CM, Liu CL, Wong J. Prospective evaluation of Pringle loss rather than major hepatectomies, thus minimizing maneuver in hepatectomy for liver tumors by a randomized study. Ann Surg. 1997; 226(6):704-713. the excision of nontumoral liver parenchyma and 6. Hansen PD, Isla AM, Habib NA. Liver resection using total vascular exclusion, diminishing the risk of postoperative liver failure. This scalpel division of the parenchyma and a simple compression technique for is especially relevant in cases of liver resection for liver haemostasis and biliary control. J Gastrointest Surg. 1999;3(5): metastases, which is the most common indication for 537-542. 7. Belghiti J, Noun R, Malafosse R, et al. Continuous versus intermittent portal triad liver resection in our experience. For this indication, if clamping for liver resection: a controlled study. Ann Surg. 1999;229(3): technically feasible, we undertake liver resection to 369-375. obtain tumor clearance by performing nonanatomic 8. Melendez JA, Arslan V, Fisher ME, et al. Perioperative outcomes of major he- resection (ie, minor hepatectomy) with curative intent patic resections under low central venous pressure anesthesia: blood loss, blood to spare liver parenchyma, bearing in mind that these transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg. 1998; 187(6):620-625. patients may present with other liver metastases and 9. Farges O, Malassagne B, Flejou JF, Balzan S, Sauvanet A, Belghiti J. Risk of ma- 39 undergo second or third hepatectomies. jor liver resection in patients with underlying chronic liver disease: a reappraisal. The heat coagulative necrosis plane is created much Ann Surg. 1999;229(2):210-215. faster with this bipolar device than with the monopolar 10. Wei AC, Tung-Ping Poon R, Fan ST, Wong J. Risk factors for perioperative mor- probe, allowing us to reduce the mean (SD) parenchy- bidity and mortality after extended hepatectomy for hepatocellular carcinoma. Br J Surg. 2003;90(1):33-41. mal transection time to 43 (32) minutes with the multi- 11. Belghiti J, Hiramatsu K, Benoist S, Massault P, Sauvanet A, Farges O. Seven hun- probe bipolar radiofrequency device as opposed to 75 dred forty-seven hepatectomies in the 1990s: an update to evaluate the actual (51) minutes with the monopolar probe, without jeop- risk of liver resection. J Am Coll Surg. 2000;191(1):38-46. ardizing the effectiveness of the procedure.37 It is 12. Jarnagin WR, Gonen M, Fong Y, et al. Improvement in perioperative outcome expected that with increased experience this technique after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg. 2002;236(4):397-407. will reduce the transection time even further. 13. Imamura H, Seyama Y, Kokudo N, et al. One thousand fifty-six hepatectomies This 4-needle bipolar radiofrequency device for liver without mortality in 8 years. Arch Surg. 2003;138(11):1198-1206. resection has decreased liver parenchymal transection 14. Adam R, Pascal G, Azoulay D, Tanaka K, Castaing D, Bismuth H. Liver resection time and has been used safely for both major and minor for colorectal metastases: the third hepatectomy. Ann Surg. 2003;238(6): 871-884. hepatectomies, with minor blood loss and without 15. Scatton O, Massault JP, Dousset B, et al. Major liver resection without clamp- increasing the postoperative morbidity rate. It offers a ing: a prospective reappraisal in the era of modern surgical tools. J Am Coll Surg. useful additional method for transection of liver paren- 2004;199(5):702-708. chyma for hepatobiliary surgeons. 16. Weber JC, Bachellier P, Oussoultzoglou E, Jaeck D. Simultaneous resection of colorectal primary tumour and synchronous liver metastases. Br J Surg. 2003; 90(8):956-962. Accepted for Publication: January 5, 2007. 17. Takayama T, Makuuchi M, Kubota K, et al. Randomized comparison of ultra- Correspondence: Nagy Habib, ChM, FRCS, Depart- sonic vs clamp transection of the liver. Arch Surg. 2001;136(8):922-928. 18. Sugo H, Mikami Y, Matsumoto F, et al. Hepatic resection using the harmonic ment of Surgery, Hammersmith Hospital, Imperial Col- scalpel. Surg Today. 2000;30(10):959-962. lege School of Medicine, Du Cane Road, London 19. Yamada T, Sasaki Y, Yokoyama S, et al. Practical usefulness of bipolar scissors W120NN, England ([email protected]). in hepatectomy. Hepatogastroenterology. 2002;49(45):597-600. Author Contributions: Study concept and design: Ayav, 20. Romano F, Franciosi C, Caprotti R, Uggeri F, Uggeri F. Hepatic surgery using the Jiao, Dickinson, Nicholls, Milicevic, Pellicci, LigaSure vessel sealing system. World J Surg. 2005;29(1):110-112. 21. Sakamoto Y, Yamamoto J, Kokudo N, et al. Bloodless liver resection using the Bachellier, and Habib. Acquisition of data: Ayav. Analy- monopolar floating ball plus LigaSure diathermy: preliminary results of 16 liver sis and interpretation of data: Ayav and Jiao. Drafting of resections. World J Surg. 2004;28(2):166-172. the manuscript: Ayav, Jiao, and Dickinson. Critical revi- 22. Rau HG, Schardey HM, Buttler E, Reuter C, Cohnert TU, Schildberg FW. A com- sion of the manuscript for important intellectual content: parison of different techniques for liver resection: blunt dissection, ultrasonic aspirator and jet-cutter. Eur J Surg Oncol. 1995;21(2):183-187. Ayav, Jiao, Nicholls, Milicevic, Pellicci, Bachellier, and 23. Navarra G, Ayav A, Weber JC, et al. Short- and long-term results of intraopera- Habib. Statistical analysis: Ayav. Administrative, techni- tive radiofrequency ablation of liver metastases. Int J Colorectal Dis. 2005; cal, and material support: Dickinson. Study supervision: 20(6):521-528. Habib. 24. Weber JC, Navarra G, Jiao LR, Nicholls JP, Jensen SL, Habib NA. 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INVITED CRITIQUE

he use of hepatic resection for metastatic colorec- this report include Dr Habib, who helped to develop this de- tal cancer has grown enormously during the past vice. This is a report of their use of the device in 62 consecu- T few decades. Because of data compiled from numer- tive liver resections. The report shows that using the device ous centers throughout the world, it has become clear that resultedinminimalbloodlossandacceptableoperativetimes. patients with 1 to 3 hepatic metastases will be cured with a The complications were the same as those seen after hepa- hepaticresection30%ofthetime.Nochemotherapycanoffer tectomies. This report is not a randomized study, but this comparable statistics. Furthermore, there are no data to sug- kind of device does not really require a randomized study. gest that taking out a lobe or a full segment is superior to The point of the device is to help surgeons perform resec- just removing the metastases as long as the margin is 1 cm. tions more easily and without additional complications. Many new instruments have been developed to help with This report has shown us that the Habib 4X can be hepatic resections by reducing bleeding. Among them have used safely and, in experienced hands, it performs well. been the CUSA ultrasonic surgical aspiration system, har- Now it is up to other surgeons to decide whether this is monic scalpel, and others. The introduction of such in- useful to them. struments has generally come after laboratory research and marketing on the part of the manufacturers. Actual stud- M. Margaret Kemeny, MD ies of the clinical usefulness of these instruments, such as the present report, have generally not been performed. Correspondence: Dr Kemeny, Cancer Center of Queens, The Habib 4X is a multiprobe bipolar radiofrequency de- Queens Hospital Center, 82-68 164th St, Jamaica, NY vice developed to assist in liver resections. The authors of 11432 ([email protected]).

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