This technique causes a greater amount of tissue necrosis than the other techniques, which may lead to the infectious complications observed in their study. In addition, there is a theoretical potential for thermal insult to major biliary structures. Radiofrequency ablation is generally reserved for ablating liver tumors that are unresectable. However, it is

not effective in tumors next to portal vessels due to the heat sink cause by blood flow. The liver parenchyma in these situations will not be high enough to cause the Inhibitors,research,lifescience,medical coagulation necrosis of the tumor. Figure 7 Radiofrequency-assisted liver resection. The probe (left) is inserted into the parenchyma along the chosen line of transection in serially overlapping areas. The precoagulated tissue can then be divided with a scalpel (right). (Courtesy of AngioDynamics). … Water-jet Dissection This technique Inhibitors,research,lifescience,medical find more employs a high-pressure water jet to break apart the liver tissue and selectively isolate small vascular and biliary structures, potentially decreasing blood loss. These vessels and ducts must then be ligated and divided individually according to preference. It is this necessary Inhibitors,research,lifescience,medical second step that may put this technique at a time disadvantage to others which offer simultaneous transection and hemostasis. Nonetheless,

the precise delineation of the transection plane (Figure 8) produced by the water-jet dissector (ERBEJET 2, ERBE USA Inc, Marietta, GA, USA) can be advantageous for exposing the major vessels more effectively, especially in the context of closely adjacent tumors. Additionally, this technique spares the surrounding tissue from any thermal damage. Rau and colleagues presented a series of 350

liver resection performed exclusively Inhibitors,research,lifescience,medical with the water-jet dissector, in which they were able to reduce their blood loss, transfusion requirements, use of Pringle maneuver, and resection time in comparison to CUSA or blunt dissection (38). The data from randomized trials, however, has not shown a similar benefit (26,28,39). Figure 8 Close-up image of the water-jet dissector. (Courtesy of ERBE USA). Vascular Inhibitors,research,lifescience,medical stapler technique Vascular staplers have become an accepted method of liver transection. STK38 Initially used primarily for division of major vessels, their use has been expanded to divide hepatic parenchyma. Staplers have the potential to be serially applied and fired in quick and efficient fashion, thus increasing their popularity. A common strategy is to use a large clamp to fracture the liver parenchyma along the line of transection, followed by serial firings of an Endo-surgical stapler with a vascular load (Ethicon Endo-Surgery, Cincinnati, OH, USA or Covidien, Mansfield, MA, USA) (Figure 9) (40,41). Reddy and colleagues published a retrospective series of greater than 200 patients over 10 years who underwent partial hepatectomy with either the crush-clamp alone or vascular stapler techniques.