How to dissect the liver parenchyma: Excavation with cavitron ultrasonic surgical aspirator

Background A large amount of blood flows in and out of the liver through the inflow system consisting of the portal vein and hepatic artery within the Glissonean cord and the outflow system constituted by the hepatic veins. Methods During liver parenchymal dissection, useful methods to maintain a dry operative field are to control the inflow system with the Pringle maneuver and the outflow system by managing the central venous pressure. Additionally, mature techniques of dissecting the liver parenchyma, which can prevent injury to the blood vessels and appropriately and promptly stop bleeding, are fundamental. Similar to archaeological excavation, in which buried remains are unearthed and exposed in intact form, the Glissonean cords and hepatic veins buried in the liver parenchyma should be exposed or isolated without causing injury to these structures during liver parenchymal dissection. Results The cavitron ultrasonic surgical aspirator (CUSA) is useful as a surgical device for excavation because it has multiple functions in one device. However, there have been no systematic guidelines on how to use it effectively during hepatectomy. Conclusion We herein describe how to use the CUSA, based on our knowledge and experiences.