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Tadatoshi Takayama, MD; Masatoshi Makuuchi, MD,PhD; Keiichi Kubota, MD; Yasushi Harihara, MD; Ai-Min Hui, MD; Keiji Sano, MD; Masayoshi Ijichi, MD; Kiyoshi Hasegawa, MD

Arch Surg. 2001;136:922-928.

Hypothesis  Hepatic parenchymal transection is a technical priority in liver surgery. The use of an ultrasonic dissector for hepatectomy may result in less blood loss than conventional clamp crushing.

Design  Randomized controlled trial.

Setting  University teaching hospital.

Patients  The 132 patients scheduled to undergo partial hepatectomies were randomly assigned to receive hepatic transection by ultrasonic dissector or by clamp crushing (66 patients by each method).

Interventions  All resections were performed with inflow occlusion and were guided ultrasonographically. Hepatectomies were graded according to a predefined system based on 6 criteria (blood loss, transection time, technical error, surgical margin, landmark appearance, and postoperative morbidity), each with 3 scores (lower scores indicating higher quality).

Main Outcome Measures  Blood loss and hepatectomy grade.

Results  No difference was found between the ultrasonic and clamp groups in median blood loss (515 mL [range, 15-2527 mL] vs 452 mL [range, 17-1912 mL]; P = .63), transection time (61 minutes [range, 16-177 minutes] vs 54 minutes [range, 7-205 minutes]; P = .58), or transection speed (1.1 cm²/min [range, 0.4-4.0 cm²/min] vs 1.0 cm²/min [range, 0.4-3.0 cm²/min]; P = .90). Ultrasonic dissection caused more frequent histologically proven tumor exposure at the surgical margin (9 vs 3 patients; P = .09), incomplete appearance of landmark hepatic veins on the cut surface after anatomical resection (12 vs 4 patients; P = .03), and postoperative morbidity (20 vs 14 patients; P = .32) than did clamp crushing. The hepatectomies with clamp crushing had significantly higher grades than those with ultrasonic dissection (P = .05), as indicated by the lower median sum score (4.0 [range, 0-12] vs 5.0 [range, 0-19]; 95% confidence interval for difference, -2.0 to 0; P = .03). The transection method independently influenced hepatectomy grade (adjusted odds ratio = 3.06; 95% confidence interval, 1.35-6.92; P = .01).

Conclusions  Ultrasonic dissection offers no reduction in blood loss compared with clamp crushing for transection of the liver. Clamp crushing results in a higher quality of hepatectomy and is therefore the option of choice.

From the Division of Hepato-Biliary-Pancreatic and Transplantation Surgery, Department of Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan.

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