title: Expert opinion on advanced techniques for hemostasis in liver surgery.
abstract: BACKGROUND
  Reduction of perioperative blood loss and intraoperative transfusion are two major factors associated with improving outcomes in liver surgery. There is currently no consensus as to the best technique to achieve this.
  
  
  METHODS
  An international Panel of Experts (EP), made up of hepatobiliary surgeons from well-known high-volume centres was assembled to share their experience with regard to the management of blood loss during liver resection surgery. The process included: a review of the current literature by the panel, a face-to-face meeting and an on-line survey completed by the EP prior to and following the face-to-face meeting, based on predetermined case scenarios. During the meeting the most frequently researched surgical techniques were appraised by the EP in terms of intraoperative blood loss.
  
  
  RESULTS
  All EP members agreed that high quality research on the subject was lacking. Following an agreed risk stratification algorithm, the EP concurred with the existing research that a haemostatic device should always be used along with any user preferred surgical instrumentation in both open and laparoscopic liver resection procedures, independently from stratification of bleeding risk. The combined use of Ultrasonic Dissector (UD) and saline-coupled bipolar sealing device (Aquamantys(®)) was the EP preferred technique for both open and laparoscopic surgery.
  
  
  CONCLUSIONS
  This EP propose the use of a bipolar sealer and UD for the best resection technique and essential equipment to minimise blood loss during liver surgery, stratified according to transfusion risk, in both open and laparoscopic liver resection.
authors.affiliation: Newcastle Upon Tyne and Newcastle NHS Trust, Tyne and Wear, NE1 7RU, UK. Electronic address: derekmanas@btinternet.com.
authors.forename: D M
authors.initials: DM
authors.lastname: Manas
authors.affiliation: Josep Trueta Hospital in Girona, Avinguda de França, S/N, 17007 Girona, Spain. Electronic address: jfigueras.net@icloud.com.
authors.forename: J
authors.initials: J
authors.lastname: Figueras
authors.affiliation: Henri Mondor Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France. Electronic address: daniel.azoulay@aphp.fr.
authors.forename: D
authors.initials: D
authors.lastname: Azoulay
authors.affiliation: University of Barcelona, Gran Via de Les Corts Catalanes, 585, 08007 Barcelona, Spain. Electronic address: JCVALDE@clinic.ub.es.
authors.forename: J C
authors.initials: JC
authors.lastname: Garcia Valdecasas
authors.affiliation: Newcastle Upon Tyne and Newcastle NHS Trust, Tyne and Wear, NE1 7RU, UK. Electronic address: Jeremy.French@nuth.nhs.uk.
authors.forename: J
authors.initials: J
authors.lastname: French
authors.affiliation: University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4, Canada. Electronic address: Elijah.Dixon@albertahealthservices.ca.
authors.forename: E
authors.initials: E
authors.lastname: Dixon
authors.affiliation: Wesley Medical Centre, 30 Chasely St, Auchenflower, QLD 4066, Australia. Electronic address: orourke.nick@gmail.com.
authors.forename: N
authors.initials: N
authors.lastname: O'Rourke
authors.affiliation: Medtronic Regional Clinical Center, Via Aurelia 475-477, 00165 Rome, Italy. Electronic address: nicoletta.grovale@medtronic.com.
authors.forename: N
authors.initials: N
authors.lastname: Grovale
authors.affiliation: National Cancer Institute, Via Venezian 1, 20133 Milano, Italy. Electronic address: vincenzo.mazzaferro@istitutotumori.mi.it.
authors.forename: V
authors.initials: V
authors.lastname: Mazzaferro
mesh_terms: D006488:Hemostasis, Surgical / Q000295:instrumentation / Q000379:methods*; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods
keywords: Haemostasis; Liver resection; Sealing device