title: How should transection of the liver be performed?: a prospective randomized study in 100 consecutive patients: comparing four different transection strategies.
abstract: OBJECTIVE
  To identify the most efficient parenchyma transection technique for liver resection using a prospective randomized protocol.
  
  
  BACKGROUND
  Liver resection can be performed by different transection devices with or without inflow occlusion (Pringle maneuver). Only limited data are currently available on the best transection technique.
  
  
  METHODS
  A randomized controlled trial was performed in noncirrhotic and noncholestatic patients undergoing liver resection comparing the clamp crushing technique with Pringle maneuver versus CUSA versus Hydrojet versus dissecting sealer without Pringle maneuver (25 patients each group). Primary endpoints were intraoperative blood loss, resection time, and postoperative liver injury. Secondary end points included the use of inflow occlusion, postoperative complications, and costs.
  
  
  RESULTS
  The clamp crushing technique had the highest transection velocity (3.9 +/- 0.3 cm/min) and lowest blood loss (1.5 +/- 0.3 mL/cm) compared with CUSA (2.3 +/- 0.2 cm/min and 4 +/- 0.7 mL/cm), Hydrojet (2.4 +/- 0.3 cm/min and 3.5 +/- 0.5 mL/cm), and dissecting sealer (2.5 +/- 0.3 cm/min and 3.4 +/- 0.4 mL/cm) (velocity: P = 0.001; blood loss: P = 0.003). Clamp crushing technique was associated with the lowest need for postoperative blood transfusions. The degree of postoperative reperfusion injury and complications were not significantly different among the groups. The clamp crushing technique proved to be most cost-efficient device and had a cost-saving potential of 600 to 2400 per case.
  
  
  CONCLUSIONS
  The clamp crushing technique was the most efficient device in terms of resection time, blood loss, and blood transfusion frequency compared with CUSA, Hydrojet, and dissecting sealer, and proved to be also the most cost-efficient device.
authors.affiliation: Department of Visceral and Transplant Surgery, University Hospital of Zürich, Rämistrasse 100, CH-8091 Zürich, Switzerland.
authors.forename: Mickael
authors.initials: M
authors.lastname: Lesurtel
authors.forename: Markus
authors.initials: M
authors.lastname: Selzner
authors.forename: Henrik
authors.initials: H
authors.lastname: Petrowsky
authors.forename: Lucas
authors.initials: L
authors.lastname: McCormack
authors.forename: Pierre-Alain
authors.initials: PA
authors.lastname: Clavien
mesh_terms: D000704:Analysis of Variance; D016063:Blood Loss, Surgical / Q000517:prevention & control; D001803:Blood Transfusion / Q000706:statistics & numerical data; D016009:Chi-Square Distribution; D005260:Female; D006498:Hepatectomy / Q000295:instrumentation* / Q000379:methods*; D006801:Humans; D008107:Liver Diseases / Q000601:surgery*; D008297:Male; D011446:Prospective Studies; D013525:Surgical Instruments; D016896:Treatment Outcome; D014465:Ultrasonics