CUSA is able to dissect tissue but does not offer coagulation or hemostasis. Among CUSA’s benefits, it provides a very well-defined transection plane, which is useful in situations of close proximity between tumors and major vascular structures. Also, it can be used in cirrhotic as well as non-cirrhotic livers,

and is associated with a low blood loss and low risk of bile leak (30). Transection time using CUSA is generally slower than conventional methods. Nonrandomized studies have shown decreased blood loss, morbidity, and mortality using CUSA, however, larger randomized trials have not shown this benefit Inhibitors,research,lifescience,medical over the traditional crush-clamp method (31). Figure 4 The Cavitron Ultrasonic Surgical Aspirator (CUSA) being used to transect the parenchyma. This

strategy allows a clear transection place but does not offer coagulation or hemostasis. (Used with permission from: Poon RT. Current techniques of liver transection. … The Harmonic Scalpel (Ethicon Inhibitors,research,lifescience,medical Endo-Surgery, Cincinnati, OH, USA) uses a similar principle of ultrasound energy applied to vibrating ultrasonic shears to seal and divide blood vessels up Inhibitors,research,lifescience,medical to 3mm in diameter. The vibration of the blades at 55,500 times per second simultaneously cuts and coagulates tissues by causing denaturization of proteins, rather than heat, as with conventional electrocautery. This allows for a more precise transection plane and reduces lateral thermal damage as well. The Harmonic Scalpel Inhibitors,research,lifescience,medical finds its best application during laparoscopic liver resections. In a nonrandomized study by Kim, et al. use of the Harmonic Scalpel was associated with decreased operative time and a trend toward decreased blood

loss and transfusion requirement. However, Inhibitors,research,lifescience,medical it was also associated with a significant increase in the incidence of postoperative bile leaks (32). Sealing Devices Sealing devices help in accomplishing liver parenchymal transection by sealing small vessels before division. These devices can be useful in the setting of laparoscopic or non-anatomic liver resections. Mephenoxalone The potential benefit of this technique involves simultaneous parenchymal division and ATM Kinase Inhibitor price Vessel hemostasis, which can theoretically lead to decreased transection times. They are typically used in combination with other techniques or devices (33). The Ligasure Vessel Sealing System (Covidien, Mansfield, MA, USA) is a bipolar vessel sealing device which can permanently occlude blood vessels up to 7 mm in diameter by combining pressure and energy to fuse the collagen matrix in the vessel wall (Figure 5). Figure 5 The LigaSure bipolar vessel sealing system. A. The vessel is sealed and B transected without requiring additional clips or ties. (Used with permission from: Poon RT. Current techniques of liver transection.