History

The complex anatomy and multiple functions of the liver have afforded it proper respect from surgeons over the years. During 2000 to 3000 BC, the liver was used through animal sacrifices, in the art of divination and was considered the seat of the soul.1,2 The Greeks continued this tradition and in the legend of Prometheus, illustrated the regenerative properties of the liver.3

Berta performed the first liver resection in 1716, by resecting a part of the liver that was protruding following trauma.4 von Bruns, who operated on an injured soldier in the Franco-Prussian war, repeated the procedure only in 1870.5 Langenbuch performed a left hepatectomy for a mess lesion and, therefore, carried out the first successful elective liver surgery in 1888.

In 1902, Pringle described the concept of vascular inflow occlusion by clamping the portal triad and controlling bleeding.6 In 1903, for the first time, Anschutz described the finger fracture technique.7 Wendel performed the first anatomical lobectomy for a right-sided tumour in 1911.8 By 1940, successful liver resections for matastatic colorectal cancer were being reported by Cattell.9 Ligation of portal pedicle and hepatic vessels prior to hemihepatectomy was performed by Lortat-Jacob in 1952.10 Total Hepatic Vascular Exclusion (TVE) was introduced by Heaney in 1966. This involved the occlusion of the portal structures, the infra and the supra-hepatic vena cava, and the supra-coeliac aorta prior to liver resection.11 In the 1980s, Bismuth and Huguet modified Heaney's technique by omitting aortic clamping. This yielded acceptable mortality and morbidity figures, enabling 12--14

more extensive use.12 14

The prevention of blood loss is one of the first priorities of the surgeon during hepatic resection. Blood transfusions have been linked to increased postoperative morbidity and mortality.15--17 In addition, perioperative blood transfusion in cancer patients has been postulated to induce immunosuppression that adversely affects postoperative outcome and duration of cancer-free survival.18--20

In the past few decades, surgical techniques to facilitate haemosta-sis have been developed, and they have improved the outcomes of liver resection. The techniques include monopolar and bipolar diathermy, infrared coagulation,21 argon beam coagulation,22 CUSA,23,24 ultrasonic (harmonic) scalpel,25 water jet cutter,26,27 and

Table 1. Classification of Different Techniques of Haemostasis in Liver Surgery

Dissection Techniques

Finger fracture Ultrasonic dissector Water jet

Haemostatic Techniques

Infrared coagulation

Diathermy

Argon beam

Laser photocoagulation

RF assisted

Topical sealants

Combined Techniques

Ultrasonic (harmonic) scalpel

CUSA

Floating ball (tissue link)

radio frequency (RF) assisted resection.28 These devices are welcome adjuncts to the basic techniques of finger fracture and electrocautery (Table 1).

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