The posterior intrahepatic approach to liver resection

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Background Hepatic resectional surgery has rapidly evolved since the realisation of the segmental anatomy of the liver and the intrahepatic distribution of the portal trinity (the hepatic artery, hepatic duct and portal vein). This portal trinity is enveloped by a sheath, derived from Glisson's capsule. In the classical intrafascial or extrahepatic approach, the appropriate branch of the portal vein, hepatic artery and the hepatic duct is isolated outside the liver substance, whereas in the extrafascial approach the whole sheath of the pedicle is dissected, after division of a substantial amount of hepatic tissue. In the transfissural or intrahepatic approach, these sheaths can be approached either anteriorly (after division of the main, right or umbilical fissure) or posteriorly, from behind the porta hepatis, through the distal fissure. Methods We describe the technique of the intrahepatic posterior approach to the glissonian sheath, with its contained hepatic pedicle structures and branches. Results This technique allows early delineation of a liver segment, without the need for ancillary manoeuvres. Discussion The indications for the use of this technique in an oncological setting are also discussed.