January 23, 2007 11:4 WSPC/SPI-B415: Haemostasis in Surgery ch05

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M. Pai, R. Canelo & N. Habib

time.34 It is useful in controlling intrahepatic vessels. A disadvantage

of the technique is that at a power level of three, it may take 5 to
30 seconds for coagulation to be complete. This may seem tedious
compared with simple ligation, in open surgery. CS applied directly to
liver parenchyma without the forceps fracture method is also unfea-
sible as the ultrasonic energy is easily dispersed and not adequately
concentrated, resulting in poor coagulation. As long as the blood
vessel has enough coagulum material, vessels up to 6 mm may be
coagulated.25 Therefore, it should be able to coagulate most intra-
hepatic vessels. CS is not good at controlling bleeds from small trib-
utaries or pinholes, however, it is comparable to the forceps fracture
method.

WATER JET
The water jet method has been used during hepatic resection. The
instrument cuts the hepatic tissue with the high pressure of the
fine water flow, while the exposed elastic intrahepatic vessels are
spared injury. The jet cutter26,27,35 produces selective cutting, but
the thermal methods cannot discriminate between the vessels and
the parenchyma. The loosely connected parenchyma is washed away
from the more resilient vessels by shooting a beam of NaCl through
a 0.1 to 0.2 nozzle at pressures of 10 to 80 bar. The distance between
jet and liver is 1.5 cm and is kept constant by using a suction device. A
higher jet pressure is needed to cut the fibrotic hepatic parenchyma.
In the case of normal liver, the intrahepatic vessels of more than
0.2 mm are well preserved.
The loss of blood during transaction of the hepatic parenchyma
can be easily reduced with a jet pressure of 15 to 16 kg/cm2 . This pre-
serves the fine vessels, more than 0.2 mm in diameter, without injury.
When the same pressure is applied in the cutting of a cirrhotic liver,
it takes a longer time compared with that of a non-cirrhotic normal
liver parenchyma. A disadvantage is the formation of air bubbles,
which obscure the operative field. In addition, after the vessels are
isolated, conventional ligation or clipping is still required and is time
consuming.