‘Inside-Out’ Transection: Simple and Safe Way of Laparoscopic Anatomical Liver Resection

Abstract

Introduction: In open anatomical liver resection, liver parenchymal transection from the peripheral part to the hilum because of restricted surgical view. Confirmation of transection line as a demarcation line using dye-injection method or extrahepatic glissonian approach, Modification of disorientation during liver parenchymal transection by intraoperative ultrasonography are too complicated and technical-demanding procedures for laparoscopic approach. Theoretically considering the directions of branched Glissonian pedicles and hepatic veins, parenchymal transection should be done from the hilum to the the peripheral, in other words, ‘inside-out’. We recently perform laparoscopic anatomical ‘inside-out’ liver resection utilizing laparoscopic caudal view. Methods: Anatomical resection starts from parenchymal transection around the root of the corresponding Glissonian pedicle and a tip of CUSA is moved inside-out to the direction with low resistance between the glissonian pedicles, which leads to the right intersegmental plane. The direction of transection can also be corrected by visually checking the ramification of branched Glissonian pedicles that are clearly recognizable in laparoscopic view. The corresponding Glissonian pedicle is dissected on the way of paremchymal transection when surgical space is made for safe procesures. ‘Inside-out’ transection also prevents from bleeding from the root of branched hepatic veins and enables to keep a good surgical view and tension on the dissection point. Liver peripheral parenchyma is dissected in the end. The process of laparoscopic anatomical ‘inside-out’ liver resection is so simple because all procesures is completed on one direction way. Conclusions: Laparoscopic anatomical ‘inside-out’ liver resection is simple and safe utilizing the advantages of laparoscopic approach.