Initial experience with a new articulating energy devicefor laparoscopic liver resection

Eren Berber • Muhammet Akyuz • Federico Aucejo •

Shamil Aliyev • Erol Aksoy • Onur Birsen •

Eren Taskin

Received: 27 July 2013 / Accepted: 1 October 2013 / Published online: 14 November 2013

� Springer Science+Business Media New York 2013

Abstract

Background Although significant advances have been

made in laparoscopic liver resection (LLR), most tech-

niques still rely on multiple energy devices and staplers,

which increase operative costs. The aim of this study was

to report the initial results of a new multifunctional energy

device for hepatic parenchymal transection.

Methods Fourteen patients who underwent LLR using

this new device were compared to 20 patients who had

LLR using current laparoscopic techniques (CL). Data

were collected prospectively.

Results The groups were similar demographics and tumor

type and size. Although the type of resection was similar

between the groups, the parenchymal transection time was

less in the Caiman group (32 ± 5 vs. 63 ± 4 min,

respectively, p = 0.0001). The operative time was similar

(194 ± 21 vs. 233 ± 16 min, respectively, p = 0.158).

There was reduction of the number of advanced instru-

mentation used in the Caiman group, including the staplers.

Estimated blood loss, size of surgical margin, and hospital

stay were similar. There was no mortality, and morbidity

was 7 % in the Caiman and 20 % in the CL group.

Conclusions This initial study shows that the new device

is safe and efficient for LLR. Its main advantage is short-

ening of hepatic parenchymal transection time. This has

implications for increasing efficiency and cost saving in

LLR.

Keywords Hepatectomy � Laparoscopic � Liver

surgery � Operative time

Over the last few years, laparoscopic liver resection (LLR)

has been shown to be superior to open hepatectomy in

regards to blood loss, postoperative recovery, and hospital

stay in selected patients [1–5]. With increasing experience,

many centers in the world have incorporated LLR into the

treatment algorithm of patients with benign and malignant

liver tumors [6–9]. Furthermore, techniques for laparo-

scopic major hepatectomies have also been described [10–

13]. Our group has also previously reported various tech-

niques and favorable outcomes regarding LLR [14, 15].

The liver is a very vascular organ with the need to seal

and divide multiple vascular and biliary structures during

resection. Because of limited exposures and difficulties in

intracorporeal suturing in case of intraoperative bleeding,

LLR techniques rely on advanced energy devices (Har-

monic scalpel, LigaSure), clips, staplers, as well as RF-

assisted hemostatic instruments (Habib, TissueLink,

Aquamantys). Although it is possible to mimic open

techniques with laparoscopy with fine dissection and

individual vessel ligation, these techniques require signif-

icant skill and experience to master. As a result, one of the

criticisms for LLR has been that the operative costs are

higher than open surgery.

The utilization of different energy devices for different

steps of the operation is also cumbersome in terms of the

flow of the procedure, and it also requires a certain skill for

proper use. It is important to develop hybrid instruments

that are multifunctional to increase the efficiency of the

E. Berber � M. Akyuz (&) � F. Aucejo � S. Aliyev � E. Aksoy �O. Birsen � E. Taskin

Department of General Surgery, Cleveland Clinic, Cleveland,

OH, USA

e-mail: makyuz@gmail.com

E. Berber

e-mail: berbere@ccf.org

E. Berber

9500 Euclid Avenue/F20, Cleveland, OH 44195, USA

123

Surg Endosc (2014) 28:974–978

DOI 10.1007/s00464-013-3262-3

and Other Interventional Techniques

procedure and to decrease costs. In this regard, the current

study describes a new multifunctional device that has the

potential to increase the efficiency of LLR and assesses the

safety and efficacy in an initial series of patients.

Materials and methods

Between November 2012 and September 2013, a new

vessel sealer (Caiman, Aesculap Inc., Center Valley, PA,

USA) was used in 14 LLRs at the Department of General

Surgery, Cleveland Clinic. These cases were compared to

20 consecutive LLRs matched by the type of resection in

which this device was not used (the result of unavailability)

between January 2010 and February 2013. All procedures

were performed by the same surgical team (EB, FA). The 2

groups were compared regarding demographic, clinic and

perioperative parameters from a prospective, institutional

review board–approved database. Intraoperative time data

were obtained from operative video recordings.

The technique for LLR at our institution has been

reported elsewhere [14, 15]. In all cases, after pneumo-

peritoneum was established and exposure obtained, lapa-

roscopic ultrasound was used to identify the tumor. Inflow

occlusion was not used in any case. In the first group

(Caiman), the ligaments were divided using the Caiman

device. The device was introduced through a 12-mm trocar.

The instrument has 5-cm articulating jaws. Then the

resection line was marked on the liver capsule using

electrocautery on a hook. Caiman was subsequently used to

divide the parenchyma, similar to the stapling technique

(Figs. 1 and 2). The device was activated by closing the

tips using a mechanism similar to laparoscopic linear sta-

plers and pushing a button at the handle. The generator

alerts the user to the completion of the hemostasis cycle by

making a beeping sound, and then the operator, using a

trigger at the handle, divides the tissue (Fig. 3). This device

is approved by the U.S. Food and Drug Administration for

tissue bundles and vessel ligation up to 7 mm. Intrapa-

renchymal vascular and biliary structures were divided

using this device, with a stapler reserved for division of the

hepatic veins extra-hepatically, as in case of left lateral

sectionectomy. If hemostasis on the remnant liver surface

was adequate, an additional energy device was not used. If

deemed inadequate, then either TissueLink (TissueLink

Medical, Dover, NH) or laparoscopic Aquamantys (Med-

tronic Advanced Energy LLC, Portsmouth, NH) was used

for further hemostasis. In the latter conventional laparos-

copy (CL) group, the ligaments were divided using Har-

monic scalpel (Ethicon Endo-Surgery, Cincinnati, OH).

The resection line was marked on the liver capsule using

electrocautery on a hook. Then, Harmonic scalpel was used

to crack the liver parenchyma. Individual vessels and

biliary ducts were exposed and divided using a combina-

tion of using clips, ties, staplers, Habib (AngioDynamics,

Latham, NY), TissueLink (TissueLink Medical, Dover,

NH) or Aquamantys (Medtronic Advanced Energy LLC,

Portsmouth, NH).

Statistical analysis was performed by t test and chi-

square test. All data are expressed as mean ± standard

error of the mean (SEM).

Results

Table 1 shows the comparison of the groups regarding the

data analyzed. The groups were similar in terms of

demographic and clinical data. Pathology was malignant in

the majority of the patients in each group (Table 2). In the

Caiman group, 35 % of the cases were purely laparoscopic

and 65 % hand-assisted, whereas 60 % of the cases

(n = 12) were purely laparoscopic and 40 % hand-assisted

in the CL group (p = 0.161). Although the type of resec-

tion was similar between the groups, the parenchymal

transection time was shorter in the Caiman group (32 ± 5

vs. 63 ± 4 min, respectively, p = 0.0001). The operative

time was less in the Caiman group (194 ± 21 vs.

233 ± 16 min, respectively), but this was not statistically

significant (p = 0.158).

Fig. 1 Intraoperative photos showing the usage of Caiman for a left

lateral sectionectomy. Parenchymal bites are taken with the device

similar to staplers. Because the device is activated as it is closed,

hemostasis is also applied to the raw liver tissue

Surg Endosc (2014) 28:974–978 975

123

There was reduction of the number of advanced instru-

mentation used in the Caiman group (regarding energy

devices and staplers). A linear stapler was used in 4 cases

in the Caiman (28 %) versus 13 cases (65 %) in the CL

group (p = 0.034). Estimated blood loss, size of surgical

margin, and length hospital stay were similar (Table 1).

There was no mortality, and morbidity was 7 % in the

Caiman group and 20 % in the CL group. The complication

in the Caiman group was a wound infection in 1 patient; the

morbidity in the CL group included Clostridium difficile

colitis in 2 patients, pneumonia in 1 patient, and ileus in 1

patient.

Discussion

With advancements in technology, training, and surgeon

experience, LLR has been a significant breakthrough in the

treatment of patients with liver tumors [6, 16]. The

worldwide experience has been exponentially accumulat-

ing, as evidenced by 38 % of the liver resection abstracts in

the most recent World Congress of the International Hep-

ato–Pancreato–Biliary Association in Paris involving lap-

aroscopic or robotic studies [17].

A major issue regarding LLR is that the techniques and

instruments vary significantly from center to center.

Because the transition to acquiring an efficient technique

similar to open liver resection takes time, energy devices

and staplers play a larger role on the conduct of the oper-

ation in LLR. As hospitals become more sensitive to cost,

LLR procedures have recently been a focus of scrutiny.

Laparoscopic resections in general utilize more advanced

instrumentation, such as energy, dissection, and stapling

devices, than open procedures. In this initial report, we

have described a new-generation instrument that uses

bipolar energy. Compared to other devices, it uses tissue

feedback to adjust the energy. Its design is similar to a

linear stapler, and its articulation renders this device suit-

able for LLR. Because its closes at the tip, not the hinge,

activation of this device while crushing the tissue provides

both hemostasis to the vascular structures and also to the

raw liver parenchyma. Thus, it combines the functionality

of a vessel sealer, stapler, and tissue coagulator. This

benefit was demonstrated in the current study with a

reduction of the number of advanced instruments, includ-

ing vessel sealers, staplers, and parenchymal coagulating

devices, which resulted in a faster parenchymal transection

time as well. Previously it was shown that LLR is more

cost-effective for the hospitals because the patients are able

to be discharged home earlier compared to open liver

resection [15]. We believe that these additional cost sav-

ings in the operating room will render LLR more attractive

to hospitals.

Because of the size of the device, it is most appropriate

for resections that involve a linear transection line, such as

left lateral sectionectomy or right posterior sectorFig. 2 Intraoperative photos demonstrating a segment 7 tumor

resection using the Caiman

Fig. 3 Photo showing the

Caiman device, which is a

12-mm device with an active

5-cm jaw. It articulates, and

once the tissue is crushed

between the blades, a button on

the handle is pushed. When the

generator beeps, the tissue can

be divided by pulling a trigger

on the handle

976 Surg Endosc (2014) 28:974–978

123

resections. We are also in the phase of trialing the device

for major LLRs, in which the benefits may be more

prominent because there is a larger amount of parenchyma

that needs to be divided.

It is unknown whether this device could provide an

adequate seal on the biliary ducts. We have not seen any

bile leaks in the procedures where the biliary radicles to

segments 2 and 3 were taken with this instrument, but this

needs to be verified in future studies.

With multiple firings of the instrument, charring can

occur on the blades, which can impede the hemostasis in

subsequent applications. Therefore, we recommend clean-

ing the blades after 4 or 5 firings.

In summary, this study assesses the safety and efficacy

of a new multifunctional energy device for LLR. The initial

experience presented is favorable, mainly because of a

more efficient parenchymal transection. This is an oppor-

tunity for intraoperative cost saving in LLR with the

reduction in the number of energy devices and staplers

used. We are continuing to assess the technology in our

prospective LLR protocol. We believe that this device will

contribute to advance the technique of LLR.

Disclosures Eren Berber is a consultant for Aesculap Inc. and

Ethicon Inc. Muhammet Akyuz, Shamil Aliyev, Erol Aksoy, Onur

Birsen, and Eren Taskin have no conflicts of interest or financial ties

to disclose.

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Table 1 Demographic, clinical, and operative data in the study patients

Parameter Caiman (n = 14) CL (n = 20) p value

Age, years, mean ± SD (median) 64.2 ± 4.1 61.9 ± 3.3 0.673

Gender, M/F 5/9 9/11 0.587

Tumor size, cm, mean ± SD (median) 3.7 ± 0.4 3.8 ± 0.3 0.860

No. of tumors, range, mean ± SD (median) 1.7 ± 0.2 (1–5) 1.3 ± 0.1 (1–3) 0.166

Benign/malignant 3/11 4/16 0.919

Pure laparoscopic/hand-assisted 5/9 12/8 0.161

No. of devices, mean ± SD, median 1.8 ± 0.2 (1.5) 3.1 ± 0.1 (3) \0.0001

Left lateral segmentectomy/wedge resection or segmentectomy 5/9 7/13 0.965

Operative time, min, mean ± SD (median) 194 ± 21 233 ± 16 0.158

Transection time, min, mean ± SD (median) 32 ± 5 63 ± 4 0.0001

Estimated blood loss, ml, mean ± SD (median) 289 ± 106 430 ± 88 0.316

Margin, cm, mean ± SD (median) 0.49 ± 0.10 0.37 ± 0.08 0.383

Hospital stay, days, mean ± SD (median) 3.3 ± 0.5 (3) 3.8 ± 0.4 (4) 0.458

Complications, n (%) 1 (7 %) 4 (20 %) 0.278

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Neuroendocrine tumor 2 2

Melanoma 1 0

Angiosarcoma 1 0

Paraganglioma metastasis 0 1

Breast cancer metastasis 0 1

CL current laparoscopic techniques

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