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Randomized clinical trial of stapler hepatectomy versus LigaSure™ transection in elective hepatic resection. BJS 2018; 105: 1119-1127.

Published: 11th July 2018

Authors: J. Fritzmann, J. Kirchberg, D. Sturm, A. B. Ulrich, P. Knebel, A. Mehrabi et al.


Previous studies have demonstrated stapler hepatectomy and use of various energy devices to be safe alternatives to the clamp‐crushing technique in elective hepatic resection. In this randomized trial, the effectiveness and safety of stapler hepatectomy were compared with those of parenchymal transection with the LigaSure™ vessel sealing system.


A total of 138 patients were analysed, 69 in the LigaSure™ and 69 in the stapler hepatectomy group. Baseline characteristics were well balanced between the groups. Mean intraoperative blood loss was significantly higher in the LigaSure™ group than the stapler hepatectomy group: 1101 (95 per cent c.i. 915 to 1287) versus 961 (752 to 1170) ml (P = 0·028). The parenchymal transection time was significantly shorter in the stapler group (P = 0·005), as was the total duration of operation (P = 0·027). Surgical morbidity did not differ between the groups, nor did the grade of complications.


Stapler hepatectomy was associated with reduced blood loss and a shorter duration of operation than the LigaSure™ device for parenchymal transection in elective partial hepatectomy. Registration number: NCT01858987 (http://www.clinicaltrials.gov).

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David Vass

9 months ago

We read with interest the study by Fritzman et al. which compared hepatic parenchyma dissection with stapler versus LigaSure (1). The overall mortality reported in the series is significantly high at near 8% (1) which is not in keeping with other large series and studies where mortality following liver resection is 0.3-2% (2,3). This was not acknowledged within the paper with no explanation of the underpinning reasons (1). It would not appear to be due to a high rate of hilar cholangiocarcinoma resection as these were excluded from the study (1). Both stapler and Ligasure transection techniques have been reported previously with mortality approaching <1% (4,5). We would value the authors comments on why the mortality in this series is higher than expected.

David G Vass
Declan FJ Dunne

1. Fritzmann J, Kirchberg J, Sturm D, Ulrich AB, Knebel P, Mehrabi A, Büchler MW, Weitz J, Reissfelder C, and Rahbari NN. Randomized clinical trial of stapler hepatectomy versus LigaSure™ transection in elective hepatic resection. Br J Surg. England; 2018Aug;105(9):1119-1127.
2. Zimmitti G, Roses RE, Andreou A, Shindoh J, Curley SA, Aloia TA, and Vauthey JN. Greater complexity of liver surgery is not associated with an increased incidence of liver-related complications except for bile leak: an experience with 2,628 consecutive resections. J Gastrointest Surg. United States; 2013Jan;17(1):57-64; discussion p.64-5.
3. Dunne DF, Yip VS, Jones RP, McChesney EA, Lythgoe DT, Psarelli EE, Jones L, Lacasia-Purroy C, Malik HZ, Poston GJ, and Fenwick SW. Enhanced recovery in the resection of colorectal liver metastases. J Surg Oncol. United States; 2014Apr8;110(2):197-202.
4. Buell JF, Gayet B, Han HS, Wakabayashi G, Kim KH, Belli G, Cannon R, Saggi B, Keneko H, Koffron A, Brock G, and Dagher I. Evaluation of stapler hepatectomy during a laparoscopic liver resection. HPB (Oxford). England; 2013Nov;15(11):845-50.
5. Patrlj L, Tuorto S, and Fong Y. Combined blunt-clamp dissection and LigaSure ligation for hepatic parenchyma dissection: postcoagulation technique. J Am Coll Surg. United States; 2010Jan;210(1):39-44.

    NN Rahbari

    9 months ago

    We would like to thank Vass and Dunne for their interest in our study. These authors addressed the high mortality rate in our trial.

    It is correct that the mortality of about 8% is higher compared to previous reports on stapler hepatectomy. In fact, 7 of the 11 patients who died postoperatively had a type IIIA or type IV hilar cholangiocarcinoma. Without exceptions, all of these patients underwent a extended right hepatectomy. As it is well know that hepatectomies in these patients are associated with higher mortality compared to other indications, the observed mortality rates are not surprising.

    However, we would like to take this opportunity to clarify the eligibility criteria of the trial. As outlined in our initial manuscript we excluded patients with intrahepatic tumours in close proximity to the hilar plate. In these cases curved or even twisted transection planes are required to preserve the hilar plate (i.e. to avoid a hepaticojejunostomy), rendering stapler hepatectomies difficult. In contrast, extended resections for hilar cholangiocarcinoma commonly have straight transection planes down to the hilar plate which is divided in a planned fashion. In these cases stapler hepatectomies are usually feasible. For this reason patients with hilar cholangiocarcinoma were eligible for inclusion in the trial and contributed to the higher mortality rates compared to previous series.

    NN Rahbari
    Department of Surgery
    Mannheim University Medical Centre
    University of Heidelberg
    Theodor‐Kutzer‐Ufer 1‐3
    68167 Mannheim