Hi! Dr. Lombardi:

A safe liver resection depends on considerations of liver function (severity of cirrhosis), method of inflow and outflow controls, ischemic time, resected liver volume, hypertrophy method of remnant volume, control of intraoperative blood loss and bile leak from the raw surface, opertion time, and posteroperative management. If the liver is normal such as metastatic liver tumors, then it will be much safer and easier to handle about the inflow, outflow and ischemic time control.

The above mentioned instruments can be applied only on one of those considerations of safe liver resection and that is control of intraoperative blood loss. These instruments enable more surgeons to perform liver resections, and more difficultly located tumors becoming approachable. Currently these instruments are useful during laparoscopic liver resection. However, there are expensive, time consuming, and not universally available to the underdeveloping countries or to the poor who is unable to pay for the use of these instruments.

I have developed a long straight needle to simplify the operation. It is cheap and not disposable. Blood loss, operation time, training time, facility and technical demands can be reduced. Now I am developing a long curve needle to overcome the limitations of the straight needle. Hopefully there needles can someday be implemented into the laproscopic or robotic hepatic resections.

http://www.google.com.tw/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&ved=0CCYQFjAA&url=http%3A%2F%2Fwww.springer.com%2Fcda%2Fcontent%2Fdocument%2Fcda_downloaddocument%2F9788847026216-c2.pdf%3FSGWID%3D0-0-45-1439713-p174307175&ei=Rl2RU_zkE8vFkQWO34Eg&usg=AFQjCNFtd-Hcq-OY_aTR9oWKMImPozBtiw&sig2=1G_XD210HpGcIT5r0FTIqw

Article Simplified Hepatic Resections With the Use of a Chang's Needle

Article Blocking intrahepatic inflow and backflow using Chang's need...

Dear Yu -Chung Chang, I read your articles and I think that your procedures are very interesting and cheap technologies, but I disagree with you about the operation time , the training and the reproducibility of the technique because I think that for your procedure is necessary an excellent knowledge of anatomy and ultrasound-anatomy of the liver in order to perform a correct surgical hepatic transection that only a liver surgeon with a good experience and ability, may have.

Dear Lombardi:

It is nice to receive your response and thank you for reading my articles.

In Taiwan or Japan where I practice liver surgery, using ultrasound is a "must". About the anatomic knowledge requirement, there will be all the same, no matter what instruments you are going to use. My basic criteria to decide the resection area is that the remnant liver will have a patent arterial inflow and biliary outflow. Therefore knowing major branches of hepatic artery, portal vein, bile duct and hepatic vein is essential and not difficult. About the operation timing, a typical right hepatic lobectomy will bo down in 1 hours. I bend the straight needle to a curve form to perform left hepatectomy in 40 minutes, which will be good indication for ALPPS. In majority of cases (not always) blood loss were minimal. If you are willing to try, please let me know. Now I am retired and it is not easy for me to increase my case number.

Hi dr Yu-Chung Chang , I think the straight needle procedure very interesting for to perform an alternative type of ALPPS. I haven't a big experience of ALPPS , because I was an assistant only in four complete procedure, but in literature is reported also ,as alternative of traditional procedure = a partial parenchyma partition with ligature (Or embolisation) of residual parenchyma. The focus of ALPPS, for the contralateral hypertrophy, is the liver parenchyma partition. A liver parenchyma division by two rows of interlocking mattress sutures and portal branch ligature (or embolisation) without parenchyma transection, may be sufficient in the first time , for contralateral hypertrophy. What's your opinion?

Hi! Lombardi:

Good question, I haven't thought of that. It is feasible to cause hypertrophy by only blocking the parenchymal without transection as well. I don't have the chance to perform ALPPS. My opinion is that since you have to remove the counter part in the subsequent staged hepatectomy, why not perform the formal partition in the first stage procedure? In that case, a long curve is the one to use. What's your purpose of not to doing partition?

Hi Chung , in my opinion I agree with you that for to perform an ALPPS is necessary, in the first time, the liver partition, but in case of a very small residual liver parenchyma, I think that to leave in side the liver without partition, may be supply the possible liver failure. I don't know if in the second time, the contralateral hypertrophy could make more difficult the liver transection.

Hi! Lombardi:

I agree with your thoughtful consideration. Thank you!! Although in most instance of a normal liver, liver partition will not cause liver failure.

By the way, my straight needle can't puncture the liver perpendicularly if there is a IVC underbeneath the liver when partition are going to be done in this area. One doctor had tried to puncture the liver obliquely to overcome the above problem. But a cure needle is much easier.

Best regards,