PRE-COAGULATIVE LIVER RESECTION CAROLINAS MEDICAL CENTER CHARLOTTE, NORTH CAROLINA June 19, 2007

Transcription

1 PRE-COAGULATIVE LIVER RESECTION CAROLINAS MEDICAL CENTER CHARLOTTE, NORTH CAROLINA June 19, :00:15 ANNOUNCER: This program is made possible through an educational grant from Valleylab. Welcome to this live webcast presentation of a pre-coagulative liver resection performed at the Carolinas Medical Center by Dr. David Iannitti. During the next hour, Dr. David Iannitti will provide a live introduction and answer live questions after the procedure. He will discuss the advantages of using precoagulative technology in the treatment of liver cancer. 00:00:42 DAVID A. IANNITTI, MD, FACS: Where radio-frequency-assisted liver resections is helpful is to decrease and minimize the amount of oozing from the cut edge of the liver that, you know, can be problematic and add to blood loss and volume shifts. So pre-coagulating the liver certainly does help with that continued ooze that we expect to see doing the parenchymal transection. 00:01:03 ANNOUNCER: OR-Live makes it easy for you to learn more. Just click on the "request information" button on your webcast screen and open the door to informed medical care. Now let's join Dr. David Iannitti. 00:01:17 DAVID A. IANNITTI, MD, FACS: Good evening. My name is Dr. David Iannitti, and I'm coming to you live from Charlotte, North Carolina, and Carolinas Medical Center. I'm the chief of hepatobiliary surgery, and I'm very happy that you're able to join us tonight for this program from OR-Live. Tonight what we're going to do is we're going to talk about the techniques of pre-coagulation for liver surgery, and we've used a cool-tip radio-frequency electrode to achieve that pre-coagulation. We're going to review a case here of a 63-year-old woman who has metastatic neuroendocrine tumor to the liver. And we have two resections that we're going to do for this particular individual with pre-coagulation technology. It's a very exciting video, and I'm more than happy to answer all your questions as the procedure endures. And without any further ado, here's the video. 00:02:08 ALBERT CHEN, MD: Hello, I'm Dr. Albert Chen here at Carolinas Medical Center in Charlotte, North Carolina. In a few minutes, we'll be joining Dr. David Iannitti, a hepatobiliary surgeon, where he will be demonstrating radio-frequency ablation techniques in terms of pre-coagulation for liver resection. And now we'll be joining Dr. Iannitti. 00:02:27 DAVID A. IANNITTI, MD, FACS: Good afternoon, and welcome to Carolinas Medical Center in Charlotte, North Carolina. I'm Dr. David Iannitti. Working with me here is Dr. Brian Layton and Julia, my famous scrub nurse here. Today we are planning to do a left lateral segmentectomy with radio-frequency assisted pre-coagulation. Part of doing any liver resection is full mobilization of the liver. Whenever we do any liver

2 resection is ultrasound the liver to look for other lesions. So I think now would be a good time to do that, before we commit ourselves to any resection. So again, we're just doing a standard ultrasound here. You can see that this is all tumor, so the left lateral segments are pretty much replaced with tumor. You can see, here's the vascular pedicle right here. Okay, so large vessels just adjacent to the tumor, so we'll need to take those most likely with a vascular stapler. Okay, and then as I come over to segment four, we can see here's the hepatic veins coming into the vena cava right there. It's the confluence of hepatic veins and vena cava. And what I'm really looking for now is other lesions. So again, here's the vascular pedicle. This is the left portal pedicle here, as we're seeing. And we're just going to go very systematically, coming down segment 4A and 4B. This is the portal bifurcation, coming through. I need to get my hand way inside here now. Coming back down segment 8. Again, here's the right hepatic vein, so everything anterior to the right hepatic vein is segment 8. Coming down, again, that looks good. Coming down through segment 5, there's the left -- the right portal pedicle here. And no other lesions there. And then coming back to segment 7, and here's the right hepatic vein right there, so this is posterior to the right hepatic vein. You can see the right hepatic vein very clearly. So all this tissue that we're looking at is segment 7, and as we come down we're into segment 5. You can see, there's the right hepatic vein, so again, the tissue posterior to that is segment 6. And that, I'll -- oh, looky there. We just found another lesion. 00:04:42 ALBERT CHEN, MD: And what segment is that one in? 00:04:44 DAVID A. IANNITTI, MD, FACS: That's in segment 6. So we need to deal with that. Tom, can you measure that? So it's the value of ultrasound, intraoperative ultrasound. So that's about a one and a half centimeter lesion in segment 6, so we'll need to either resect or ablate that. 00:05:01 ALBERT CHEN, MD: And with the current system that you're using, will you be able to perform an ablation with this cool tip? 00:05:06 DAVID A. IANNITTI, MD, FACS: Absolutely. That'd be absolutely no problem for this particular device. So I don't see anything else on the surface here. This'll allow you now to very clearly see the -- here's the lesion we found here. You guys can see that pretty well? 00:05:21 ALBERT CHEN, MD: Yes. 00:05:23 DAVID A. IANNITTI, MD, FACS: Great. Okay. I'm just going to kind of ignore what's going on here. All right, so we're just getting some packs around the liver. Just getting ourselves ready to go here, everything all nice-nice as we say in Rhode Island. One thing we need to look at is blood supply here, and certainly it's not uncommon -- pull the liver up, Bri. Pull this up. Is you want to look for an accessory left hepatic artery, and it would be right in here. Pick up. If you're going to have an accessory left, you can see -- I don't know if you guys can see this, but this is the hepatic branch of the vagus nerve right here. And if you're going to have -- if you're going to have an accessory left, it would be right here, and you would want to ligate that at this point if it were there, but we don't have one. So it's always nice to check that. Okay, and we're just going to lay a lap pad down, folded on top of the stomach. That'll keep everything nice and straightened out. Okay, Bri, that's good. All right, great. So we have our liver up in the air here. One of the things I like to do is I like to put a couple of liver sutures in just to use as a handle and helps with a little bit of

3 inflow control here in the umbilical plate again. Can I have a Adson? I'll try to keep my head out of the field. I'm just going to open this plate up a bit. That's nice. I don't know if you can see that well. So this is again opening up the umbilical plate. And I think the way to do liver resections nowadays is all segmental. I'm going to ligature that; that's probably a vessel right in there. I'm just going to lig-- there's a vessel in here. And I'll tell you, the triad is so much faster than first generation ligature. Even hitting it three times, that's probably the time it would take to do one. Opening up the hilar plate on a segment 2/3 resection is definitely a good thing to do. You can see another pedicle coming right in here and another pedicle right in here. You can actually feel the pulse of the left lateral segment pedicles -- segment 2/3 pedicles. I'm going to open it up a little bit more. Again, just opening up to expose the in-flow vessels here. And again, in this situation, we're just going to be pretty much demonstrating the technique of pre-coagulation. And again, this is what we would normally do for a resection like this. We do anatomic resections pretty much. You can see a nice hypertrophied vessels here in the tumor, looking for a little more blood supply. Okay, we can see a nice little vessel here to segment And we'll just come right around that. What we'll do is, the small ones we'll just ligate individually, 3-0 tie. Can you see that? Okay, just tie it. Tie it right up against that vessel. Yeah. Can you guys see okay? 00:0:01 ALBERT CHEN, MD: Yes, things are very clear here. 00:09:05 DAVID A. IANNITTI, MD, FACS: Again, this is just a little vessel going into segment 3. We're just going to take as many as we can, and the larger pedicles we'll take with a vascular stapler. Okay, we're just going to keep on working here on the umbilical plate. All right. Now you can see here a nice big pedicle right back here. That's the segment 2 pedicle right there. Again, this is the same thing you would do laparoscopically or open is a portal vein pedicle here. And again just behind it, I don't know if you can see the pulsing artery, and there's usually a bile duct that goes along with the artery. Here's the large portal vein branch. We'll tie it. 3-0 tie. Large portal vein branch going to segment 3 -- segment 2, excuse me. Tie that up. Again, the tumor's getting close to this area, so again, I'm individually ligating. Normally what I would do is I would push a Kelly through the parenchyma and I would take this with a vascular stapler. But because we're close to the tumor -- again, we'll still have a clear negative margin here -- pull it towards me. I'm going to use -- cut that with a knife. I'm going to individually ligate these vessels. Obviously it's nice to take these arteries and these large vessels before you dive into the parenchyma, and certainly will facilitate the pre-coagulation as well if you have less heat-sync. 00:10:49 ALBERT CHEN, MD: For those who are unfamiliar with RFA techniques, could you describe a little bit more about that? 00:10:53 DAVID A. IANNITTI, MD, FACS: Sure. Well, there's different issues there. Heat-sync - - as we know, the liver -- I would sort of think of the liver as a large radiator, where you have a large amount of blood passing through the liver, and if you're -- our goal here is to pre-coagulate tissue by heating it up. Now, if you have a lot of blood flow through the area, then that blood flow is going to take that heat away, and that's what the heat-synch effect is. So what happens when you're doing an ablation for instance -- hold that back -- is that the tissue on the other side of the vessel opposite of the electrode won't get -- you won't have conductive heat. I'll just get this, this is a big artery here. Tie that. We're just trying to hold everything open for you here so you can see what we're doing. It's a very large hypertrophied vessel going into the left lateral segments of the liver. So we're just ligating everything

4 individually. Again, the reason we're not throwing a big stapler in right now is because we're fairly close to the tumor itself, so again, we want to have a better surgical margin. It's interesting that two vessels came together. Usually -- I don't see that too often. I'm going to add some clamps. Can you guys see that vessel? Tied off? 00:12:24 ALBERT CHEN, MD: Yes. It's very -- very clear. 00:12:28 DAVID A. IANNITTI, MD, FACS: Excellent. We can cut it with the scissors. Brian's going to do it in a way to block your view. Very nice. Scissor. That we're decreasing the blood flow here so the liver's going to get darker than the perfused side of the liver. Okay, so we're just going to continue to work here in the umbilical plate, taking as much as we can as early as we can. And I don't think that -- whatever precoagulation device that one chooses to use does not replace what we're doing here now. I would view that only as a way of decreasing the ooze. Now, I think as I was mentioning before, there are various techniques for pre-coag-- I'm going to lig that. And one way is to pre-coagulate the liver and then just divide it sharply with a scissor or knife. And again, I can't advocate that technique. Cut it. I again, like to dissect all the larger vessels and bile ducts, particularly the bile ducts. We're not sure if there's anything in there. We can see how fast the second-generation ligature is, which is very nice. Okay. Okay, Adson. You can see the next round of vessels coming up right here. Trying to keep my head out of there. And now we're going to -- these are really more intraparenchymal. So we'll probably be starting to use a stapler for this part. And that's what I think we're going to do. Okay, so we've taken some good-sized vessels here, we got some other pedicles coming up. Okay, so I'm going to take these pedicles now with a stapler. Okay, would you hold that open, Brian? So now one way to do this is to do -- apply a Pringle maneuver, okay? And then we can pass a large, extra-long Kelly through the parenchyma and then take the vascular pedicle. Because now we're off the tumor, so we're in a much better situation than we were just a few minutes ago. So I'm just going to drop the Pringle down here for just a couple min-- just a minute or two, and I'm going to need a large Kelly. Now, the key when you're doing this, when you're going through the parenchyma, you want to feel your way through, you don't want to -- you don't want to -- you don't want to force your way through the parenchyma or through the tissue. You want to basically feel and get around your structures like that, see? And that gets me here. So that gets me all the way down to there. You can do this without a Pringle if you have to, and you see here that's what I'm going to take with the stapler, okay? So I'm going to use the U.S. Surgical Endo-GIA Stapler, which is the only FDA-approved stapling device. 00:15:33 ALBERT CHEN, MD: And is that a gray load that you're using there? 00:15:35 DAVID A. IANNITTI, MD, FACS: This is their vascular load, it's a 2mm load, and we're just going to push the button and we're just going to take it. I should have two 40s. And we're just going to remove that and we're just going to change our load. You can see how that opens that up. I'll take another large Kelly. Slide right up here to the hepatic vein level, and then we'll get the hepatic vein on the other side. We're just going to take this. Remember, we have a Pringle down right now. Stapler. Okay, so just nice and easily, we're just going to pass that through. We don't want to force it through anything. Should push the green button and just push forward. You want to push forward when you shoot this particular stapler. And that's nice. And we're going to take a 30 load next. Can I have a piece of -- you can see here we have a minimal blood loss right now because we have vascular in-flow occlusion. So I'm just

5 going to put a hemostatic agent in here so I can take the Pringle clamp off as we get our next load ready. I'm just going to slide that in here for the moment, and we're just going to release our Pringle, so that's about a two-minute worth of Pringle, going nice and easy. And you can see here, look, there's really not a lot of blood loss. So we're going to come over the top now, do a little bit -- do our best to show you what we're doing. Okay, and this -- this -- yeah. And then this is around the left hepatic vein. I don't know if you can see the -- can you see that Kelly around the vein? 00:17:33 ALBERT CHEN, MD: Yes. 00:17:35 DAVID A. IANNITTI, MD, FACS: Okay. So we're just going to take the left hepatic vein with a a 30 shot here, a 30cm load. And Brian's going to lift that up, and you can see the stapler going across. Can you guys see that? 00:17:47 ALBERT CHEN, MD: Yes. 00:17:49 DAVID A. IANNITTI, MD, FACS: Okay, we're going to take the vessel loop off in a nice, smooth fashion. There we go. Push the green button and then shoot your stapler. So now we've taken the in-flow and the out-flow. That's pretty okay. That's definitely acceptable. You can see that the liver now is much softer than it was. And now we're just going to finish it off by pre-coagulating, okay? So we're going to take the RF. Somebody's going to need to take a shot of the panel. Now, okay. I might just want to change that sponge in the back there, so just -- just to keep things neat and clean. I know, I'm trying not to. Now, this should go fairly quickly. Yeah. All right, now we're going to spread the liver out here, and we have a standard clustered cool-tip electrode. Now, normally what we do for cool tip is we pump iced saline through the electrodes, but in this particular technique, we're not going to use the iced saline, and basically we're going to pass the electrode through the liver parenchyma, and you can either do it parallel with the floor or perpendicular to the floor based on the type of resection that you do. You'll have a better -- we'll go -- we'll use a different technique when we use that segment 6 lesion resection. So basically what we want to do in this particular situation -- I already know where my vascular pedicles are, but -- ultrasound -- but one common and probable safe thing to do is if you're doing pre-coagulation, whatever device that you're using, you probably want to check your line with ultrasound, okay, to make sure that you're not crossing any major ves-- here's tumor here. So this is going to be our transection line here. Let me just reposition what I'm going to do here. I'm going to come in underneath and I'm going to look at my ultrasound. You can see that my RF needles, and I'm just going to follow that sponge, that's why I placed the sponge. You can see here the needle's right here, we're going to work all the way up. Here are my tips, and that's to the top of the liver, okay? So now I've passed it. I know I didn't pass it through any portal pedicles, and now what we're going to do is we're going to run the machine without any cooling, so you can see the sequence there, you can see our baseline impedance is relatively high. And we're just going to turn up the current. Now, I'm looking at two numbers here. I'm looking at my impedance, which is the number on the left, and I'm looking at the temperature that Vanna is showing us, on the right. Now, the temperature, we can see, we're starting to get into the 80s, so she's going to start coming back on that current a little bit. I want to try to keep my temperature just in the 90, 95 range. When I get there, I'm going to pull back, telling here I'm pulling back, and she can turn the current up. We want to get up into that 90 range. Once I'm there, I'm going to pull back, I'm going to pull back, there we go. Again, it's a combination of looking at the impedance and the

6 temperature. And we're just going to keep going. And then whenever you're using any pre-coagulation device, the key is patience. You can see our temperature is 65, she's going to crank the current as I've just pulled back, and this is going to give me about a 1cm width of pre-coagulation. Happens fairly -- moves along fairly quickly. See, we're both working in concert together. And I'm pulling back, you know, just less than a centimeter every time. And you can see the temperature drops just as soon as I move back. And then I'm out. Okay, I'm just going to clean off my tips. I'm going to go to a more superficial line here and come right in the edge of the liver. Again -- yeah, yeah, yeah. And then you can see the microbubble formation through that resection line, so that's why, if you're going to do this technique, you want to start from deep and then go superficially. You can see the needle being passed through the non-coagulated tissue as I'm working my way up to the top of the liver. There's my tips right there. All the way to the top of the liver. 00:22:23 ALBERT CHEN, MD: And you said this creates a zone of pre-coagulation of approximately one centimeter, is that correct? 00:22:27 DAVID A. IANNITTI, MD, FACS: About 1cm wide, yeah. So we're going to go back up. You can see our temperature's 74-5 degrees. Impedance is relatively high. I can feel the popping under my hand. Once I get to that 90 degrees, I'm going to pull back a little bit. We're still up in the 90-degree range, so I'm going to pull back. And this is where we want to be, right around 90 degrees is perfect. And every time we get close, I'm going to pull back and she's going to cut off the current. When the temperature drops, she's cranking the current again. When I get to 90, I'm just going to start slowly pulling my hand. You can see it's nice and hot under my hand. Now we're definitely coagulating. We're trying not to cause tissue desiccation, we're just pre-coagulating. There's a difference between -- between the two. Again, we're around 90, my impedance is fairly high. So I'm watching my impedance as well. So I'm at 70 degrees here. We're close to the end of the electrode. You can start to see the bubbles, the boiling tissue, and we're out. Okay, I'm just going to wipe off my tips again. And I think we need probably one or two more shots here. But again, the key to any pre-coagulation device is patience. Ultrasound. 00:23:44 ALBERT CHEN, MD: What's the normal baseline impedance that you normally encounter? 00:23:47 DAVID A. IANNITTI, MD, FACS: Yeah, normal baseline impedance for a liver usually is in a range. And I'm just going to pass the electrodes here. And you can see, I'm right underneath the surface. I don't know if you can appreciate that on video. So I'm now looking at it with ultrasound. And we're going to go right ahead again. You should start -- you should see some surface changes here. So where our baseline impedance is a little bit higher because we've devascularized the liver and the liver here is relatively thin. When we go to the other side of the liver to resec, you'll notice that the impedance should be a lot lower. She does have a bit of a fatty liver as well, and that's going to certainly affect tissue impedance. You can see our temperature now is like 75, 77, we're sneaking up. This has actually gone very smoothly. And we're just going just along the falciform ligament here. And this is great. And here's the tip. Crank that. And we can see the burning. And we're out. Again, you don't want to let it hit 100. You see that the tips are...a little bit of char. Now, the other -- the other way to do this is using the switcher box, the switcher controller box, and you can do three individual electrodes with cooling and put them in a line and then just kind of move -- you know, about 30 seconds per application, and then move or jump frog or leapfrog your electrodes. I'm going to go just

7 subcapsule here. My temperature is -- I'm sure it's fairly high, 56 degrees. And go ahead. Again, this is just one of many ways to pre-coagulate the liver. I think that pre-coagulation is definitely a developing technique, especially in the laparoscopic world, as well as maybe somebody who doesn't have a huge amount of experience doing liver surgery and just needs another tool to try to decrease blood loss. So you can see, this liver's definitely coagulated here without a problem. Okay, and we're done. Okay. So that's all it took. Now, again, we have no -- no in-flow occlusion here. I mean, we've taken the pedicles, but there's nothing else. You know, there should be some crossing vessels where we're going to go. Now we're just going to divide the liver in the normal techniques. Some people like to use a CUSA, some people go through with other things. I just like to use a regular Adson clamp. And then again, we're just going to be able to -- can I have a -- suck that up -- we're just going to get ourselves ready here to go through the parenchyma. Julie, you can give us a little sucking action. Just use your left hand. And give me my landing -- my landing zone. Let's just do a little housekeeping here. We're going to do this again for the other lesion as well, so I'll have a couple shots at doing this. 00:26:43 ALBERT CHEN, MD: Are there other people who use the argon beam to kind of mark the surface of the liver at times? 00:26:48 DAVID A. IANNITTI, MD, FACS: You could. I mean, I generally just use the electrocautery to mark out my resection line and we'll -- yeah. Argon beam isn't really going to help you a whole lot until after parenchymal transection. Yeah, scissors, right angle, and go. Okay. So now here's our transection line. It's easy for us because it's just going to be just to the patient's left of the falciform ligament, and you can see -- I don't know if you can appreciate that on film, but you can see that that line is already coagulated. Okay, great. So again, I'm just going to go through like I normally go through, and Dr. Layton is going to suck away the liver parenchyma. He's going to buzz that capsule. You can cut -- actually cut right through the capsule. And there should be no blood. Get that from the capsule down there so we're not ripping the liver. Little dabble. Swing your hand out. All right, so that's going to be our transection line, and I'm sure Dr. Layton can appreciate the difference in the texture of the tissue already. Okay, good. now what we'll do is we're just going to come through. We're just going to march our way through. Now, again, some companies advocate just cutting this with a knife or a scissor. But again, I think I like to come through and ligating any major vascular pedicles. You can see - - you can see how well that liver is coagulated. I can't help it, I've got a big head. So you can see, here's a vein right here, if you can see that. We're going to ligate that with a 4-0 tie. This vein is probably coagulated, but I sort of would -- I feel better about ligating these things. And I think if you miss there -- we'll edit that out for Dr. Layton. So I think, if you can see -- can you see the vein down here? You see the vein? 00:28:42 ALBERT CHEN, MD: Yes. Yes, it's pretty clear. 00:28:45 DAVID A. IANNITTI, MD, FACS: Good. All right, and we're just going to ligate that with a 4-0 silk. Scissor. I'm just going to -- we're just going to tie this. I'm personally not a big fan of clips. That hand over. All right, we're just going to cut through. But you can clearly see how well the liver parenchyma is coagulated. And Dr. Layton is going to keep on going with his electrocautery. See. Now, you can see here it went right through, no problem, but we have a vessel down there. Again, this is all coagulated. There's a vessel here we're going to tie off, tie that with a 4-0. Realistically, I could just cut through this, but again, we try to be a little on the

8 conservative side. If push came to shove, we could... Just grab it. I was trying to help him. It wasn't working. That's good. All righty then. So there's a hepatic vein down there. We can buzz through this little vessel here. That's a tie. Better tie it. Never mind. Four is fine. A little bit of oozing is coming from this hepatic vein which is down here. We're going to ligate that. There's no real in-flow bleeding, just backbleeding through the hepatic vein, a branch of one of the hepatic veins. And my -- my reason for trying to go and individually ligate things -- there's a big vein down there, we might have to take that with another shot of the stapler. You can see a larger -- this is an in-flow vessel. Here's a pedicle here. And there's probably a bile duct in there, so I definitely want to ligate that even though it's well-coagulated, this is something I want to ligate. There's just some back-bleeding coming out of a hepatic vein here, but the parenchyma itself is actually in pretty good shape, not really bleeding. Just this little hepatic vein down there. But these are the things that I could not advocate just cutting through with a knife regardless of the preablation -- pre-coagulation technique that one uses. Right angle. And I just want -- Julie, can you suck, please? Okay, this is the vein we need to get. This goes straight down. 3-0 tie. And again, the pre-coagulation isn't really going to help you with big hepatic veins. And that's where we're just oozing a little bit from right now, but he's going to get it hopefully with this tie. That looks like it helped. But the parenchyma itself is not bleeding at all, and that's the goal of using these techniques for coagulation. And keep on going. Suck. It's the vein itself -- I can see the wall itself is bleeding, and that's okay. Adson. Julie, can you suck for us, please? And we're just crushing away, crushing our normal technique. That vessel wall is going to stop bleeding by itself. We can certainly burn through this. There's nothing in here except for that vessel right there. Tie that. Then we'll just put a little Ultrafoam on that, that'll take care of that. Scissors. Just a little strip would be fine. okay. Parenchyma's nice and dry, just a little oozing off this hepatic vein here. And we just got a little bit -- one more clamp to go, I think. Want to tie that off? Just a little vessel in here. Tie over there. Yeah, so again, we're just tying off our last vessel. Again, just want to reiterate that we're not doing this -- the Pringle clamp is off, the liver is being perfused, and that was our last division. We're just going to put a little collagen on the edge of the liver here for a moment, and then we'll change out for a second. Want to just let that sit for a minute. And here's the tumor itself. Clean lap pads. Yeah, I do. What I want to show you is the line itself. A little bit of packing on the edge of the liver goes a long way. But again, here's -- here's the transection line. So here's our transection line here. Adson. And you can see that this is all well-coagulated, it's all pre-coagulated. Just a little bit of char there on the surface, but you're not seeing charring, you're not seeing tissue desiccation. What you're seeing is coagulation. One thing I can do -- give me that 10 blade, please. I'm going to just incise this so I can show you the level of penetration here. Yeah. Okay. So you can see that the -- this is about half the width of the coagulation, and this is about -- probably just under a centimeter. So you're probably getting a little bit over a centimeter for what we just did in terms of width, okay? You can actually see the -- the needle tracks. See the needle tracks right there? See one, two, three? Can you guys see that on film? 00:34:50 ALBERT CHEN, MD: Yes. 00:34:52 DAVID A. IANNITTI, MD, FACS: All right. That's the needle. That was the needle tracks. That was where I pushed the RF electrode through. So you can see the coagulation around -- the immediate coagulation around the needle tracks, and then you've got this deeper penetration here, okay? That's kind of nice. It's a beautiful -- it's a beautiful shot. I think that laparoscopic liver resections definitely lends itself very well to pre-coagulation because you have so much less control laparoscopically

9 than you do open. Where in open surgery, you can easily -- well, if you're doing straight laparoscopy. If you're doing a hand-assisted laparoscopic liver resection, you have certainly a bit more control. I tend to do my laparoscopic liver resections straight laparoscopy, even if I'm doing a lobe. So I generally don't use a hand-assist. I know many people do, and that's fine. But when you do straight laparoscopy, again, you have a little bit less control, and so it's very nice. It's a nice luxury to precoagulate the liver first. You can see here it's only that little oozing on that hepatic vein, the side wall of the hepatic vein, but really the rest of the liver is nice and dry. Scissor. 00:36:01 ALBERT CHEN, MD: And is it a different probe that, if you decide to do a laparoscopic technique that -- 00:36:06 DAVID A. IANNITTI, MD, FACS: Yeah, well, we just use a short -- a 15cm RF electrode. We can use 20s if we're going to do a laparoscopic liver resection. All right, we've got to figure out what we're going to do here. I think I'm going to put two sutures around this and then coagulate it and just excise it. 00:36:24 ALBERT CHEN, MD: Planning on just doing a pure RF ablation, you would just place the tines directly into the tumor itself? 00:36:31 DAVID A. IANNITTI, MD, FACS: Right, well, that would be a standard ablation technique. And generally, we place our electrode or antennas with ultrasound guidance. And place it -- usually you start off in a deep part of the lesion first and then run your device based on the size of the lesion, device that you're using, whatnot. 00:36:53 ALBERT CHEN, MD: And what time of impedance and temperature numbers would you be looking at if you're doing ablation. 00:36:58 DAVID A. IANNITTI, MD, FACS: Yeah, sure, you know that really anything -- normal perfused tissue can tolerate temperatures, you know, up to 45 degrees. And we know that above 50 degrees is cytotoxic certainly, so you'd like your tumor temperatures to be above 60 is generally safe. 00:37:12 ALBERT CHEN, MD: So 60 degrees Celsius, correct? 00:37:14 DAVID A. IANNITTI, MD, FACS: That's correct, 60 degrees Celsius. You're in segment 6? Okay, can you see that okay? Can you see the bottom down here okay? 00:37:21 ALBERT CHEN, MD: Yeah. 00:37:22 DAVID A. IANNITTI, MD, FACS: Okay. Oh, yeah, that's cool. That's the lesion. Brian, fold that back. See if you can turn that so it's -- this is pointing out there, okay. You see down here is the right portal pedicle, so we need to stay off of that and away from that. We don't want to suture through it, that would be bad form. You can see the needle tip just right in front of the pedicle there. Nice perfect shot. Get a nice short needle driver, which is great. And again, we're just trying to lay this -- push the habitus right there. Very good. I'm just going to try to lay this right under there. Nice. Sorry, guys. Again, this is a nice handle. She's got a very, very soft liver. Going to be a little bit of a different situation. What I'm going to do is actually I'm going to ablate this lesion, and then I'm going to resect it and use that peripheral tissue that we've ablated as our pre-coagulation. So I'm going to do a different technique here.

10 How's that sound? Let me just get underneath the tumor. I'm just trying to keep my stitch off the right main portal pedicle. It's hard for me to express how soft this liver is. We're actually going to radio-frequency ablate the lesion itself and then excise it. And so that the tissue around the lesion will be pre-coagulated. I think this will be an easier approach to do for this particular lesion. So this is our standard cool-tipped radio-frequency electrode. This time, I'm -- I've got the cooling circuits hooked up, so now we've cooled down the temperature. And you can see the box there, our probe temperature now is 18 degrees Celsius. We want it -- yeah, okay, sorry. The - - you can see our tissue temperature is -- our electrode temperature is 20 degrees, or less than 20 degrees. And so I can do this under direct visualization here. You can also do it under ultrasound. Here's my spacer, I'll use my spacer. And again, I'm just going to pass this directly into the tumor. I know it's about a centimeter and a half. And it's a firm one. And that's about as far as I'm going to go because I don't want to damage that right pedicle. So now I'm not going to use a Pringle maneuver because, again, we have the right pedicle immediately posterior to where I'm working and we're going to turn the current as we cool down. Our temperature is 16 degrees, which is great. Just got to read our impedance here, which is interestingly, reading a little high. And it's going to read the baseline impedance over the first 30 seconds, and then the main current will kick on. Our impedance is high, I think, for two reasons. One is because she's got a fatty liver and secondly because I put those transhepatic sutures in place. Now, normally, if we're ablating a tumor, normally what we like to do is six minutes with a Pringle maneuver and 12 minutes without a Pringle maneuver. Our impedance is coming down a little bit now, which is nice. And that will give us consistently a volume of thermocoagulation of about four centimeters. This lesion is a centimeter and a half. I've got these two sutures in place, so effectively, they're acting like a Pringle maneuver for this local area of liver, okay? And so I'm basically going to ablate for -- actually, I'm probably going to go at about four minutes is I think going to be plenty. So we'll just keep an eye on things. So right now our impedance is relatively high for a liver, which is 100 ohms. We're not delivering -- we're pushing the current at 102 watts. The current flow is almost one amp of current. And you can see, we're actively cooling to a temperature of 16 degrees. Now, you can see here -- I need to keep that off. Now, I don't really need to ablate this for a long time. Again, we're only a centimeter and a half -- actually, one of the other reasons -- can you squirt some saline in here, Brian, right on the pedicle? Can I have a large vein retractor? Cool that down. Cool it down. Just keep on cooling it. So I'm retracting the right pedicle away. And I'm going to -- just suck a little bit. Squirt it on there. I'll squirt, you suck, Brian. So we're at two minutes now. You can already see tissue changes, which is probably plenty for pre-coagulation. So I'm probably only going to do this for about two or three minutes. Cool. Cool. Cool saline. We're running at about one amp of current. Our impedance has gone up from our baseline already to 110 ohms. Again, I'm trying to protect that right pedicle. The -- actually, probably one of the bigger reasons that the impedance is high is because part of the active tip of the electrode is out because I'm trying to stay off of that right pedicle, and that's okay. You can see the color change around the lesion. I'll take anything. Suck, Brian. And we're probably there. How many minutes? We've been going at it for three minutes now, and I'm going to call it quits right now. I'm going to stop the pump. Shut the pump off, and we'll see what our temperature is. Our temperature's probably going to be in the 60-degree range, I would estimate. Yep. Oh, 75. Suck -- keep on sucking, Brian. So we have a temperature of 75 degrees in the center of the lesion, and that's -- so we know that the peripheral aspect is easily in the 50-degree range, and that's all we really need. Up in the 80 degrees. So I'm going to take the electrode out. And you can see that the whole

11 tissue around the tumor now is brown, so we coagulated it. I just want to cool it, cool everything down. Just going to irrigate here for a second. 00:44:24 ALBERT CHEN, MD: And would there be changes you could see on ultrasound? 00:44:26 DAVID A. IANNITTI, MD, FACS: Sure, this will all be very -- I'll ultrasound it for you. And it's going to be very hypoechoic. Again, we're just cooling the temperature down right now because, again, we don't need the heat, we're not trying to ablate, we're just trying to thermocoagulate, and again, we're adjacent to the right main portal pedicle, and we don't want to cause any damage. That's why we're irrigating the whole time, we did a very short ablation. Now we're just going to -- I was going to say we're just going to use the bowl; every time I look the bowl is -- is filled up again, so... Yeah, just cooling the tissue off. We'll do the very scientific thermometer method. All right, so we're back down. We're actually cooler than -- cooler than normal body temperature. But you can see now, you can see the tumor -- you can see the -- pick up. You can see the parenchyma around the tumor is all thermocoagulated, okay? And we know that there should not be any major portal pedicles in here, so we can pretty much go through in a fairly straightforward fashion now. So this is kind of how to do an RF-assisted liver resection. And again, you can't use the traditional standard timelines, wattages; you just need to set based on the goal that you're trying to achieve. Again, we were -- I have two sutures through, so I know that for this area, there's not a lot of flow through this area itself. So we know right off the bat we're not going to need a whole lot of current. And we're adjacent to a critical structure. So again, yet another reason why we don't use a lot of current. And again, we don't need to bring this temperature all the way up to 100 degrees. I'm just going to excise this. Okay, now... 00:46:33 ALBERT CHEN, MD: Dr. Iannitti, could you again explain to us the temperatures you're talking about in terms of 50 degrees versus 100 degrees Celsius? 00:46:42 DAVID A. IANNITTI, MD, FACS: Well, really, once you get above 50, especially in the 60 range -- you can buzz that -- the tissue's going to be thermocoagulated. You can buzz that. You can see here now, our temperature in the center of this -- yep -- our temperature in the center of this lesion was high 70s, and so you can clearly see the effect that it has on the liver parenchyma. There is -- there is no blood flowing here. Everything is completely thermocoagulated. So again, even if I had a relatively close surgical margin, I know that I probably have a good five millimeters in here. There's a vessel right there which you're going to buzz. And I'm just going to go through, making sure that there aren't any major vascular structures in here. Dr. Layton, swing your head back there. So you can see here, again, what temperatures we were talking about, and you can see the effect that it has on the tissue. And that was about a three-minute ablation with cooling, without Pringle. So again, we maintained flow in that right pedicle to -- we want a heat sync in that particular situation. Just come across there, Bri. Yep. So again, around the 50-degree range is certainly to 60 degrees is plenty to achieve coagulation. We're just taking it off. Again, we're using cautery except right there's a vascular pedicle. So there's one pedicle in this area. There's a little vein, a little vessel right there. And that's it. Very straightforward. And come underneath. We're going to tie one vessel here. Just cut it off. And that's it. So now let's just tie this and I'll show you the tumor. So that's an RFA-assisted liver resection as opposed to an RF pre-coagulation. Does that make sense? 00:48:55 ALBERT CHEN, MD: Yes. Can you tell us --

12 00:48:58 DAVID A. IANNITTI, MD, FACS: Yep, absolutely. Yeah, we just got to tie this one thing. 00:49:02 ALBERT CHEN, MD: Could you tell us what this operation would have been like if you had not done the pre-coagulation in terms of how much more ooze or blood loss there would have been and so forth? 00:47:10 DAVID A. IANNITTI, MD, FACS: Sure, I mean, what we did today was very straightforward liver resection. Now, you can see there -- see, there's the right pedicle. It's nice, it's soft, it's cool, but all the tissue around it is thermocoagulated, so again, there's no blood loss in that little resection. Let's get rid of these two sutures, Brian. What we did today was, you know, a surface of segment 6 and a left lateral segment, and those are fairly straightforward liver resections, but again, may be associated with some oozing, but we had good vascular control. Just going to leave a sponge in there for a minute. Can I have a blue -- a green towel here? Can I have a knife? So here's our tumor. Okay? You don't have a 10, do you? All right. I'm just going to open this up, and you can see here. So there's our -- remember, this tumor's ablated. We have a closed margin here, remember, this is metastatic neuroendocrine, so we have -- alls we need is a positive margin, but just remember, when you're doing -- this is a good reason for RFA-assisted liver resections is if you're resecting a tumor where you're going to have a very close margin, you're getting probably another five millimeters at least on the liver side of things. So this margin is better than it looks when you use RF-assisted because the tissue here is all dead. Well, thank you very much for joining us today from Carolinas Medical Center in Charlotte, North Carolina. I hope this has been interesting and useful for everybody today and one should consider doing RF-assisted pre-coagulation when performing open and laparoscopic liver resections. Thank you again. Well, we're back here live at Carolinas Medical Center, and I hope that everybody enjoyed this video and I hope that it's going to be helpful to you. During this broadcast, we were able to field several questions that we've received on , and I hope to answer as many as I possibly can, so keep the questions coming. And if I don't get to your individual question, we can assure you that we'll you back an answer. So here's an e- mail from Dr. Smith from Middletown, Ohio -- just kidding -- is: How often do you find additional tumors during surgery and are you usually able to ablate or resect them? Well, that's an interesting question. Certainly when you're dealing with metastatic colon cancer, about 25-30% of patients will have additional lesions that aren't recognized by preoperative imaging, even though we have great, you know, 64 detector CT scans, MR with gadolinium, PET/CT, we still miss numbers of lesions. And so the most accurate way to assess for the number and extent of disease within the liver is still with intraoperative ultrasound, whether that be laparoscopically or open, so I think that if you're going to do liver surgery, then you need to be prepared to deal with additional lesions, and that's why whenever I do any sort of liver surgery, the patient is usually grounded for radio frequency and we have a radio frequency generator or other generators in the room at the time of liver surgery. So if we do find other lesions, we're able to deal with them, whether that be with additional resection or ablation. Okay. I'm just reading off some more questions here: why do you choose this particular resection technique? How does this RF device differ from others? Well, there are all sorts of differences in radio frequency technologies, and why do I do pre-coagulation? Well, as I mentioned and as you can see, when you pre-coagulate the liver for a liver resection, it significantly decreases the oozing from the cut edge of the liver parenchyma. Now, again, any precoagulation technique is not going to stop the major bleeding from the major

13 vascular in-flow vessels or the hepatic veins. So again, I use the pre-coagulation to stop that raw surface oozing that's very common during a liver resection. Now, there are all sorts of devices out there for liver pre-coagulation. There's the -- now, certainly regular electrocautery would not suffice because the current concentration at the tip is so high that the tissue desiccates around the electrode, the tissue boils off, you get char, and so you're not delivering energy into the tissue itself. So one way to subvert that would be to use saline-tipped electrodes such as a TissueLink coagulator that will allow you to penetrate current into the tissue to pre-coagulate it. Now, that penetrates to about a centimeter, so generally the technique there is to pre-coagulate, incise that parenchyma, pre-coagulate, incise the parenchyma. There is other devices such as the Habib device, which is also a very good device that works very similarly to the technique that we just did. But I personally choose the cool tip because I like the cool tip for ablation, and also we've learned how to use this for pre-coagulation, so we have one device that can ablate and resect without having to change the disposable electrodes. Now, there are different ways of doing ablation with a cool-tipped electrode. You saw our technique here, which was with a clustered electrode. Again, we didn't cool it for the pre-coagulation part of the resection. We did use cooling for the ablation-assisted resection. Now, the other technique that can be used with the cool-tip system is using a single-needle electrode with a switcher controller box. And what the switcher controller box is it basically has three channels in it that can each drive a single-needle electrode, and then what you would do is use active cooling on the electrodes and then basically place them like a picket fence through the liver parenchyma, space them about a centimeter, centimeter and a half apart, and then basically run each electrode for about 30 seconds. And then what you do is just basically jump the electrodes one after the next. And that actually works very well as well. I think both are fairly comparable. Again, I personally like to use the clustered electrode because that's the device and the technique that I'm most familiar with, but either are certainly okay. I think I answered that question. How do you know when to move the electrode? Okay, that's a very nice, simple technical question. Again, if you're using this particular system in a non-cooled fashion with a clustered electrode, then basically you're looking at two things. You're looking at the tissue impedance and you're looking at the tissue temperature. The tissue impedance is important because that's going to rise fairly quickly. Now, generally, once you start getting above 30, 40, and certainly up to 50 ohms above your baseline impedance, then that tissue's going to be fairly well-coagulated. Now, remember, this isn't ablation, so we don't need to get our tissue temperatures up to 100 degrees. We're basically trying to get ourselves about a one centimeter line of thermocoagulation that we can go down for transection to minimize our blood loss. So when do we move the electrode? In this particular technique, I was probably running the temperatures around degrees. I think that if you were in the -- it doesn't necessarily have to be that high. I think that if you're in the -- certainly degree range, you're probably fairly good. you're probably going to get about close to a centimeter. Once you start getting into that 90-degree range, then you're probably at around a centimeter and a half, so you need to judge that for yourself, but certainly shooting for 85 to 90 degrees I think is safe for most liver resections. And again, when it comes to impedance, if your impedance is shooting up to 100 above baseline, then you know that that tissue is certainly coagulated, you pull back your electrode, you'll see your impedance drop, you'll see your temperature drop, and then you know it's time to move your electrode and then turn your current back up. What temperature do I really need to kill the proper margin of tissue? Well, as we talked about during the video, normal perfused temper-- tissue can tolerate temperatures of up to 45 degrees Celsius. Once you hit 50 degrees Celsius, then you're starting to