Background In recent years, laparoscopic anatomical liver resection (LALR) has gained recognition for its efficacy and safety.<CitationRef CitationID="CR1">1</CitationRef>,<CitationRef CitationID="CR2">2</CitationRef> However, segments VII and VIII remain challenging due to their deep location and proximity to major vessels.<CitationRef CitationID="CR3">3</CitationRef> Inadvertent manipulation can easily cause serious complications including massive bleeding and CO2 gas embolism. Therefore, we propose an innovative ultrasonic scalpel scraping technique for hepatic vessel skeletonization in LALR. Patient and Methods A male patient was admitted with hepatic mass. Three-dimensional liver modeling showed the tumor located in segment VIII without major vessel invasion. The liver parenchyma dissecting-first ventral approach was used. Inflow occlusion was managed by an intermittent Pringle maneuver using a Foley catheter. Initially, liver parenchymatransection was attemptedwithout inflow occlusion, but asthe transverse plane deepenedand the skeletal process of themiddle hepatic vein(MHV),right hepatic vein(RHV), andVIII Glisson segmentprogressed, the Pringlemaneuver was applied toenhance safety and visibility. During parenchymal dissection, the ultrasonic scalpel remained in a continuously activated state, scraping back and forth between the liver parenchyma and the surface of blood vessels (Fig. <InternalRef RefID="Fig1">1</InternalRef>). The activated working surface maintained close liver contact throughout. Small vessels and bile ducts were directly coagulated and sealed by ultrasonic energy, avoiding injury to deep structures. During vessel skeletonization, the ultrasonic scalpel was positioned at 15–30° angles, gently separating parenchyma covering vessels through scraping rather than clamping. This method avoided vessel damage from tissue clamping. Even brief adventitial contact caused no vascular injury. During this process, small venous branches of the MHV and RHV were sometimes severed, producing small holes in venous walls. Most were immediately sealed by ultrasonic energy, while persistent oozing was controlled with bipolar coagulation. A small portion needed to be treated with Hem-o-Lock clips or 5-0/6-0 Prolene sutures. Results A total of six cycles of inflow occlusion were performed using the Pringle maneuver, with a cumulative clamping time of 90 min. Operative time was 280 min and blood loss was 100 ml. Histopathological diagnosis was moderately differentiated intrahepatic cholangiocarcinoma. No postoperative complications occurred and the patient was discharged 7 days after surgery. Conclusions The continuously activated ultrasonic scalpel scraping technique in LALR not only achieves rapid vessel skeletonization, but also ensures vessel integrity.

Scraping Hepatectomy Using Ultrasonic Scalpel for Complex Liver Segment Resection

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发表日期：

2025年9月20日

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Yufeng Li,
Lei Zhou,
Kang Chen,
Qian Jian,
Jiajin Yang,
Bo Sun,
Chuang Peng,
Wei Cheng,
Xianbo Shen,
Sulai Liu

摘要

Background

In recent years, laparoscopic anatomical liver resection (LALR) has gained recognition for its efficacy and safety.^1,2 However, segments VII and VIII remain challenging due to their deep location and proximity to major vessels.³ Inadvertent manipulation can easily cause serious complications including massive bleeding and CO₂ gas embolism. Therefore, we propose an innovative ultrasonic scalpel scraping technique for hepatic vessel skeletonization in LALR.

Patient and Methods

A male patient was admitted with hepatic mass. Three-dimensional liver modeling showed the tumor located in segment VIII without major vessel invasion. The liver parenchyma dissecting-first ventral approach was used. Inflow occlusion was managed by an intermittent Pringle maneuver using a Foley catheter. Initially, liver parenchymatransection was attemptedwithout inflow occlusion, but asthe transverse plane deepenedand the skeletal process of themiddle hepatic vein(MHV),right hepatic vein(RHV), andVIII Glisson segmentprogressed, the Pringlemaneuver was applied toenhance safety and visibility. During parenchymal dissection, the ultrasonic scalpel remained in a continuously activated state, scraping back and forth between the liver parenchyma and the surface of blood vessels (Fig. 1). The activated working surface maintained close liver contact throughout. Small vessels and bile ducts were directly coagulated and sealed by ultrasonic energy, avoiding injury to deep structures. During vessel skeletonization, the ultrasonic scalpel was positioned at 15–30° angles, gently separating parenchyma covering vessels through scraping rather than clamping. This method avoided vessel damage from tissue clamping. Even brief adventitial contact caused no vascular injury. During this process, small venous branches of the MHV and RHV were sometimes severed, producing small holes in venous walls. Most were immediately sealed by ultrasonic energy, while persistent oozing was controlled with bipolar coagulation. A small portion needed to be treated with Hem-o-Lock clips or 5-0/6-0 Prolene sutures.

Results

A total of six cycles of inflow occlusion were performed using the Pringle maneuver, with a cumulative clamping time of 90 min. Operative time was 280 min and blood loss was 100 ml. Histopathological diagnosis was moderately differentiated intrahepatic cholangiocarcinoma. No postoperative complications occurred and the patient was discharged 7 days after surgery.

Conclusions

The continuously activated ultrasonic scalpel scraping technique in LALR not only achieves rapid vessel skeletonization, but also ensures vessel integrity.