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Liver Resection with a New Multiprobe Bipolar Radiofrequency Device

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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 transfu- sion. 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 in- creases 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- (REPRINTED) ARCH SURG/ VOL 143 (NO. 4), APR 2008 WWW.ARCHSURG.COM 396 ©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 ap- plied 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 non- tumoral 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, espe- cially for major hepatectomies or when multiple tumor- ectomies 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 multi- probe 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
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