In addition to conventional major or minor classification in liver resection (LR), recently, a complexity classification with 3 categories (low, medium, or high) according to its technical difficulty was proposed and validated. We describe the technique and the outcomes of high complexity major LR by Thunderbeat® (TB) as a sole device with the Pringle maneuver and infra-hepatic inferior vena cava (IVC) clamping. Of 95 patients undergoing LR between July 2013 and September 2020 at our institution, we reviewed eight (8.4%) patients who underwent this procedure. Following the Pringle maneuver and infra-hepatic IVC clamping, the transection of the liver parenchyma was started with TB. During parenchymal transection, only the pedicles equal or larger than 3rd branches of Glissonean pedicles or main branches of major hepatic veins were ligated and divided, the other smaller ones were generally sealed with TB. Eight patients underwent extended right hepatectomy with hepaticojejunostomy (n = 4), anatomical middle hepatectomy (n = 2), and right trisectionectomy (n = 1) or extended left hepatectomy (n = 1) with IVC resection and reconstruction. The parenchymal transection time (PTT) [median (range)] was 18 (13-45) min. The surgical blood loss (SBL) [median (range)] was 1,685 (540-2,730) mL. Two patients experienced postoperative major complications (Clavien-Dindo classification IIIa: n = 1, IIIb: n = 1). There was no in-hospital mortality. Seven patients are currently alive without recurrence with a median follow-up of 26 months. In conclusion. TB with the Pringle maneuver and infra-hepatic IVC clamping is feasible and seems to offer the combination of rapidity, simplicity, and safety during high complexity major LR.

Dr. Komokata, MD, PhD, is currently a chief director in the Department of
Surgery, National Hospital Organization Kagoshima Medical Center. He is also a clinical
professor at Kagoshima University School of Medicine. He had a fellowship training in
Liver/GI transplant unit, Miami University School of Medicine, USA from 2000 to 2001.
His membership and certification are Japan Surgical Society (JSS) Board Certified Instructor
(2003-present), the Japanese Society of Gastroenterological Surgery (JSGS) Board Certified
Instructor in Gastroenterology (2003-present), Japanese Society of Hepato-Biliary-Pancreatic
Surgery (JSHBPS) Board Certified Instructor in HBP surgery (2008-present), Japanese
Society for Endoscopic Surgery Endoscopic surgical skill qualification system: qualified
surgeon (2015-present), International Hepato-Pancreato-Biliary Association (2015-present),
and American College of Surgeons (2019-present).