Tailored Strategy for Dissecting the Glissonean Pedicle in Laparoscopic Right Posterior Sectionectomy: Extrahepatic, Intrahepatic, and Transfissural Glissonean Approaches (with Video).

Abstract

Selective inflow control of the liver is important to identify the ischemic transection boundary and reduce blood loss during liver resection. The Glissonean approach is a widely used inflow control method that can be divided into three types: extrahepatic, intrahepatic, and transfissural Glissonean approaches. This report describes the tailored strategy and technical details of the three Glissonean approaches in laparoscopic right posterior sectionectomy. Based on the ramification type of the right posterior Glissonean pedicle (RPGP), anatomical variation, and technical feasibility, the particular Glissonean approach was selected. Extrahepatic Glissonean approach: The entering gap between the Glissonean pedicle and Laennec's capsule was entered. Without liver parenchymal transection, the RPGP was dissected extrahepatically. Intrahepatic Glissonean approach: The parenchymal transection between the right side of the cystic plate and Rouviere's sulcus was dissected. With minor parenchymal transection, the RPGP was dissected intrahepatically. Transfissural Glissonean approach: Parenchymal transection along the right portal fissure was performed. With major parenchymal transection along the right portal fissure, the RPGP was dissected transparenchymally. Eighteen patients underwent laparoscopic right posterior sectionectomy (lap-RPS) using the Glissonean approach: extrahepatic (n = 11), intrahepatic (n = 5), and transfissural (n = 2) Glissonean approaches. The median operation time was 270min (range, 190-310min), and the median estimated blood loss was 130mL (range, 30-700mL). Postoperative morbidity occurred in three patients (16.7%). There were no deaths. The feasibility and safety of the Glissonean approach in lap-RPS could be increased through appropriate selection of extrahepatic, intrahepatic, and transfissural Glissonean approaches.