Essential lifesaving steps for laparoscopic major hepatectomy: in case the linear cutting stapler fails

Abstract

In laparoscopic major liver resection, linear staplers is used in division of the major hepatic vein as a final critical step of the operation. The have been over 112 deaths reported in all sorts of surgery due to failure of stapler. Although most of the cases are related to open surgery, it has been criticized that a patient is doomed if stapler failure occurs in laparoscopic major hepatectomy as remedial measures may be difficult and expertise dependent. The key to prevent dreadful misadventure is good surgical planning and anticipation of possible adverse event during surgery. Essential lifesaving steps are demonstrated in a video of pure laparoscopic right hepatectomy for liver cancer. Essential steps to save life during hepatic vein division: 1) Make sure the origin of the right hepatic vein is seen after parenchymal transection and division of the bile duct and hepatic inflow. 2) Ensure adequate length of right hepatic vein is exposed for stapler landing 3) Put a non-crush clamp (laparoscopic Debakey forceps) across the Hepatic vein origin. 4) Fire the stapler while the Debakey Forceps are controlling the hepatic vein origin. 5) Remove the stapler and exchange to laparoscopic forceps. Grasp the stump of the stapler line (to prevent retraction of the stump). 6) Release the Debakey Forceps temporarily to check for completeness of the stapler. 7) Control the bleeding by Debakey forceps in case of stapler failure/ stapler line leaks. Suture can be applied accordingly.