Aryal et al. BMC Surgery (2018) 18:86
https://doi.org/10.1186/s12893-018-0423-2

RESEARCH ARTICLE

Open Access

Evaluation of THUNDERBEAT® in open liverresection- a single-center experience
Bibek Aryal1,2, Teruo Komokata1*, Hiroto Yasumura1, Daisaku Kamiimabeppu1, Maki Inoue1, Kota Yoshikawa1,
Mamoru Kaieda1 and Yutaka Imoto2

Abstract
Background: THUNDERBEAT® (TB) (Olympus Medical Systems Corp., Tokyo, Japan) is a dynamic energy system
device that simultaneously delivers ultrasonically generated frictional heat energy and electrically generated bipolarenergy. TB is being routinely used in various operative procedures, however, less is known about its utility in liverresection. We, herein, report our early experience of using TB in open liver resection particularly in patients withnormal or near-normal liver parenchyma.
Methods: We retrospectively reviewed the clinical characteristics, and evaluated the perioperative outcome oftwenty-eight patients who underwent liver resection with TB, and twenty-four patients who underwent liverresection with basic procedure in our institution. The resection type was stratified into: major hepatectomy;resection of 3 or more than 3 Couinauds segments, and minor hepatectomy; resection of less than 3 Couinauds
segments.
Results: Liver resection time (mean ± SD) in TB group with major hepatectomy was significantly shorter: 16.7
± 8.8 compared to 62.8 ± 39.4 min in basic procedure group (P < 0.0001). Accordingly, the liver resection time(mean ± SD) in TB group with minor hepatectomy was also significantly shorter, 8.3 ± 2.9 min compared to45.2 ± 23.9 min in liver resection with basic procedure (P < 0.001). No significant difference was observed
between the groups in terms of intraoperative blood transfusion ratio, postoperative complication and postoperative
liver dysfunction.
Conclusion: TB as a new energy device can offer a safe, reliable and substantially rapid liver resection particularly inpatients with normal or near-normal liver parenchyma.
Keywords: THUNDERBEAT®, Liver resection, Energy device

BackgroundThe steady progress achieved in the outcomes of liver resection has emerged as a result of the upgraded surgical
techniques that carry the advantage of technological advancements. A majority of liver resections performed
these days involves the use of some energy device for cutting, coagulation or sealing, such as Cavitron Ultrasonic
Surgical Aspirator (CUSA, Tyco Healthcare, Mansfield,
MA, USA), the Harmonic Scalpel (Ethicon Endo-Surgery,Cincinnati, OH, USA), the Ligasure Vessel Sealing System* Correspondence: komokata@kagomc2.hosp.go.jp
1
Department of Surgery, Kagoshima Medical Center, National Hospital
Organization, 8-1 Shiroyamacho, Kagoshima-shi, Kagoshima 892-0853, Japan
Full list of author information is available at the end of the article(Covidien, Mansfield, MA, USA) and several other dissecting sealers [1–8].
Use of energy devices in the liver parenchyma transection is popular for faster and safer hepatectomy [6, 7].
THUNDERBEAT® (TB) (Olympus Medical Systems
Corp., Tokyo, Japan) is the first device to simultaneously
integrate ultrasonically generated frictional heat energy
and electrically generated bipolar energy [9]. The ultrasonic technology is used for rapid cutting and precise
dissection while the bipolar technology performs reliable
vessel sealing. TB is considered vibrant due to its ability
to gain a rapid surge in temperature with minimal thermal spreading [9].
Despite plenty of reports on the utility of other devices, little is known about the relevance of TB in liver© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Aryal et al. BMC Surgery (2018) 18:86

resection. In this retrospective cohort study, we used TB
as a single device, assisted by Pringle maneuver with orwithout infra-hepatic inferior vena cave (IVC) clamping,in open liver resection, and compared the perioperative
outcomes with the patients who underwent liver resection with basic procedure.

Methods
Between April 2016 and April 2018, patients who underwent open liver resection with TB were retrospectively
enrolled in the study. Similarly, a control group of patients who underwent open liver resection with basic
procedure between June 2013 and February 2018 wasincluded.
All the patients underwent routine blood tests, tumor
markers evaluation, triphasic liver dynamic computed
tomography (CT), and double contrast magnetic resonance imaging (MRI). Liver function was estimated using
technetium-99 m galactosyl serum albumin scintigraphy,
and remnant liver volume was assessed by athree-dimensional volume analyzer (SYNAPSE VINCENT; FUJIFILM Medical Co., Tokyo, Japan) in major
hepatectomy.
The fibrosis score was assessed based on a five-point
scale: F0 = no fibrosis, F1 = portal fibrosis without septa,
F2 = few septa, F3 = numerous septa without cirrhosis,
F4 = cirrhosis. Liver parenchyma with F0 was defined as
normal and F1 was defined as having near normalparenchyma.
Operative techniqueFollowing exploratory laparotomy, with the aid of intraoperative ultrasonography, the extent of the diseasealong with its relationship to vascular structures wasPage 2 of 5

assessed in all resections. The description of the procedure in each resection group is listed below.
TB resection

The liver was mobilized, and the hepatic pedicles weretapped with or without the intra-hepatic IVC taping. 1–
0 Vicryl® stay sutures were placed on the hepatic edges
for symmetric traction (for major hepatectomy), and thetransection of the liver parenchyma was started with TB(Fig. 1). During parenchymal transection, only the pedicles equal or larger than 3rd branches of glissonian
sheath or main branches of major hepatic veins were ligated and divided, the other vessels were sealed with TB.
Liver resection was performed with Pringle maneuver incycles of clamp/unclamp time of 15/5 min.
Basic resection

Inflow occlusion was performed by hepatic pedicle
clamping along with ligation of glissonian or selective
ligation of the portal vasculature and hepatic artery supplying the portion of the liver being resected. Liver wasmobilized and stay sutures were placed on the hepatic
edges, and about 1 cm of the superficial liver parenchyma was transected with an energy device like harmonic scalpel. Parenchymal transection was performed
either by the crush-clamp method or using the CUSA.
CUSA was mostly used in association with Kelly clamp
rather than a single device. The exposed vessels or ducts
were divided using sutures ligation. Intermittent inflow
occlusion with the Pringle maneuver was performed in asimilar way to the TB resection.
In both techniques, after removal of the specimen,
hemostasis was achieved with Z-shaped sutures (4–0/5–
0 Prolene®) when required, and Tachosil® was applied toFig. 1 Demonstration of technique of parenchymal transection with TB Liver parenchyma being divided using TB in a patient withleft hepatectomy

Aryal et al. BMC Surgery (2018) 18:86

the raw surface. A closed suction drain was placed at theend of the procedure.
Perioperative assessment

Liver resection time indicates the duration recorded
from the beginning of the parenchyma resection to theremoval of the en-bloc specimen of liver.
Liver resections were defined according to the International Hepato-Pancreato-Biliary Association, Brisbane(IHPBA) 2000 nomenclature; major hepatectomy: resection of 3 or more than 3 Couinauds segments, minor
hepatectomy; resection of less than 3 Couinauds segments. Clavien-Dindo classification was applied to define
postoperative complication [10]. The postoperative liver
dysfunction was assessed on the basis of Balzan 50–50
criteria [11].
Statistical analyses

Statistical analyses were conducted with SPSS software(version 25; SPSS, Inc., Chicago, IL) and Graph Pad
Prism (version 6.0d for Mac OS X, USA, GraphPad Software, San Diego California, USA), and were based on
nonparametric tests (Mann-Whitney’s U test). The
Chi-square or Fisher’s exact test was used to evaluatefrequencies between categorical variables.

Results
The clinical details and perioperative outcomes of thegroups are compared in Table 1. Most of the patientswere diagnosed with HCC, followed by metastatic colorectal cancer (mCRC), perihilar or intra-hepatic cholangiocellular carcinoma (CCC), gallbladder cancer (GB Ca)
and a few other lesions (hemangioma, IgG4-related cholangitis, cystic adenoma, hepatolithiasis and gastric cancer metastasis). On examining the fibrosis score, except
HCC patients, all other patients had normal tonear-normal liver parenchyma (F0 - F1). Two patients in
TB group and 4 patients in basic procedure group, with
mCRC, received chemotherapy after colon resection andprior to liver resection.
Liver resection time in TB group with major hepatectomy was significantly shorter than the patients who
underwent liver resection with basic procedure (16.7 ±8.83 vs. 62.8 ± 39.4 min; P < 0.0001). Similarly, the minorgroup who underwent liver resection with TB had also significantly shorter liver resection time than the group withbasically (8.4 ± 2.9 vs. 45.2 ± 23.9 min; P < 0.001). There
was no significant difference in terms of intraoperative
blood transfusion ratio between the groups. There was nodifference in terms of postoperative complication between
the groups; CD3a was encountered in 2 patients in TB (1bile leakage and 1 hepatico-jejunostomy failure) and 1 patient in basic procedure group (wound infection), andCD3b was encountered in 1 patient in TB (postoperative

Page 3 of 5

bleeding) and 1 patient in basic procedure group (wounddehiscence). Pringle along with IVC clamping was carriedout in 11 patients in TB group, and only 1 patient in thebasic procedure group. None of the patients in any groupdeveloped postoperative liver dysfunction. None of thecases encountered thermal injury or device-related complications in TB group. Tumor-free margin (R0) was
achieved in all cases except for one case in TB group. No
mortality was recorded in any group.

Discussion
Our data provide early evidence on the feasibility of TB
as an advance device in open liver resection for selectedcases. In this study, we reserved the use of TB in
patients, particularly with normal to near-normal liver
parenchyma, undergoing open liver resection. The commendable feature of TB observed in our study was anextensively rapid parenchyma transection time.
We have been using TB in open major or minor hepatectomy cases with HCC, perihilar CCC, T2 GB Ca,
metastatic lesions and specifically in patients with normal or near-normal liver parenchyma. Parenchyma transection time was remarkably shorter even in major
hepatectomies. In most of the cases, liver resection wascompleted with a single Pringle maneuver with or without infra-hepatic IVC clamping.
TB produces high heat compared to other energy devices (more than 200 °C compared to 100 °C for electrosurgery), thus, may not be suitable in cirrhotic, friable orsteatotic liver parenchyma where the transection becomes riskier posed by the frequent distortion or displacement of intra-hepatic vessels by the tumor.
There is still inadequate evidence for one energy device to be considered superior to the other. TB has beenfrequently compared with other common energy devices[9, 12–17]. TB was found superior to other energy devices in animal models [15]; however, none of the existing human studies have concluded its salient advantage
over the other energy devices. In a randomized controlled trial in patients undergoing laparoscopic radical
hysterectomy, TB was linked to shortened operation
time and less postoperative pain [18]. Use of TB in laparoscopic colorectal surgery has also concluded thesafety of the device [16, 17]. There is still a paucity ofevidence on its utility in liver resection. In a recent
retrospective study, Badawy et al. compared TB andultrasonic Harmonic devices in 80 patients who underwent laparoscopic liver resection and concluded that TB
is safe and effective, but not superior to ultrasonic harmonic devices [16, 17]. In this study, we compared theadvantages of the TB assisted liver resection with basic
procedure, our results indicate that compared to thebasic procedure, TB enables exceptionally rapid parenchyma transection time with no substantial difference inAryal et al. BMC Surgery (2018) 18:86

Page 4 of 5

Table 1 Comparative analysis of patients’ characteristics and perioperative variables
Variables

Resection with TB(N = 28)

Resection with basic procedure(N = 24)

P-value

73.5 (57–88)

71.0 (31–88)

0.61

0.003

Age (Years)
Median (Range)
Sex (M/F)
Male, n12

20

Female, n

16

4

HCC

12 (42.9)

8 (33.3)mCRC

6 (21.4)

5 (20.8)CCC

4 (14.2)2 (8.3)GB Ca

3 (10.7)

3 (12.5)

Others3 (10.7)

6 (25.0)97Diagnosis, n (%)
0.687

Fibrosis score (HCC)
F0 – F1, n
F2 – F4, n

1.00

3

1

2

4

0.39

Major (mean ± SD)

16.7 ± 8.8

62.8 ± 39.4

< 0.001

Range (Min- Max)

7.0–45.0

18.0–115.0

Chemotherapy prior liver resection, nTransection time (Minutes)

Transection time (Minutes)
Minor (mean ± SD)

8.3 ± 2.9

45.2 ± 23.9

Range (Min- Max)

5.5–16.0

9.0–95.0

8 (28.6)

11 (45.8)

0.19

0.003

Intraoperative blood transfusion, n (%)< 0.0001

Vascular clamping
Pringle, n

17

23Pringle + IVC, n

111

3 (7.1)2 (8.3)

1.00

0

0

NA

Postoperative complication
CD ≥ 3a, n (%)
Postoperative liver dysfunction, nM male, F female, N number, HCC hepatocellular carcinoma, mCRC metastatic colorectal carcinoma, CCC cholangiocellular carcinoma, GB Ca gall bladdercarcinoma, SD standard deviation, IVC inferior vena cava, CD Clavien- Dindo NA not applicable

complications or the transfusion ratio. In this study, thenumber of infra-hepatic IVC clamping was higher in the
TB group that is attributed to the fact that the majorityof patients in the basic resection underwent minor
resection.
From the prospect of cost containment, TB retains thecost-effective benefit, in that it equips the surgeon with
one instrument, without the aid of any other devices,
capable of any tissue dissection and sealing efficiently.
TB did not only make the dissection rapid but also offered additional benefits of reliable sealing without jeopardizing the safety and oncological clearance.
Each device used in liver resection has relative advantages and disadvantages; understanding the utility of thedevices are essential in deciding which energy source
better suits for a specific procedure [19]. Open liverresection with TB is our preliminary experience; we,therefore, do not stipulate a clear consensus for the procedure. Furthermore, this study has limitations including
a relatively small number of patients, the retrospective
design of the study and limited to the open procedure.
Clamp-crushing or CUSA-based technique in liver resection is conventional, standard and still commonlyused [6]; we also adopt the same technique during anatomical resections. In our cohort, we encountered a few
postoperative complications including a case of bile leakage in TB group; this issue also requires careful consideration in future studies. In our experience, TB appears
as an appealing device in liver transection for its rapidity, safety, and simplicity; however, the clinical benefits
and the inclusion criteria for liver resection need to bebetter clarified from a larger randomized trial.

Aryal et al. BMC Surgery (2018) 18:86

Conclusions
The specific use of TB in liver resection remains unclear,with little evidence available in literature.
Besides safety, the principal feature in using this device, and what endorses it peculiarly in liver resection,
would be the combination of rapidity and simplicity it
offers during the parenchyma transection.
Acknowledgements
We thank Miss Tomoko Matsueda, Department of Surgery, Kagoshima Medical
Center, for her kind assistance.
Funding
Dr. Bibek Aryal is a fellow of Japan society for the promotion of science (JSPS)
and his fellowship is supported by Grants-in-Aid for Scientific Research, JSPS
KAKENHI Grant Number: 16F16420 and 18F16420.
Availability of data and materials
The authors declare that data supporting the findings of this study areavailable within the article. Additional data sets generated during and/or
analysed during the current study are available from the corresponding
author on reasonable request.
Authors’ contributions
Conception and design: BA, TK, YI; acquisition of data: HY, DK, MI, KY, MK;analysis and interpretation of data: BA, TK; manuscript drafting: BA, TK; criticalrevision: TK, YI; approval for publication: TK, YI. All authors read and approved
the final manuscript.
Ethics approval and consent to participate
Ethical approval was not applicable because of the retrospective design ofthe study. Informed consent for surgery was obtained in a written documentfrom all individual participants included in the study.

Page 5 of 5

6.
7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.
Consent for publication
Not applicable.
18.
Competing interests
The authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.
Author details
1
Department of Surgery, Kagoshima Medical Center, National Hospital
Organization, 8-1 Shiroyamacho, Kagoshima-shi, Kagoshima 892-0853, Japan.
2
Cardiovascular and Gastroenterological Surgery, Graduate School of Medical
and Dental Sciences, Kagoshima University, Kagoshima, Japan.
Received: 10 July 2018 Accepted: 5 October 2018

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