Devices for minimally invasive liver parenchyma transection: the SICE (Italian Society of Endoscopic Surgery) Italian and International survey

Abstract

Backgrounds: Minimally Invasive Liver Surgery (MILS), encompassing laparoscopic (L-MILS) and robotic (R-MILS) approaches, has revolutionized liver surgery, offering reduced morbidity, shorter hospital stays, and improved outcomes while maintaining oncological efficacy. Despite the widespread use of L-MILS, parenchyma liver transection techniques and devices remain debated. This study investigates the adoption of transection devices (TDs) in MILS among 86 hospitals, focusing on surgical practices, device utilization, and outcomes.

Methods: The Italian Society of Endoscopic Surgery (SICE) endorsed a cross-sectional internet-based survey targeting general and Hepato-Pancreato-Biliary surgeons.

Results: Responses from 86 centers revealed that 77% of institutions is available a robotic platform, with an adoption rate of 87.50% in high-volume centers. L-MILS remains the predominant technique for liver resections, also in case of major hepatectomies, although R-MILS is increasingly utilized. For minor L-MILS, more than 50% of respondents use ultrasonic shears and electrosurgical pencil and advanced bipolar devices, while about 40% of surgeons adopt Cavitronic Ultrasonic Surgical Aspirator (CUSA) in major resections. R-MILS procedures predominantly used Maryland bipolar forceps and vessel sealers, with hybrid techniques (30%) integrating laparoscopic devices (e.g., CUSA) to address robotic device limitations.

Conclusion: The minimally invasive approach to liver parenchymal transection is a key component of this surgical procedure. For major hepatectomies, the CUSA device remains the most effective tool, whereas ultrasonic shears, electrosurgical pencil, and advanced bipolar devices are more suited for minor resections. Despite limited access to specialized instruments, R-MILS achieves favorable outcomes in liver transection by employing the crash-clamp technique or hybrid strategies.

Keywords: High energy device; High volume; Indocyanine green fluorescence; Laparoscopic liver surgery; Liver parenchyma; Liver surgery; Low volume; Medium volume; Minimally invasive surgery; Robotic liver surgery.

Fig. 1

A, Distribution of hospital types by Central vs. Peripheral and Public vs. Private policy (p value = < 0.0001); B, Number of centers according to Minimally Invasive Liver Surgery volume (p value = 0.579)

Fig. 2

Radar plots comparing the utilization of surgical devices in different procedures. A, Minor versus major laparoscopic resections: Utilization levels of ultrasonic shears/electrosurgical pencil devices, advanced bipolar devices, monopolar or bipolar radiofrequency needles, advanced bipolar and ultrasonic systems, and Cavitronic Ultrasonic Surgical Aspirators. B, Minor versus major robotic resections: Utilization levels of Robotic Maryland Bipolar, Da Vinci Vessel sealer or SynchroSeal, robotic scissors, Harmonic ACE®, and combinations of other laparoscopic devices

Fig. 3

The dominance of traditional techniques: Clamp-crush technique and layer-by-layer transection constitute 60% of the reported methods. The hybrid approaches, thanks to laparoscopic CUSA devices, play a notable role, reflecting variability in surgical practices