Harmonic shears

Intraoperative ultrasound was used for intraoperative intrahepatic staging, to identify tumour margin and hepatic anatomy. If required, subsegmental resection was performed to clear the future liver remnant of tumour. Anatomical resection was performed in accordance with Couinaud's liver segmental classification. Portal and hepatic arterial inflow to the segments for resection were dissected extrahepatically and occluded with vascular bulldog clamps to allow for ICG clearance assessment (ICG3). Liver parenchymal transection was performed using a combination of an ultrasonic surgical aspirator (CUSA, Radionics, Burlington, MA, USA), Harmonic shears (Ethicon, Somerville, NJ, USA), and linear surgical stapler (EndoGIA, Covidien, Mansfield, MA, USA; Echelon Endopath, Ethicon, Somerville, NJ, USA). Following complete parenchymal transection, an ICG clearance was performed with the inflow occluded and with outflow (hepatic vein) patent (ICG4). A final ICG clearance was performed with both inflow and outflow occlusion (ICG5). Following this step, the liver resection was completed with ligation and division of the hepatic artery, portal vein, and hepatic vein to the pertinent hemiliver.

Device removal was performed laparoscopically by the implanting surgeon in most cases. The outer fibrous capsule surrounding the LINX device was opened with Harmonic Shears (Ethicon, Johnson and Johnson, Raritan, NJ) or laparoscopic scissors and each anterior bead was sequentially freed of its capsular attachments. Once sufficient exposure was achieved, the device was disconnected either by disarticulating the clasp or cutting the interconnecting wire with Harmonic Shears. Further capsular dissection followed, systematically freeing the posterior beads while applying gentle traction until the device was free. Whenever possible, the device was removed in one piece through the abdominal port. The inner capsule, in contact with the esophagus and anterior vagus nerve, and the small portion of outer capsule in the region of the posterior vagus nerve were left unviolated. After removal from the body, the beads were counted and the surgical sites and surrounding tissues were carefully inspected for injury. Upper endoscopy was performed to confirm no perforation or bleeding. Hiatal hernia repair and/or further anti-reflux procedures were then performed, if indicated.