Intrahepatic Glissonian Approach for Laparoscopic Right Trisectionectomy

Abstract

A 22-year-old woman with a giant angiomyolipoma was referred for surgical treatment. The patient was placedin aleft semilateral decubitus position with the surgeon between the patient’s legs. Five trocars (three 12 and two 5mm) were used. The pneumoperitoneum is established at a pressure of 12mm Hg. Round and falciform ligaments are taken down close to the abdominal wall in order to facilitate left-liver fixation at the end of the procedure. The falciform and coronary ligaments are divided by using laparoscopic coagulation shears (Harmonic Scalpel LCS; Ethicon Endo-Surgery Industries, Cincinnati, OH)toexpose thesuprahepaticinferiorvenacava. After cholecystectomy, the right hepatic artery is ligated, resulting in an ischemic delineation of the right liver. Due to previous right-portal-vein embolization in this patient, the hepatic pedicle was not fully dissected. The right liver is then fully mobilized, and the inferior vena cava is dissected. A large inferior right hepatic vein arising from segment 6 is ligated and divided between metallic clips. Another accessory right hepatic vein from segment 7 (middle-right hepatic vein) is divided with a vascular endoscopic stapler. The right hepatic vein is finally encircled, and downward retraction permits the safe application of a vascular endoscopic stapler. The stapler is fired, leaving three lines of metallic clips. With this maneuver, the anterior surface of the retrohepatic vena cava is completely exposed. The main trunk, including the middle and left hepatic veins, is now the only venous drainage of the liver. It is encircled and traction or temporary clamping permits complete outflow control of the liver, minimizing bleeding during liver transection. At this time, the intrahepatic access to the main right Glissonian pedicle is achieved with two small incisions: An incision is performed on the right portion of the caudate lobe and another anterior incisionismadeinfrontofthehilum.Anendoscopicvascular