Yonago Acta medica 2014;57:93–98

Original Article

Effectiveness of the LigaSure Small Jaw Vessel-Sealing System in Hepatic
Resection
Miwa Yoshimoto, Kanenori Endo, Takehiko Hanaki, Joji Watanabe, Naruo Tokuyasu, Teruhisa Sakamoto, Soichiro
Honjo, Yasuaki Hirooka and Masahide Ikeguchi
Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504,
Japan

ABSTRACT

without foreign bodies such as clips, a smaller number ofties required to complete the procedure, and the ability
to close vessels that are of larger diameter, up to 7 mm,
than those that can be closed by electrocautery. These
procedures are all performed using a single instrument.
In February of 2011, the LigaSure Small Jaw(Covidien, Boulder, CO) (Fig. 1) was introduced as thenewest instrument in the LigaSure family of advanced
surgical vessel-sealing devices with a cutting blade. The
instrument is a manual device 18.8 cm in length that isdesigned to be used in confined surgical spaces where
access and visibility are limited. This instrument is designed for open surgery, offers the ability selectively to
cut or grasp tissue and permanently seal vessels up to
and including those 7 mm in diameter, lymphatic vessels
and tissue bundles without sutures, staples or clips.
We considered the features of this instrument to resemble those of a Pean clamp, which is used to perform
crimping and crushing. Although the LigaSure Small
Jaw is somewhat wider than a Pean clamp, the device
can be effectively used to crush liver parenchyma. More
importantly, liver resection is known to have a relatively
high risk of intraoperative hemorrhage; therefore, bleeding must be strictly controlled.
Studies evaluating the advantages of LigaSure
instruments compared with the conventional clump
crushing method have demonstrated reduced blood loss
during liver resection;6–8 however, LigaSure Small Jaw
has not yet been evaluated with respect to a reductionin blood loss in liver resection. LigaSure Small Jaw is
a smaller size than conventional LigaSure instruments,
and it is easy to handle and manage, similar to the conventional clump crashing method. We expected that thedevice would reduce the amount of bleeding in laparotomy for liver resection.
We have found the LigaSure instrument to confer
distinct advantages, including control of bleeding, crush-

BackgroundIn hepatic resection for liver tumors, reducing operation time and blood loss are important forpostsurgical complication prevention. This study aimed
to compare the safety and efficacy of the LigaSure Small
Jaw (Covidien, Boulder, CO) with those of the Cavitation
Ultrasonic Surgical Aspirator (CUSA) system (Integra
Life Sciences, Plainsboro, NJ) in hepatic surgery.
Methods We enrolled 102 patients with liver tumors,of whom 51 underwent liver resection with the CUSA(CUSA group) between March 2004 and April 2011.
Another 51 underwent resection with the LigaSure
Small Jaw (LS group) between June 2011 and July 2012.
We stratified patients by time period depending on the
instrument used, and compared operative duration; intraoperative bleeding; and postoperative liver function
and complication rate.
Results
Total operation time (mean ± SD) was significantly shorter in the LS group than in the CUSA
group (358.8 ± 91.7 versus 460.6 ± 146.1 min, P < 0.001).
Blood loss was not significantly different between the 2groups. Frequency of postoperative complications was
lower, but not significantly, in the LS group.
Conclusion The LigaSure Small Jaw may allow a
shorter total operative duration than the CUSA device.
Key words

blood loss; LigaSure Small Jaw; liver resection; operative time

In recent years, vessel-sealing systems have beendeveloped and used widely in the fields of urologic,
gynecologic, and gastrointestinal surgery.1–5 Our department previously used the Cavitation Ultrasonic
Surgical Aspirator (CUSA) (Integra Life Sciences,
Plainsboro, NJ) for liver resection. Under this system,
liver resection generally comprises two separate procedures: First, crushing of the liver parenchyma andsubsequent aspiration of the crushed tissue and blood
to expose the intrahepatic vessels; and second, ligationor sealing of the exposed vessels, which is typicallyachieved by manual ligation, clips, or electrocautery.
The use of LigaSure instruments confers several
advantages, including sealing of the intrahepatic vessel

Corresponding author: Miwa Yoshimotom-yoshimoto@med.tottori-u.ac.jp
Received 2014 February 20
Accepted 2014 March 31
Abbreviations: ALT, alanine aminotransferase; AST, aspartate
aminotransferase; CUSA, Cavitation Ultrasonic Surgical Aspirator; LS, LigaSure

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M. Yoshimoto et al.

Fig. 1. LigaSure Small Jaw (Covidien; Boulder, CO). Left: whole image of the vessel (18.8 cm in length). Right: enlarged
image of the vessel head when the vessel is in an opened state, viewed from the bottom of the vessel head.

ing ability similar to that of a Pean clamp, and the ability to seal and cut almost simultaneously during livertransection. We therefore switched from the CUSA to
the LigaSure Small Jaw in June of 2011. The goal ofthis study was to compare the safety and efficacy of the
LigaSure Small Jaw vessel-sealing system with those of
the CUSA in liver resection.

intermittently with 15 min of clamping and 5 min of unclamping, patients were excluded if the intestinal adhesion
proximal to the hepatoduodenal ligament was severe.
In the CUSA group, liver parenchyma was crushed
using the CUSA device and exposed vessels were successively manually ligated or clipped, then sealed andcut. In contrast, the LigaSure Small Jaw was used tocrush liver parenchyma similarly to using a Pean clamp,
seal residual vessels up to about 7 mm in diameterand complete dissection throughout the procedure. Allprocedures, such as abdominal section, detaching andunfolding liver, washing surgical field, indwelling drain
tube and abdominal closure, were similarly performed
throughout the operations between the 2 groups.

MATERIALS AND METHODSThis was a retrospective study of 225 patients who
underwent hepatic resection at our institution between
March 2004 and July 2012. Patients were assigned togroups treated with liver resection with the CUSA device (CUSA group, n = 51) from March 2004 to April
2011, or the new LigaSure Small Jaw vessel-sealing
system (LS group, n = 51) from June 2011 to July 2012.
Between March 2004 and April 2011, we performed all
operations using the CUSA. Patients were consecutively
selected during the trial period, but excluded if they had
undergone laparoscopic liver resection, or were missing
data related to pre- or post-operative liver function. This
resulted in 102 patients being chosen to be analyzed inthis study. The difference in the recruitment period for
the CUSA and LS groups is a result of the increase inoperations for liver cancer in recent years; our institution
had more patients in the latter period compared withthose in the former period.

Surgical outcomes

Surgical outcomes included operative duration, intraoperative blood loss and postoperative variables. Postoperative
variables were liver function and complications. Postoperative liver function was assessed by measuring laboratory
data on postoperative days 1, 3, 5 and 7. Of these data, themaximum transaminase value, maximum bilirubin value
and minimum albumin value were used for analysis.
Statistical analysis

Quantitative variables were compared using analysis ofvariance. Comparisons between groups were performed
using the chi-square test and Student’s t-test. All data areexpressed as the mean ± SD. P < 0.05 was considered torepresent statistical significance.

Surgical technique

Two surgeons (K. E. and Y. H.) alternately performed all
operations in this study. No patient was specifically assigned to either doctor. Liver transection was achieved
using primarily either the CUSA or LigaSure Small Jaw.
In both groups, water-cooled bipolar forceps and the VIO
BiClamp (ERBE GmbH, Tübingen, Germany) were usedin combination. The Pringle maneuver was performed

RESULTS
Characteristics of the 102 patients are presented inTable 1. The LS group was older than the CUSA group(P < 0.05). No statistically significant differences were
found between the 2 groups for clinical features, in94

LigaSure Small Jaw vessel-sealing system
Table 1. Background characteristics
Number of patients
Duration of use
Sex (male/female ratio)
Age, mean ± SD [range], yr
Background liver
Hepatitis B
Hepatitis C
Others
Cause of disease
Hepatocellular carcinoma
Metastatic liver tumor
Cholangiocarcinoma
Pathological findings of non-cancerous region
Normal liver (nl)Chronic hepatitis (ch)Liver cirrhosis (lc)
Preoperative liver function, mean ± SD
Total bilirubin, mg/dL
Aspartate aminotransferase, U/L
Alanine aminotransferase, U/LAlbumin, g/dL
Indocyanine green retention, %Type of hepatectomy
Partial hepatectomy
Subsegmentectomy
One hepatic segmentectomy
Two hepatic segmentectomy or over

CUSA group

LS groupP

51
Mar. 2004–Apr. 2011
38/13
63.9 ± 11.2 [40–81]

51
Jun. 2011–Jul. 201243/8
68.9 ± 9.9 [46–85]

0.3273†< 0.05††

19 (37.2%)
17 (33.3%)
15 (29.4%)

23 (45.1%)
10 (19.6%)
18 (35.3%)

0.2911†33 (64.7%)
13 (25.5%)
5 (9.8%)33 (64.7%)
14 (27.5%)
4 (7.8%)0.9286†13 (25.5%)
26 (51.0%)
12 (23.5%)

11 (21.6%)
32 (62.9%)
8 (15.7%)

0.3301†0.73 ± 0.27
40.1 ± 49.9
36.3 ± 28.8
3.97 ± 0.44
12.6 ± 5.9

0.74 ± 0.26
36.8 ± 21.6
32.7 ± 23.2
4.01 ± 0.40
13.8 ± 6.1

0.9412††0.6607††0.4177††0.2165††0.3754††14 (27.5%)
8 (15.7%)
11 (21.6%)
18 (35.3%)

9 (17.6%)
4 (7.8%)18 (35.3%)
20 (39.2%)

0.2391†CUSA group, group treated with the Cavitation Ultrasonic Surgical Aspirator system; LS group, group treated with the LigaSure Small
Jaw system.
Statistics: †chi-square test; ††Student’s t-test.
Table 2. Operative duration
Operative duration [range], min
Non-cancerous region
Non-cirrhosis (nl/ch)
Cirrhosis (lc)

CUSA group

LS group

460.6 ± 146.1 [160–803]

358.8 ± 91.7 [177–630]< 0.0001

442.7 ± 1498.8
518.8 ± 121.2

350.9 ± 95.3
401.0 ± 56.3

< 0.005< 0.05P

Data, mean ± SD.
ch, chronic hepatitis; CUSA group, group treated with the Cavitation Ultrasonic Surgical Aspirator system; lc, liver cirrhosis; LS group,group treated with the LigaSure Small Jaw system; nl, normal liver.
Statistics: Student’s t-test.

There was less intraoperative blood loss in the LSgroup (681.7 ± 543.7 mL; range, 34–2,500 mL) than in
the CUSA group (894.0 ± 856.2 mL; range, 20–3,710mL) but the difference was not statistically significant.
Postoperative liver function parameters for eachgroup are listed in Table 4. Among these outcomes,
aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were much higher after procedures
using the LigaSure Small Jaw than in those using the
CUSA. Postoperative total bilirubin and albumin were
not statistically different between the 2 groups.

cluding condition of the livers (cirrhotic versus noncirrhotic), cause of disease, pathological findings of noncancerous regions and preoperative liver function; or for
type of hepatectomy.
Operative duration is shown in Table 2 and total
blood loss is shown in Table 3. The entire operative duration was 460.6 ± 146.1 min (range, 160–803 min) for
the CUSA group and 358.8 ± 91.7 min (range, 177–630
min) for the LS group. Total operative duration was significantly shorter in the LS group for both non-cirrhotic(P < 0.005) and cirrhotic (P < 0.05) livers.
95

M. Yoshimoto et al.
Table 3. Intraoperative blood loss
Intraoperative blood loss [range], mL
Non-cancerous region
Non-cirrhosis (nl/ch)
Cirrhosis (lc)

CUSA group

LS groupP

894.0 ± 856.2 [20–3710]

681.7 ± 543.7 [34–2500]

0.1641817.3 ± 822.7
1143.3 ± 951.5

672.2 ± 552.2
733.1 ± 527.7

0.37330.3459Data, mean ± SD.
ch, chronic hepatitis; CUSA group, group treated with the Cavitation Ultrasonic Surgical Aspirator system; lc, liver cirrhosis; LS group,group treated with the LigaSure Small Jaw system; nl, normal liver.
Statistics: Student’s t-test.

Table 4. Postoperative liver function
Total bilirubin, mg/dL
Aspartate aminotransferase, U/L
Alanine aminotransferase, U/LAlbumin, g/dL

CUSA group

LS groupP

1.82 ± 1.14
442.5 ± 259.6
356.6 ± 253.1
2.75 ± 0.34

1.91 ± 1.17
683.7 ± 500.6
599.9 ± 439.0
2.66 ± 0.35

0.4329< 0.005< 0.0010.1726

Data, mean ± SD.
CUSA group, group treated with the Cavitation Ultrasonic Surgical Aspirator system; LS group, group treated with the LigaSure Small
Jaw system.
Statistics: Student’s t-test.
Table 5. Postoperative complications
Bile leakage
Bile duct stenosis
Pleural fluid
Wound infection
Intraperitoneal abscess
Pneumonia

CUSA group

LS groupTotal

8 (15.7%)
0 (0.0%)3 (5.9%)4 (7.8%)3 (5.9%)0 (0.0%)2 (3.9%)1 (2.0%)4 (7.8%)2 (3.9%)1 (2.0%)1 (2.0%)10 (9.8%)
1 (1.0%)7 (6.9%)6 (5.9%)4 (3.9%)1 (1.0%)P
0.0539> 0.9999> 0.9999
0.67790.6175> 0.9999

CUSA group, group treated with the Cavitation Ultrasonic Surgical Aspirator system; LS group, group treated with the LigaSure Small
Jaw system.
Statistics: Student’s t-test.

Postoperative complications occurred in 18 patients in the CUSA group and in 11 patients in the
LS group (Table 5). Eight patients (13.9%) in CUSA
group and 2 patients (5.6%) in LS group experienced
bile leakage, with a difference that was not significant.
Other complications, including bile duct stenosis, pleural fluid, wound infection, intraperitoneal abscess andpneumonia, were not significantly different between
the 2 groups.

crushing, then sealing and cutting a vessel using a single
device, which greatly reduced performance time. For
safety, the most challenging exposures of major hepaticveins and Glisson’s capsule were performed using a
Pean clamp.
This study shows that the LigaSure Small Jaw canbe safely used during liver parenchymal resection andsignificantly reduces the operation time for liver resection compared with the CUSA device. This result represents an operative duration approximately 100 min
shorter for the LS group than for the CUSA group (P <0.0001). Shortening the operation time in liver resection
has been demonstrated in previous studies using conventional LigaSure,6 but not yet with the newest device,
LigaSure Small Jaw. Time reduction was also observed
for resection of cirrhotic livers, which are difficult tosever by the crush-clamp technique using a Pean clamp

DISCUSSION
A randomized clinical trial comparing ultrasonic withmanual clamp transection of the liver showed no difference in blood loss or operation time.9 In our practice,
exposure of vessels and bile ducts using the CUSA
required a great deal of time, whereas the LigaSure
Small Jaw made it possible to expose residual vessels by
96

LigaSure Small Jaw vessel-sealing systemdefect of the vessel-sealing system,14, 15 whereas several
studies have shown a decreased rate of this complicationin the LigaSure instrument groups.6, 16, 17 Comparisonof postoperative bile leakage between LigaSure andconventional-method groups was reported in 3 randomized controlled trials6, 11, 18 and 3 non-randomized
studies.8, 16, 19 The overall risk of bile leakage was 63%
lower in the LigaSure groups than in the conventionalmethod groups (odds ratio 0.37; 95% confidence interval
0.17–0.78; n = 559). This outcome supports the theory
that an advantage of the LigaSure is its ability to seal
both biliary and vascular structures. Our results confirm
this, showing a low incidence of bile leakage associatedwith the use of the vessel-sealing system. Our results did
not statistically demonstrate the efficacy in reducing bile
leakage in the LS group, which was presumably because
the number of occurrences was too small for comparison; however, our results do suggest the LigaSure Small
Jaw can potentially reduce the incidence of bile leakage.
The LigaSure Small Jaw Instrument was superior
to the CUSA in terms of shortening operative time. It
was also better at reducing intraoperative hemorrhage
and postoperative complications, but these effects did
not reach clinically significant levels. Overall, using
LigaSure Small Jaw Instrument can be advantageous inliver resection.

and often difficult to achieve hemostasis. An advantage
of using the LigaSure is that sealing of blood vessels
does not require direct exposure, which can increase operative time and cause unnecessary bleeding.
Previous studies have demonstrated that using
LigaSure instruments reduced the amount of blood loss
in liver resection compared with conventional clump
crash methods.6–8, 10 However, Dokelstic et al. compared
3 instruments, the clamp crushing method, CUSA and
LigaSure in liver resection, and found no difference in
the intraoperative blood loss between the groups.11
A study comparing the LigaSure Small Jaw withconventional suture ligation in thyroidectomy showed
intraoperative blood loss to be statistically significantly
less for the LigaSure Small Jaw.12 Although this single
study showed a reduction in blood loss by the LigaSure
Small Jaw in thyroidectomy, this device had not yet been
evaluated in liver resection.
Our results showed that total blood loss in patientswith non-cirrhotic liver in the LS group was approximately 20% less than in the CUSA group, and in patients with cirrhotic liver, blood loss in the LS group was
also 20% less than in the CUSA group. However, thesedata were not significantly different. LigaSure’s advantage over CUSA with respect to mitigating bleeding has
not yet been demonstrated.
Postoperative transaminase was considerably higher
in the LS group than in the CUSA group. In one study,
LigaSure diathermy was shown to be associated withsignificantly higher transaminase levels than conventional techniques.7 According to those authors, the scaldedliver parenchyma on the cut surface may have explained
this increase, as the maximum AST value was significantly correlated with the resection time and area. Follow-up computed tomography revealed the burned areaon the cut surface on the liver. In that study, the levels of
AST and ALT were not significantly different on postoperative day 5 between the 2 groups, and were nearly
the same level on postoperative day 7. In this study, we
also demonstrated that the level of these enzymes weresimilar on postoperative day 5 between the 2 groups(date not shown). An explanation for this may be that thedamage to scalded liver parenchyma resolved over time
and transaminases reverted to normal levels.
In a study examining and comparing 4 sealing devices, including LigaSure instruments, the degree oflateral thermal spread of the LigaSure instruments was
55.5 ˚C, 2 mm away from the cut surface.13 This supports the hypothesis that tissue was burned by thermal
spread with the devices, which caused increased postoperative transaminase levels.
Among postoperative complications, an increased
risk of bile leakage had been identified as a possible

The authors declare no conflict of interest.
References
1 Romano F, Caprotti R, Franciosi C, De Fina S, Colombo G,
Uggeri F. Laparoscopic splenectomy using Ligasure: preliminary experience. Surg Endosc. 2002;16:1608-11. PMID:
11984666.
2 Strasberg SM, Drebin JA, Linehan D. Use of a bipolar vesselsealing device for parenchymal transection during liver surgery. J Gastrointest Surg. 2002;6:569-74. PMID: 12127123.
3 Levy B, Emery L. Randomized trial of suture versus electrosurgical bipolar vessels sealing in vaginal hysterectomy.
Obstet Gynecol. 2003;102:147-51. PMID: 12850621.
4 Daskalopoulos G, Karyotis I, Heretis I, Delakas D. Electrothermal bipolar coagulation for radical prostatectomies andcystectomies: a preliminary case-controlled study. Int Urol
Nephrol. 2004;36:181-5. PMID: 15368689.
5 Takada M, Ichihara T, Kuroda Y. Comparative study of electrothermal bipolar vessel sealer and ultrasonic coagulating
shears in laparoscopic colectomy. Surg Endosc. 2005;19:2268. PMID: 15573241.
6 Saiura A, Yamamoto J, Koga R, Sakamoto Y, Kokudo N, Seki
M, et al. Usefulness of LigaSure for liver resection: analysis byrandomized clinical trial. Am J Surg. 2006;192:41-5. PMID:
16769273.
7 Sakamoto Y, Yamamoto J, Kokudo N, Seki M, Kosuge T,
Yamaguchi T, et al. Bloodless liver resection using the monopolar floating ball plus ligasure diathermy: preliminary resultsof 16 liver resections. World J Surg. 2004;28:166-72. Epub
2004 Jan 8. PMID: 14708050.

97M. Yoshimoto et al.
8 Chiappa A, Bertani E, Biffi R, Zbar AP, Viale G, Pruneri G,
et al. Effectiveness of LigaSure diathermy coagulation in liver
surgery. Surg Technol Int. 2008;17:33-8. PMID: 18802881.
9 Arita J, Hasegawa K, Kokudo N, Sano K, Sugawara Y,
Makuuchi M. Randomized clinical trial of the effect of asaline-linked radiofrequency coagulator on blood loss during
hepatic resection. Br J Surg. 2005;92:954-9. PMID: 16034832.
10 Alexiou VG, Tsitsias T, Mavros MN, Robertson GS, Pawlik
TM. Technology-assisted versus clamp-crush liver resection:a systematic review and meta-analysis. Surg Innov. Epub 2012
Dec 14. PMID: 23242518.
11 Doklestic K, Karamarkovic A, Stefanovic B, Stefanovic B,
Milic N, Gregoric P, et al. The efficacy of three transection
techniques of the liver resection: a randomized clinical trial.
Hepatogastroenterology. 2012;59:1501-6. PMID: 22115802.
12 Hirunwiwatkul P, Tungkavivachagul S. A multicenter, randomized, controlled clinical trial of ligasure small jaw vesselsealing system versus conventional technique in thyroidectomy. Eur Arch Otorhinolaryngol. 2013;270:2109-14. PMID:
23241823.
13 Lamberton GR, Hsi RS, Jin DH, Lindler TU, Jellison FC,
Baldwin DD. Prospective comparison of four laparoscopic
vessel ligation devices. J Endourol. 2008;22:2307-12. PMID:
18831673.
14 Matthews BD, Pratt BL, Backus CL, Kercher KW, Mostafa
G, Lentzner A, et al. Effectiveness of the ultrasonic coagulat-

ing shears, LigaSure vessel sealer, and surgical clip application in biliary surgery: a comparative analysis. Am Surg.
2001;67:901-6. PMID: 11565773.
15 Shamiyeh A, Vattay P, Tulipan L, Schrenk P, Bogner S,
Danis J, et al. Closure of the cystic duct during laparoscopiccholecystectomy with a new feedback-controlled bipolar sealing system in case of biliary obstruction--an experimental
study in pigs. Hepatogastroenterology. 2004;51:931-3. PMID:
15239216.
16 Evrard S, Bécouarn Y, Brunet R, Fonck M, Larrue C,
Mathoulin-Pélissier S. Could bipolar vessel sealers prevent
bile leaks after hepatectomy? Langenbecks Arch Surg.
2007;392:41-4. PMID: 17131151.
17 Nanashima A, Tobinaga S, Abo T, Nonaka T, Sawai T,
Nagayasu T. Usefulness of the combination procedure ofcrash clamping and vessel sealing for hepatic resection. J Surg
Oncol. 2010;102:179-83. PMID: 20648591.
18 Ikeda M, Hasegawa K, Sano K, Imamura H, Beck Y,
Sugawara Y, et al. The vessel-sealing system (LigaSure) in
hepatic resection: a randomized controlled trial. Ann Surg.
2009;250:199-203. PMID: 19638927.
19 Garancini M, Gianotti L, Mattavelli I, Romano F, Degrate
L, Caprotti R, et al. Bipolar vessel-sealing system vs. clamp
crushing technique for liver parenchyma transection. Hepatogastroenterology. 2011;58:127-32. PMID: 21510299.

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