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Operating room set-up and equipment for laparoscopic hepatopancreatobiliary surgery 39
Figure 3.21 The Thunderbeat is the first integration of advanced bipolar sealing and ultrasonic technologies.
3.5.5 Radiofrequency ablation
Radiofrequency ablation (RFA) is often used to destroy
small and deeply located intraparenchymal lesions while
avoiding deep parenchymal resection and significant
parenchymal volume loss. The RFA device generates a
high-frequency alternating current to cause focal tissue
destruction at the tip of the electrode, which is inserted
through a trocar or directly through the abdominal wall
and placed into the target lesion under the guidance of
ultrasonography. The technique of precise targeting using
laparoscopic ultrasonography guidance is relatively difficult. Nevertheless, it has an important role, especially in
the management of bilobar, multiple or unresectable
lesions, and in patients with impaired liver function [10].
The combination of direct visualization with ultrasonic
guidance of target lesions during laparoscopic RFA has
important benefits in certain cases over axial imageguided ablation techniques owing to the ability to directly
inspect and screen the rest of the liver and the entire
abdominal cavity.
3.5.6 Argon plasma coagulation
Argon plasma coagulation is used to create a coagulated
tissue surface (mainly the transected liver surface) by
passing electric current through a stream of ionized argon
gas. High-flow infusion of argon gas can increase intraabdominal pressure and has been reported as a risk factor
for developing gas embolism in laparoscopic surgery [11].
For this reason, argon plasma coagulation should be used
with caution, if at all, on visceral organs in laparoscopic
surgery. A significant risk stems from injecting insoluble
argon gas into an inadvertently opened hepatic vein
during laparoscopic liver surgery with potentially fatal
gas embolism.
3.6 Nonenergy devices
A significant number of specialized instruments are available for advanced laparoscopic HPB surgery with various
features for a variety of preferences. Instruments frequently used in laparoscopic HPB surgery are discussed
here.
3.6.1 Bipolar forceps
A bipolar forceps is an instrument with forceps properties
but also the ability to deliver bipolar energy, as discussed
in the previous section. Among the wide variety of bipolar
forceps available in laparoscopic surgery, the one with
wide and fenestrated tips (CEV 134, Medtronic MicroFrance,
Dublin, Ireland) (Figure 3.22, upper) is most frequently used
for HPB procedures. The tips open and close while keeping
the jaws parallel to each other. Therefore, the closing pressure
is equally distributed to the tissue between the tips. This mode
of action works efficiently in tissue dissection, clamping of an
Figure 3.22 A laparoscopic bipolar forceps with wide and
fenestrated tips and a newer handle (upper) and a bipolar
forceps with thin liner tips (lower).
40 Chapter 3
Figure 3.23 A laparoscopic grasping forceps with broad and flat tips (left) and serrated right angle forceps (right).
injured vessel, secure coagulation, and tissue retraction with
atraumatic but high grasping force. Liver parenchyma
can be transected s imilarly to the clamp crushing
method [12]. For hemostasis of small vessel s or fine
structures, a bipolar forceps with nonfenestrated thin
tips is more suitable (see Figure 3.22, lower).
3.6.2 Grasper
Grasping forceps are designed for tissue manipulation
with or without a locking mechanism (ratchet). Toothed
forceps are used to retract tissue with a lower risk of tissue
slippage but higher application of force. Forceps with
broad and flat tips are capable of more gentle grasping
with lower pressure per square unit. Among these types
of forceps, those with a lower grasping power are preferred because of their greater safety in preventing inadvertent tissue damage. Such graspers release the tissue
between the tips spontaneously when external force
is applied, which avoids serious damage to the tissue
(Figure 3.23, left). Forceps with fine tips allow for handling of delicate tissue, and those with curved tips and
pointed ends are used for tissue dissection and in developing a surgical plane (see Figure 3.23, right).
Figure 3.24 A laparoscopic retractor can alter the shape of tips
from liner to triangular configuration.
injury. Gentle retractionto achieve the small working field
is required for safe manipulation and decreases the risk of
traction injury, particularly in a fragile steatotic liver. It is
one of the advantages of laparoscopic surgery that even in
a narrow working field, an excellent view is achieved and
the procedure can be completed.
3.6.3 Retractor
A retractor should be strong enough to retract the large
and heavy liver while not perforating the liver capsule in
the process. For this purpose, most laparoscopic retractors
have a mechanism to alter their configuration after being
inserted into the abdominal cavity (e.g. articulating
triangular retractor [Figure 3.24] and balloon retractor
[Figure 3.25]), with the goal of increasing the contact area
between the tissue and instrument and decreasing the
pressure per unit area on the tissue. When retracting
delicate tissue using a grasper or dissector, placing gauze
between the tissue and forcepscan help to increase friction
for reliable retraction while decreasing the risk of tissue
Figure 3.25 The Soft-wand balloon retractor (Gyrus ACMI,
Maple Grove, USA) has an inflatable balloon covered with a
mesh. The balloon is deployed through a trocar and inflated
once inside the abdominal cavity to retract delicate tissue or
organs such as the spleen and liver gently and effectively.
Operating room set-up and equipment for laparoscopic hepatopancreatobiliary surgery 41
Figure 3.26 A laparoscopic vascular clamp with atraumatic tips of Debakey type (left) is used to manage bleeding and in case of
inadvertent injury to large veins.
3.6.4 Vascular clamp
A vascular clamp is a forceps with atraumatic tips of
Debakey forceps type (Figure 3.26, left). This is an essential instrument for laparoscopic HPB surgery because it
can be crucial in controlling intraoperative bleeding. Once
temporal hemostasis is achieved by clamping the vessel,
the surgeon can reorganize the operative field, add ports,
and find a way to obtain durable hemostasis. (e.g. coagulating, clipping, stapling, suturing or application of hemostatic agents). When dividing a major hepatic vein (left,
right or middle hepatic vein), placing a vascular clamp
within reach of the staple site (see Figure 3.26, right) to
control bleeding from an inadvertent venous tear during
stapling or malfunction of the stapler is recommended.
Another use of the forceps is to temporarily occlude a
portal pedicle to demarcate its feeding liver.
A vessel occlusion clamp (Bulldog clamp) is used to
temporarily occlude vascular flow atraumatically for
bleeding control or for vascular reconstruction (e.g.
wedge resection of the portal vein). This endoscopic
clamp is applied and removed intracorporeally using a
special laparoscopic applicator.
3.6.5 Suction and irrigation
Suction is one of the instruments most frequently used
during laparoscopic surgery. The instrument should be
equipped with a mechanism to start and stop aspiration
easily and quickly so that the surgeon avoids unnecessary
aspiration of intra-abdominal gas to maintain pneumoperitoneum (Figure 3.27). Irrigation with water rather
than normal saline can improve visualization of the
operative field through lyzing of erythrocytes.
Figure 3.27 A suction instrument offers efficient aspiration of
blood or body fluid while maintaining intra-abdominal
pressure and pneumoperitoneum for organ exposure and
hemostatic effect.
3.6.6 Needle holder and suture
Laparoscopic suturing is technically challenging but is an
essential part of advanced HPB surgery. Suturing and
ligation are performed during reconstructive procedures
in laparoscopic HPB surgery (e.g. creation of gastrojejunal,
hepaticojejunal or pancreatico-digestive tract anastomoses). However, it is also critical for the management of
complications (e.g. closure of a bowel tear or a vascular
injury) and may prevent conversion to open surgery in
some cases. Safe management of complications during
advanced HPB surgery or advanced reconstruction relies
on mastering the challenge of intracorporeal suturing.
A variety of needle holder designs with several handle
configurations is available, such as pistol, fingered or palm
(Figure 3.28) grip, according to surgeon preference.
Curved, straight, and grooved tips are available; the
42 Chapter 3
Figure 3.28 A needle holder with a palm grip.
grooved tip automatically orients the needle perpendicular to the needle holder, which facilitates the suturing
process. JAiMY (EndoControl, Grenoble, France), a 5 mm
motorized articulating laparoscopic needle holder
(Figure 3.29), is designed to allow for greater flexibility
of movement with increased degrees of freedom (flexion
of the shaft and rotation of the jaw). Robotic systems have
increased degrees of freedom of the arms and consequently enable more flexible instrumental movement
which can facilitate creation of challenging anastomoses.
A pre-tied slip-knot prepared at the beginning of the
case (Figure 3.30) saves time and effort in making the first
knot intracorporeally, which is especially useful in achieving quick hemostasis in case of bleeding. Thus, several sets
of needled sutures with a pre-tied knot can be prepared at
the beginning of the case, as they are rapidly needed when
hemorrhage occurs. Usually, a 20 cm suture equipped
with nondetachable needle is used. A barbed suture is a
Figure 3.30 An extracorporeally pre-tied knot saves time and
effort for making the first knot intracorporeally.
suture that does not requirea knot at the end. The barbs on
its surface penetrate the tissue and lock it into place,
therefore eliminating the need for a knot. An Endoloop
(Ethicon, New Jersey, USA) is a ready-to-use pretied
ligation device with the disadvantage that only a limited
number of suture types are available.
3.6.7 Surgical clip
Clips are used toocclude vesselsor bile ducts prior to division
to prevent bleeding or biliary leakage. Clips are made of
titanium or polymer in a variety of clip sizes. Applicationof a
clip to a vessel at a 90° angle with a sufficient length of vessel
cuff can prevent clip slippage. Further, a polymer clip with a
self-locking mechanism suchas Hem-o-lok (Weck, Teleflex,
Morrisville, USA) (Figure 3.31) is less likely to slip, and
division can occur flushwiththeclip.
Figure 3.29 A motorized articulating laparoscopic needle
holder.
Figure 3.31 A polymer ligation clip with a self-locking
mechanism is less likely to slip and seems to be more secure.
Operating room set-up and equipment for laparoscopic hepatopancreatobiliary surgery 43
It is important to apply the proper clip size for the vessel
diameter; applying a small clip to a thick vessel creates the
risk of the clip opening because the force of the clip closing
is increased beyond the design capacity of the clip. Applying too large a clip to too thin a vessel increases the risk of
slippage as a result of low compression pressure. For the
splenic artery, splenic vein, and other portal branches,
10 mm clips are generally applied.
Previously applied clips may interfere with the application of additional clips (e.g. clip on clip) or later stapling.
A common problem in laparoscopic HPB surgery is clip
slippage on small hepatic vein branches as the surgeon
progresses further cranial with the caval dissection, accidentally knocking clips off the vessel. Therefore, some
surgeons perform thermal sealing only on thin hepatic
vein branches off the inferior vena cava.
3.7 Endoscopic stapler
Endoscopic linear staplers occupy an important position
in laparoscopic HPB surgery. Secure hemostasis can be
achieved or an anastomosis rapidly fashioned without the
need for lengthy suturing (Figure 3.32). Linear staplers
generate at least two rows (three rows in newer generation staplers) of staples on each side of the transected
tissue. The staplers are loaded with disposable cartridges
of various lengths (30–60 mm) containing staples of various heights (2.0–5.0 mm) for use in different tissue
thicknesses. The major hepatic veins are commonly
divided using a vascular load cartridge with staples of
2.0 or 2.5 mm in height which produce tissue compression to 0.75–1.0 mm. When dividing major hepatic veins
at their origin, surgeons should be careful not to apply
shear forces (especially pulling force) to the vessel during
firing, to prevent vascular tears in a major hepatic vein or
the inferior vena cava itself. Stabilization of the shaft of
the stapler by an assistant can minimize shear forces
during the stapling and division process. A thick portal
pedicle and liver parenchyma (e.g. left lateral sectionectomy) can be divided using a cartridge with 2.5–3.5 mm
staples. The pancreatic body and stomach can be transected using a cartridge with 3.5–4.8 mm staples. When
using staples for dividing or anastomosing thick tissue, the
tissue should be compressed between the jaws for more
than 10 seconds to achieve proper tissue approximation
for secure hemostasis or anastomosis.
Applying staples that are too long for thin tissue or too
short for thick tissue carries a risk of bleeding as a result of
insufficient tissue compression or tissue dehiscence due to
improper interlock.
3.8 Tissue removal bag
A tissue bag is used for removal of specimens, to prevent
spillage of tumor cells or infected tissue, and to decrease
the risk of tumor implantation or surgical site infection.
Figure 3.32 An endoscopic linear stapler equipped with an articulated mechanism.
44 Chapter 3
The bag is inserted through a port site and removed
through a suprapubic incision or enlarged port incision.
Small specimens can be removed in the bag through a
12 mm port.
3.9 Hemostatic agent
In minimally invasive liver surgery, prevention of bleeding through meticulous dissection and pre-emptive identification of vascular structures are critical. However, once
a vascular injury and consequent bleeding occur, local
compression with gauze introduced into the abdominal
cavity can allow the anesthesia team to prepare for
further blood loss and bring devices for permanent hemostasis (bipolar cautery, vascular clamp, endoscopic clip or
stapler) to the site without excessive blood loss. The
adjunctive use of topical hemostatic agents promotes
hemostasis and enhances coagulation.
Moderate bleeding can be stopped by applying Surgicel
Fibrillar (Ethicon, New Jersey, USA) (oxidized regenerated cellulose) and compression to the bleeding site (Figure 3.33, left). Even if simple compression is not sufficient
to completely stop bleeding, it may slow it down and allow
the surgeon to remove blood from the operative field for a
brighter video image and for further blood loss to occur
without obstructing the view of the injury. Temporizing
measures allow identification of the bleeding site and
consideration of a strategy for definitive hemostasis.
TachoSil (Nycomed, Zurich, Switzerland), a biologically
active agent, is composed of a collagen sponge coated with
human fibrinogen and thrombin, and it can be used for
achieving secure hemostasis (see Figure 3.33, right) [13].
Liquid fibrin sealant is also used to stop diffuse bleeding
from the liver transection surface. However, when applying the fibrin sealant via a gas-charged applicator, development of air or gas embolism can be a concern [14].
When compression of the bleeding area with a
sponge or laparoscopic instruments is insufficient,
direct compression by the surgeon’s hand via conversion to a hand-assisted or open approach must be
performed. Nevertheless, rapid conversion during
hepaticveinbleedinginapatientwithlowcentral
venous pressure can lead to fatal air embolism. Therefore, a significant amount of preparation to prevent
bleeding and, when it occurs, techniques to control
it should be in pla ce to avoid rapid conversion in the
case of major hepatic vein bleeding. In complex liver
resections, infl ow occlusion by temporarily clamping
the hepatoduodenal lig ament (Pringle maneuver)
is another useful option to decrease the amount
of bleeding from the liver transection surface
(Figure 3.34). The pneumoperitoneum itself, however, provides a form of Pringle maneuver, and
recently surgeons have experimented with raising
the pneumoperitoneal pressure to 21 mmHg and
higher to provide some form of inflow control during
minimally invasive liver surgery.
Figure 3.33 Surgicel (left) and TachoSil (right) are used to promote hemostasis and enhance coagulation.
Operating room set-up and equipment for laparoscopic hepatopancreatobiliary surgery 45
Figure 3.34 The hepatoduodenal ligament is taped for
Pringle’s maneuver in order to decrease the amount of
bleeding during liver resection.
KEY POINTS
• Optimal positionin g of laparoscopic monitors is essential to enhance procedural precision and speed as well as to reduce physical
and mental stress on the surgical team. A dedicated minimally invasive surgery suite and special devices such as laparoscopic
mounting devices and instrument stabilizers are helpful to maintain an optimal surgeon–equipment environment during
advanced laparoscopic HPB procedures.
• Technological developments in imaging and electrosurgical devices greatly contribute to procedural safety and efficacy in
laparoscopic HPB surgery. Up-to-date knowledge of new equipment and technologies is essential.
• Mastering laparoscopic suturing is a must for advanced minimally invasive HPB surgeons.
• Because of the possibility of significant blood loss during every laparoscopic HPB surgery, equipment, instruments, and agents
for the management of intraoperative bleeding are crucial and should be prepared prior to commencing the case.
References
1 van Det MJ, Meijerink WJ, Hoff C, et al. Optimal ergonomics
for laparoscopic surgery in minimally invasive surgery suites:
a review and guidelines. Surg Endosc 2009; 23:1279–1285.
2 Gumbs AA, Crovari F, Vidal C, et al. Modified robotic light-
weight endoscope (ViKY) validation in vivo in a porcine
model. Surg Innov 2007; 14:261–264.
3 Ishizawa T, Zuker NB, Kokudo N, Gayet B. Positive and
negative staining of hepatic segments by use of fluorescent
imaging techniques during laparoscopic hepatectomy. Arch
Surg 2012; 147:393–394.
4 Sutton PA, Awad S, Perkins AC, Lobo DN. Comparison of
lateral thermal spread using monopolar and bipolar diathermy, the Harmonic Scalpel and the Ligasure. Br J Surg
2010; 97:428–433.
5 Hirokawa F, Hayashi M, Miyamoto Y, et al. A novel method
using the VIO soft-coagulation system for liver resection.
Surgery 2011; 149:438–444.
6 Scalzone R, Lopez-Ben S, Figueras J. How to transect the
liver? A history lasting more than a century. Dig Surg 2012;
29:30–34.
7 Gayet B, Cavaliere D, Vibert E, et al. Totally laparoscopic right
hepatectomy. Am J Surg 2007; 194:685–689.
8 Ishizawa T, Gumbs AA, Kokudo N, Gayet B. Laparoscopic
segmentectomy of the liver: from segment I to VIII. Ann Surg
2012; 256:959–964.
9 Seehofer D, Mogl M, Boas-Knoop S, et al. Safety and efficacy
of new integrated bipolar and ultrasonic scissors compared to
conventional laparoscopic 5-mm sealing and cutting instruments. Surg Endosc 2012; 26:2541–2549.
10 De Jong KP, Wertenbroek MW. Liver resection combined
with local ablation: where are the limits? Dig Surg 2011;
28:127–133.
11 Ikegami T, Shimada M, Imura S, et al. Argon gas embo-
lism in the application of laparoscopic microwave coagulation therapy. J Hepatobiliary Pancreat Surg 2009;
16:394–398.
46 Chapter 3
12 Takayama T, Makuuchi M, Kubota K, et al. Randomized
comparison of ultrasonic vs clamp transection of the liver.
Arch Surg 2001; 136:922–928.
13 Fischer L, Seiler CM, Broelsch CE, et al. Hemostatic efficacy of
TachoSil in liver resection compared with argon beam
Videos 1–26 will be of interest to readers of this chapter.
Visit the companion website at:
www.wiley.com\go\conrad\liver-pancreas-biliary-laparoscopic-surgery
coagulator treatment: an open, randomized, prospective,
multicenter, parallel-group trial. Surgery 2011; 149:48–55.
14 Ebner FM, Paul A, Peters J, Hartmann M. Venous air embo-
lism and intracardiac thrombus after pressurized fibrin glue
during liver surgery. Br J Anaesth 2011; 106:180–182.
CHAPTER 4
Augmented reality for laparoscopic
liver surgery
Kate Gavaghan, Matteo Fusaglia, Matthias Peterhans, and Stefan Weber
ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
EDITOR COMMENT
This chapter is a glimpse into the future of advanced laparoscopic HPB surgery. The authors, expert engineers of augmented reality
guidance solutions, describe the critical steps that lead to clinically applicable augmented reality. Augmented reality ultimately is the
supplementation of a real-world view with aligned real-time computer-generated information. The challenges of this supplementation
attributable to pre- or intraoperative data acquisition, creation of a selective augmented reality, image overlay, and tracking are shown.
Issues specific to laparoscopic HPB surgery, such as liver deformation and display of depth information, are explained in detail.Further, the
authors show how augmented reality has the potential to improve spatial understanding and the localization of underlying anatomy or
tumors. Our own experience with augmented reality suggests that this chapter is important for those HPB surgeons who are looking to
see where the field of advanced laparoscopic HPB surgery is headed.
Keywords: alignment, augmented reality, clinical application of augmented reality, image tracking, instrument tracking
4.1 Introduction
Despite its obvious benefits for patients, laparoscopic
surgery presents multiple inherent challenges. The limited view of the two-dimensional (2D) laparoscopic image
reduces depth perception and weakens spatial understanding, making localization of anatomy and prediction
of surgical margins more difficult than in open surgery.
Additionally, the lack of tactile feedback and the separation of visual feedback from the situs challenge the
identification and manipulation of anatomical structures
and greatly increase the required hand–eye coordination
skills. Recent developments in high-resolution imaging
and three-dimensional (3D) monitors have somewhat
alleviated these problems but fail to provide a comprehensive solution.
In recent decades, advances in computing have resulted
in an increase in the quality and quantity of information
that needs to be processed during surgery. Advances in
image processing techniques such as the fusion of
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
multimodality imaging and structure segmentation
have dramatically changed the way in which anatomy
and target lesions are visualized; they have also changed
the way in which surgeries are planned. The combination
of medical image visualization techniques, preoperative
planning, and surgical guidance has led to an increasing
reliance on image guidance and computer assistance
during a wide range of surgeries. While surgical guidance
technologies were initially designed for use in surgeries
on fixed anatomy such as neurosurgery, paranasal sinus
surgery, and orthopedic surgery [1], solutions designed
for soft tissue surgeries have recently become commercially available [2].
Surgeries can now be planned and visualized prior to
surgery via 3D virtual representations of the patient
anatomy and analyzed quantitatively using dedicated
software. Measurements of volume, planning of resection
margins, assessment of distances to anatomical structures, and functional parameters such as liver volumes
can be evaluated preoperatively. This information can
47
48 Chapter 4
then be used to determine surgical approaches that optimize clinical outcome and improve patient safety. Intraoperatively, stereotactic and image guidance technologies
allow virtual surgical reality to be viewed interactively
with precise capturing of surgical tools in 3D space. This
information provides guidance beyond the mental representation traditionally relied on by surgeons.
Image guidance has the potential to alleviate many
challenges currently facing laparoscopic surgeons. However, the display of increasing amounts of information in
the operating room presents its own challenges. How shall
we visualize information in a way that is useful, intuitive,
and minimally distracting to the surgeon? Further, in
laparoscopic surgery, where the surgeon relies on the
operating monitor for visual input, the addition of new
imaging information might draw the sight and attention
away from potentially critical information being displayed
via the traditional laparoscopic view (Figure 4.1).
Augmented reality (AR) enhances the surgeon’s view
by allowing additional information to be presented to the
surgeon without the need for diversion of sight away from
the patient. In this context, AR provides a useful solution
to the fusion of multiple imaging sources, allowing laparoscopic surgery to benefit from the advantages of image
guidance already offered in other surgical domains.
In this chapter, important concepts and principles of AR
and image guidance for laparoscopic surgery are presented in detail. The purpose of AR and how it is achieved
are discussed and recent live experiences with augmented
reality laparoscopic hepatopancreatobiliary (HPB) surgery are reviewed. Finally, challenges pertaining to the
realization of optimal AR solutions are described, along
with a discussion of current research topics and a vision of
the future role AR is likely to play in laparoscopic HBP
surgery.
4.2 Augmented reality
Augmented reality is defined as the augmentation or
supplementation of a real-world view with real-time
computer-generated information that is registered to
the real-world scene. AR gives the viewer an alternative
perception of the depicted scene which encompasses real
and virtual environments; this augments the classic view
of the world and ensures additional feedback. Augmentation can utilize any sense; thus it can be delivered in the
form of visual feedback, haptic feedback, or audial feedback. Historically, however, augmentation data have
been displayed visually and, in the context of imageguided surgery, typically onto a monitor, using transparent layers or directly onto the patient surface using
projection devices. Medical AR consists primarily of 3D
reconstructions of physical objects (e.g. a virtual organ
displayed onto the laparoscopic video stream) or textual
or symbolic information (e.g. patient-specific information, geometric calculations or guidance for performing a
particular procedure) overlaid at the same perspective as
the scene of interest.
Three-dimensional anatomical representations allow
structures of interest such as vessels and tumors to be
viewed in an intuitive way, allowing the user to analyze
Figure 4.1 Surgical guidance data traditionally displayed on a monitor of other surgical domains are less suited to laparoscopic
surgery because of the need for attention on a secondary monitor displaying laparoscopic images.
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