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Robert J. Porte - One of the best experts on this subject based on the ideXlab platform.

  • Role of fibrin sealants in Liver Surgery.
    Digestive surgery, 2012
    Co-Authors: Marieke T. De Boer, Ton Lisman, Elizabeth A. Boonstra, Robert J. Porte
    Abstract:

    Background: Fibrin sealants are widely used in Liver Surgery. The aim of this article is to review the literature on evidence of hemostatic and biliostatic capacities of different f

  • Prohemostatic Interventions in Liver Surgery
    Seminars in thrombosis and hemostasis, 2012
    Co-Authors: Menno D. Stellingwerff, Amarins Brandsma, Ton Lisman, Robert J. Porte
    Abstract:

    Surgical procedures of the Liver, such as partial Liver resections and Liver transplantation, are major types of abdominal Surgery. Liver Surgery can be associated with excessive intraoperative blood loss, not only because the Liver is a highly vascularized organ, but also because it plays a central role in the hemostatic system. Intraoperative blood loss and transfusion of blood products have been shown to be negatively associated with postoperative outcome after Liver Surgery. Dysfunction of the Liver is frequently accompanied with a dysfunctional hemostatic system. However, in general, there is a poor correlation between preoperative coagulation tests and the intraoperative bleeding risk in patients undergoing Liver Surgery. Strategies to avoid excessive blood loss in Liver Surgery have been an active field of research and include three different areas: surgical methods, anesthesiological methods, and pharmacological agents. Surgeons can minimize blood loss by clamping the hepatic vasculature, by using specific dissection devices, and by using topical hemostatic agents. Anesthesiologists play an important role in minimizing blood loss by avoiding intravascular fluid overload. Maintaining a low central venous pressure has shown to be very effective in reducing blood loss during partial Liver resections. Prophylactic transfusion of blood products such as fresh frozen plasma (FFP) has not been shown to reduce intraoperative bleeding and even seems counterproductive as it results in an increase of the intravascular filling status, which may enhance the bleeding risk. In patients with Liver cirrhosis, there is increasing evidence that factors such as portal hypertension and the hyperdynamic circulation play a more important role in the bleeding tendency than changes in the coagulation system. Therefore, intravenous fluid restriction rather than prophylactic administration of large volumes of blood products (i.e., FFP) is recommended in patients undergoing major Liver Surgery. Pharmacological agents such as antifibrinolytic drugs or recombinant factor VIIa may be indicated in selected individual patients, but these agents do not have a routine role in the management of patients undergoing Liver Surgery.

  • Bleeding in Liver Surgery: Prevention and Treatment
    Clinics in liver disease, 2009
    Co-Authors: Edris M. Alkozai, Ton Lisman, Robert J. Porte
    Abstract:

    Intraoperative blood loss and transfusion of blood products are negatively associated with postoperative outcome after Liver Surgery. Blood loss can be minimized by surgical methods, including vascular clamping techniques, the use of dissection devices, and the use of topical hemostatic agents. Preoperative correction of coagulation tests with blood products has not been shown to reduce intraoperative bleeding and it may, in fact, enhance the bleeding risk. Maintaining a low central venous pressure has been shown to be effective in reducing blood loss during partial Liver resections, and volume contraction rather than prophylactic transfusion blood products seems justified in patients undergoing major Liver Surgery. Although antifibrinolytic drugs have proved to be effective in reducing blood loss during Liver transplantation, systemic hemostatic drugs are of limited value in reducing blood loss in patients undergoing partial Liver resections.

David L. Bartlett - One of the best experts on this subject based on the ideXlab platform.

  • A current update on the evolution of robotic Liver Surgery.
    Minerva chirurgica, 2011
    Co-Authors: K Kitisin, David L. Bartlett, V Packiam, A Tsung
    Abstract:

    Laparoscopic Liver Surgery has evolved significantly over the past decade. Increasing understanding of hepatic anatomy and advancements in technology have extended the scope of the minimally invasive approach. Robotic-assisted technology offers solutions to the fundamental limitations of conventional laparoscopic Liver resection. Several centers have begun to utilize robotic technology to perform complex Liver surgeries. The purpose of this review is to provide a comprehensive analysis of published literature about the role of robotic-assisted laparoscopic technology in Liver Surgery. A literature search of Pubmed was used to identify all English publications about robotic Liver Surgery. Publications were selected to examine all unique patient series. Outcomes analyzed included operative time, estimated blood loss, length of stay, complication rate, conversion rate to open, cost, and oncologic outcomes. A total of eight series containing 134 unique patients were selected for review. Sixty-nine percent of patients had malignant lesions resected, while 31% had benign lesions. Segmentectomy/wedge (36%) was the most common resection performed, followed by left lateral sectionectomy (28%) right hepatectomy (16%) and left hepatectomy (9%). A meta-analysis of the remaining data was not possible due to heterogeneity in methods for reporting. Outcomes varied widely between studies. Based on analysis of early published series, robotic Liver Surgery is a feasible and safe tool for the minimally invasive resection of hepatic lesions. Further evaluation is required to assess for improvement in outcomes, and long-term oncologic outcomes are still pending.

  • Robotic Liver Surgery.
    The Surgical clinics of North America, 2010
    Co-Authors: Kamran Idrees, David L. Bartlett
    Abstract:

    Although minimally invasive hepatic resection Surgery has shown decreased morbidity in select patients, conventional laparoscopic Liver resection has inherent limitations with reduced freedom of movement within the abdominal cavity and 2-dimensional view of the operative field. Robotic Liver Surgery allows surgeons to perform advanced procedures with a potential for improved precision and ergonomics as well as a 3-dimensional view of the surgical site. However, use of the robot entails a steep learning curve and additional equipment. The purpose of this article is to summarize the emerging field of robotic Liver Surgery and include the authors' early experience with these operations.

Yuman Fong - One of the best experts on this subject based on the ideXlab platform.

  • Robotic Liver Surgery—advantages and limitations
    European Surgery, 2020
    Co-Authors: Camille L. Stewart, Yuman Fong
    Abstract:

    Robotic Surgery is now within the standard of care for many operations, including hepatectomy. Robotic Liver Surgery has advantages over laparoscopic and open surgical techniques, but these must be weighed against certain limitations when selecting an approach. Advantages and limitations of robotic Liver Surgery are discussed here based on a literature survey. Advantages include improved surgeon ergonomics, better access to posterior and superior Liver segments, excellent visualization, and ease of using indocyanine green. There may also be a shorter learning curve for use, and there are possibilities for technological assistance with Surgery in the future. Limitations are related to those known for minimally invasive Surgery in general, but also include time for docking and cost. Considerations are reviewed in detail to facilitate decision making when considering a robotic approach for Liver Surgery. The robotic platform is not appropriate for all Liver operations at this time. Benefits of robotic Surgery are most clearly realized when approaching lesions in the posterior and superior segments, and when a large incision would be required to remove a small amount of Liver parenchyma were the operation to be performed in an open fashion.

  • Robotic Liver Surgery—advantages and limitations
    European Surgery, 2020
    Co-Authors: Camille Stewart, Yuman Fong
    Abstract:

    Background Robotic Surgery is now within the standard of care for many operations, including hepatectomy. Robotic Liver Surgery has advantages over laparoscopic and open surgical techniques, but these must be weighed against certain limitations when selecting an approach. Methods Advantages and limitations of robotic Liver Surgery are discussed here based on a literature survey. Results Advantages include improved surgeon ergonomics, better access to posterior and superior Liver segments, excellent visualization, and ease of using indocyanine green. There may also be a shorter learning curve for use, and there are possibilities for technological assistance with Surgery in the future. Limitations are related to those known for minimally invasive Surgery in general, but also include time for docking and cost. Considerations are reviewed in detail to facilitate decision making when considering a robotic approach for Liver Surgery. Conclusion The robotic platform is not appropriate for all Liver operations at this time. Benefits of robotic Surgery are most clearly realized when approaching lesions in the posterior and superior segments, and when a large incision would be required to remove a small amount of Liver parenchyma were the operation to be performed in an open fashion.

  • Robotic Liver Surgery.
    Hepatobiliary surgery and nutrition, 2014
    Co-Authors: Universe Leung, Yuman Fong
    Abstract:

    Robotic Surgery is an evolving technology that has been successfully applied to a number of surgical specialties, but its use in Liver Surgery has so far been limited. In this review article we discuss the challenges of minimally invasive Liver Surgery, the pros and cons of robotics, the evolution of medical robots, and the potentials in applying this technology to Liver Surgery. The current data in the literature are also presented.

Hauke Lang - One of the best experts on this subject based on the ideXlab platform.

  • Integrative Concepts for Liver Surgery.
    Visceral medicine, 2020
    Co-Authors: Stefan Heinrich, Felix Watzka, Hauke Lang
    Abstract:

    Background Surgery is the standard treatment for primary tumors and metastases. Due to improvements in surgical outcomes as well as the efficacy of systemic treatments, the role of Surgery has changed in recent years. Summary Liver Surgery has become safe and efficient, with resectability being increased by multimodality concepts as well as staged Liver resections and orthotopic Liver transplantation. These concepts may be applied to primary Liver tumors but also to selected patients with Liver metastases from various diseases. In addition, even debulking Surgery may be indicated for selected patients with endocrine metastases. While patient selection for Liver resections was limited to clinical parameters in the past, histological and molecular characteristics have become increasingly important. Moreover, the response to regional or systemic chemotherapy has been demonstrated to be strong for a beneficial course of the disease even in advanced diseases. Key-Messages Due to the variety of available treatment options, optimal patient selection is crucial. Besides Liver Surgery, staged concepts as well as Liver transplantation are curative tools for many patients.

  • Experiences With Three-dimensional Printing in Complex Liver Surgery.
    Annals of surgery, 2019
    Co-Authors: Tobias Huber, Verena Tripke, Florentine Huettl, J. Baumgart, Hauke Lang
    Abstract:

    OBJECTIVE We present a series of cases where we used 3D printing in planning of complex Liver Surgery. BACKGROUND In Liver Surgery, three-dimensional reconstruction of the Liver anatomy, in particular of vascular structures, has shown to be helpful in operation planning. So far, 3D printing has been used for medical applications only rarely. METHODS AND PATIENTS From December 2017 to December 2019, in 10 cases where Surgery was assumed to be challenging operation planning was performed using full size 3D prints in addition to standard 3 phase CT scans. Models included transparent parenchyma, hepatic veins, vena cava, portal vein, hepatic artery, (biliary tree if requested), and tumors. In 7/10 cases vascular reconstructions were needed during the procedure. Nonstructured feedback of the surgical team revealed that the major benefit was visualization of the critical areas of vascular reconstruction, the expected dimensions of tangential vascular infiltration and the planning of reconstruction. In the multifocal tumors, 3D prints were considered to be helpful for intraoperative orientation to detect metastases and to improve planning of the resection. CONCLUSIONS In complex Liver Surgery with potential need for vascular reconstructions operation planning may be optimized using a 3D printed Liver model. Prospective studies are needed to evaluate the clinical impact of 3D printing in Liver Surgery compared to other 3D visualizations.

  • Technical aspects of laparoscopic Liver Surgery : Transfer from open to laparoscopic Liver Surgery
    Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen, 2018
    Co-Authors: Stefan Heinrich, Jens Mittler, Verena Tripke, Hauke Lang
    Abstract:

    Background Laparoscopic Surgery has become the standard for most visceral Surgery procedures in many hospitals. Now, Liver resections are also being increasingly carried out laparoscopically. The advantages of the laparoscopic technique have been demonstrated in numerous case series and in a recent randomized controlled trial. Aims The aim of this review article is to present the available techniques for laparoscopic Liver Surgery (LLS). Methods The technical variations reported in the literature as well as the own experience with LLS are reported. Results Optimal patient and trocar positions are crucial for successful LLS and they are chosen according to the planned type of Liver Surgery: the literature offers several options in particular for Surgery of the cranial and dorsal Liver segments. As for open Liver Surgery, a restrictive volume management and the application of the Pringle maneuver are helpful to reduce intraoperative blood loss in LLS. In addition, several dissection techniques have been adopted from open Liver Surgery. The Cavitron Ultrasound Surgical Aspirator (CUSA™) is particularly suitable for parenchymal dissection close to major vascular structures, since it guarantees a meticulous parenchymal dissection with minimal vascular injuries. Conclusion The developments of minimally invasive Surgery nowadays allow complex Liver resections, which can mostly be performed comparable to open Liver Surgery. Hopefully, minimally invasive Liver Surgery will further develop in Germany in the near future, since it offers several advantages over open Liver Surgery.

  • Long-term experience after ex situ Liver Surgery.
    Surgery, 2000
    Co-Authors: Karl J. Oldhafer, Hauke Lang, Hans J. Schlitt, J. Hauss, Rudolf Raab, Jürgen Klempnauer, Rudolf Pichlmayr
    Abstract:

    Abstract Background. Ex situ Liver Surgery allows Liver resection and vascular reconstruction in patients who have Liver tumors located at critical sites. Only a small series of studies about ex situ Liver Surgery is available in the literature. No long-term results have been published. Methods. Twenty-four patients were considered for ex situ Liver Surgery because conventional Liver Surgery was considered impossible or too hazardous. The patients' ages were 51.3 ± 7.5 years. Indications were various primary and secondary Liver malignancies and benign Liver tumors in 2 patients. Results. In 22 of 24 patients, the ex situ Liver resection and subsequent autotransplantation were performed. The anhepatic periods in these patients lasted for 5.6 ± 1.1 hours. In the remaining 2 patients, autotransplantation was not possible and allogenic Liver transplantation was performed 17 and 19 hours after hepatectomy. In 4 patients, Liver failure occurred after autotransplantation and required transplantation. The confluens between hepatic veins and the inferior vena cava was reconstructed in 5 patients. Fifteen patients survived the postoperative period and were discharged after 36.5 ± 16 days. The median survival time of 6 patients who had metastases of colonic carcinoma was 21 months. The 2 patients with benign Liver disease are alive 9 and 5 years after ex situ Surgery. Conclusions. Extended Liver resections with difficult reconstructions of the hepatic venous confluens are feasible by ex situ Liver Surgery and subsequent autotransplantation. However, the early postoperative mortality rate is high, especially in patients with cholestatic Livers. Early tumor recurrence remained the problem in these patients with extended local tumor spread. Ex situ Liver Surgery should only be performed in selected patients. (Surgery 2000;127:520–7.)

S Olde Damink - One of the best experts on this subject based on the ideXlab platform.

  • Development of a composite endpoint for randomized controlled trials in Liver Surgery
    British Journal of Surgery, 2011
    Co-Authors: M Van Den Broek, R Van Dam, G Van Breukelen, M Bemelmans, E Oussoultzoglou, Patrick Pessaux, C Dejong, N Freemantle, S Olde Damink
    Abstract:

    BACKGROUND: The feasibility of randomized controlled trials (RCTs) in Liver Surgery using a single-component clinical endpoint is low as such endpoints require large sample sizes owing to their low incidence. A Liver Surgery-specific composite endpoint (CEP) could solve this problem. The aim of this study was to develop a Liver Surgery-specific CEP with well-defined components. METHODS: Components of a Liver Surgery-specific CEP were selected based on a systematic literature search and consensus among 28 international hepatopancreatobiliary (HPB) surgeons. As an example, two prospective cohorts of patients who had undergone Liver Surgery in high-volume HPB centres were used to assess the event rate and effect of implementing a Liver Surgery-specific CEP. RESULTS: Components selected for the Liver Surgery-specific CEP were ascites, postresectional Liver failure, bile leakage, intra-abdominal haemorrhage, intra-abdominal abscess and operative mortality, all with a Clavien-Dindo grade of at least 3 and occurring within 90 days after initial Surgery. The incidence of this Liver Surgery-specific CEP was 19.2 per cent in one cohort and 10.7 per cent in the other. These rates led to an approximately twofold reduction in the theoretical sample size required for an adequately powered RCT in Liver Surgery using the CEP as primary endpoint. CONCLUSION: The proposed Liver Surgery-specific CEP consists of ascites, postresectional Liver failure, bile leakage, intra-abdominal haemorrhage, intra-abdominal abscess and operative mortality. It has a considerably higher event rate than any of its components. Its use as the primary endpoint will increase the feasibility and comparability of RCTs in Liver Surgery.