Glissonean Pedicle Transection Method Research Articles

Dorsal approach in laparoscopic extended left hemi-hepatectomy: A case series.

The utility of the dorsal approach has been reported for laparoscopic left hemi-hepatectomy. The aim of the present study is to show the usefulness of the dorsal approach for laparoscopic extended left-hemi-hepatectomy while ensuring safe identification of hepatic veins and dissection of the dorsal tumor margin. Tumors requiring extended left hemi-hepatectomy. After mobilization of the lateral sector and division of the Arantius plate, parenchyma above the Arantius plate is removed to expose the root of the middle hepatic vein and left hepatic vein. Each of these veins can be isolated separately either intra- or extra-hepatically. After removing the parenchyma on the cranial side of the left Glissonean pedicle continuous with the exposed hepatic veins, the left Glissonean pedicle is isolated using the Glissonean pedicle transection method. After division of the left hepatic vein and Glissonean pedicle, segment 4 (in which the main part of the tumor is commonly located) is dissected from the anterior plane of the paracaval portion of the caudate lobe by the dorsal approach, along with the hepatic hilum. Following dissection of the dorsal side of the tumor, and division of parenchyma from the anterior edge of the liver, the anterior Glissonean branches and middle hepatic vein are divided safely and the specimen is resected. Three patients underwent laparoscopic extended left hemi-hepatectomy, with no open conversions. Operative time and blood loss were 331 (concomitant with another partial hepatectomy), 277, and 315 minutes; and 200, 100, and 100 g, respectively. The postoperative courses were uneventful. The dorsal approach maximizes the advantages of laparoscopic extended left hemi-hepatectomy and can be performed safely.

Hepatectomy using a combination of extrafascial extrahepatic (Takasaki approach) and extrafascial intrahepatic pedicle approaches (Ton That Tung approach).

Selective pedicle control and anatomical liver resection are considered standard techniques in hepatectomy for hepatocellular carcinoma. In 1963, Ton That Tung made significant improvements in hepatectomy techniques with the principle of locating and ligation of Glissonean pedicle in the liver parenchyma based on precise knowledge of vascular and biliary anatomy (Tung TT, Quang ND. A new technique for operating on the liver. Lancet 1963;281:192–3). In 1986, the extrafascial Glissonean dissection was first introduced by Takasaki in 1986. This is a simple and safe technique that helps to identify the exact borders between liver sections for anatomic liver resection (Takasaki K. Glissonean pedicle transection method for hepatic resection: a new concept of liver segmentation. J Hepatobiliary Pancreat Surg 1998;5:286–91). The combination of two techniques helps minimize complications, reduce ischemic time of future liver remnant, intraoperative blood loss and avoid migration of cancer cells into other segments.

Surgical impact of an inferior right hepatic vein on right anterior sectionectomy and right posterior sectionectomy

In hepatocellular carcinoma, anatomical resection is important because of portal spread. In right anterior sectionectomy (RAS) and right posterior sectionectomy (RPS), the right hepatic vein (RHV) may not correspond with the intersectional plane if an inferior RHV (IRHV) is present. The aim of this study was to evaluate the influence of the IRHV on the exposure of the RHV retrospectively. One hundred ninety-one patients underwent RAS or RPS by the Glissonean pedicle transection method. The calibres of the RHV and IRHV were measured and assessed the extent of exposure of RHV. One hundred seventeen patients underwent RAS and 74 underwent RPS. The calibre of the RHV averaged 8.0 mm and that of the IRHV, 6.2 mm. Exposure of the RHV was divided into three groups: no exposure 31 (16.2%) (with IRHV, 20 patients; without IRHV, 11 patients), upper half exposure 49 (25.7%; with IRHV, 24; without IRHV, 25) and full exposure 111 (58.1%) (with IRHV, 16; without IRHV, 95). The effect of the IRHV on exposure of the RHV was substantial (P < 0.001). The IRHV can affect the course of the RHV and its exposure. Therefore, in RAS and RPS, it is important to evaluate the existence of the IRHV.

Hepatic resection using a liver-hanging maneuver and Glissonean pedicle transection for hepatocellular carcinoma in a patient with situs inversus totalis: report of a case

Situs inversus totalis is a rare congenital anomaly in which the major abdominal organs are located as a mirror image of their normal positions. This poses much difficulty for surgeons. We describe how we performed the liver-hanging maneuver (LHM) for hepatocellular carcinoma (HCC) in a 59-year-old man with situs inversus totalis, to resolve the difficulty of the mirror-image location of his liver. The HCC was located in the right lateral sector. Although segmentectomy of segment 7 would normally be considered minimal for a curative treatment of HCC, this was relatively complicated in this patient. Thus, we performed an extended right lateral sectionectomy using the LHM to achieve a simple transection. The hepatic hilum was dissected using the Glissonean pedicle transection method. The operation time and intraoperative blood loss were 6 h 45 min and 471 ml, respectively. No blood product transfusion was required. The LHM and the hilar Glissonean pedicle approach proved effective for resolving the difficulties of performing surgery in a mirror image for HCC in a patient with situs inversus totalis.

Curative Resection of Hepatocellualr Carcinoma Using Modified Glissonean Pedicle Transection versus the Pringle Maneuver: A Case Control Study

Objective: The Glissonean pedicle transection method of liver resection has been found to shorten operative time and minimize intraoperative bleeding during liver segmentectomy. We have compared the feasibility, effectiveness, and safety of the Glissonean pedicle transection method with the Pringle maneuver in patients undergoing selective curative resection of large hepatocellualr carcinoma (HCC).Methods: Eligible patients with large (> 5 cm) nodular HCC (n = 50) were assigned to undergo curative hepatectomy using the Glissonean pedicle transection method (n = 25) or the Pringle maneuver (n = 25). Partial interruption of the infrahepatic inferior vena cava was incorporated to further reduce bleeding from liver transection. The primary outcome measure was postoperative changes in liver function from baseline. Secondary outcomes included operating time, volume of intraoperative blood loss/transfusion, and time to resolution of ascites.Results: The two groups were comparable in age, sex, site and size of the liver tumor, segment or lobe intended to be resected, and liver function reserve, and the results were not significant statistically. All patients underwent successful major hepatectomies using the assigned method, with the extent of major hepatectomy comparable in the two groups (P = 0.832). The Glissonean approach was associated with shorter hepatic inflow interruption (30.0 ± 12.0 min vs. 45.0 ± 13.0 min, P < 0.001), lower volume of blood loss (145.0 ± 20.0 mL vs. 298.0 ± 109.0 mL, P < 0.001), reduced requirement for transfusion (0.0 ± 0.0 mL vs. 200.0 ± 109.0 mL, P < 0.0001), and more rapid resolution of ascites (9.5 ± 1.2 d vs. 15.3 ± 2.4 d, P < 0.001). Postoperative liver function measures were comparable in the two groups, and the results were not significant statistically.Conclusion: The Glissonean pedicle transection method is a feasible, effective, and safe technique for hepatic inflow control during the curative resection of large nodular HCCs.

Glissonean pedicle transection method for liver surgery (with video)

The Glissonean pedicle approach in liver surgery provides new knowledge of the surgical anatomy of the liver and advances the technique of liver surgery. The Glissonean pedicles are wrapped by a connective tissue referred to as the Glisson’s capsule and include the hepatic artery, portal vein and bile duct. The Glissonean pedicles can be approached intrahepatically or extrahepatically. The extrahepatic approach at the hepatic hilus was referred to as the extra-fascial access by Couinaud. In summary, the secondary Glissonean pedicles are encircled and ligated at the hepatic hilus without liver dissection. The angle of approach should be over the hilar plate so that the surgeon does not have to consider any variations in the arteries or bile ducts. The tertiary branches can be approached through the hepatic hilus extrahepatically or intrahepatically on the border between the sections which are fed by the secondary Glissonean pedicles. This procedure is suitable for liver cancer without hilar invasion, particularly for hepatocellular carcinoma (HCC). Patients with HCC usually have liver dysfunction and HCC easily invades the peripheral portal vein; therefore, patients with HCC should only undergo small anatomical hepatectomies such as sectionectomy or segmentectomy. Any anatomical hepatectomy can be performed using this technique which allows simple, safe and easy liver resection. Liver surgeons should, therefore, know the fundamental concept of the Glissonean pedicle transection method.Electronic supplementary materialThe online version of this article (doi:10.1007/s00534-011-0443-0) contains supplementary material, which is available to authorized users.

Right hepatectomy using Glissonean pedicle transection method with anterior approach (with video).

Right hepatectomy for hepatocellular carcinoma is the most common major operation in liver surgery; therefore, liver surgeons should know the fundamental surgical concept and techniques of the Glissonean pedicle approach. A J-shaped or reversed T laparotomy is performed in the right subcostal area. The Glissonean pedicle approach is performed at the hepatic hilus. In this approach, the right anterior and posterior Glissonean pedicles are encircled and ligated without liver dissection. The right hepatic artery, right portal vein and right hepatic duct in the hepatoduodenal ligament should be divided if the Glissonean pedicles cannot be approached easily. After confirming the border between the right and left liver, the liver parenchyma is dissected from the anterior surface of the liver to the anterior surface of the inferior vena cava (IVC). The V5 and V8 middle hepatic veins are divided and liver dissection is performed along the main middle hepatic vein. Finally, the anterior surface of the IVC and the trunk of the right hepatic vein are identified in the liver. This approach is widely known as the anterior approach described by Lai and Fan (World J Surg 20:314–8, 1996). However, this procedure had already been reported by Takasaki et al. (Shoukakigeka 7:1545–51, 1984) but since they did not report this procedure in English, their pioneering work on the anterior approach has not been recognized. The liver hanging maneuver described by Belghiti et al. (J Am Coll Surg 193:109–111, 2001) is also useful in right hepatectomy. Among the techniques used in right hepatectomy, the Glissonean pedicle approach, the anterior approach and the liver hanging maneuver are considered to be the most important.Electronic supplementary materialThe online version of this article (doi:10.1007/s00534-011-0445-y) contains supplementary material, which is available to authorized users.

Surgical Treatment of Giant Hepatic Hemangiomas: Technical Point of View

Hepatic hemangiomas are the most common benign tumors of the liver. Surgical treatment can be difficult as a result of the high risk of intraoperative hemorrhage. The present study reviewed clinical features of patients with hepatic hemangioma and surgical techniques used in their treatment. Eight patients with giant hepatic hemangiomas underwent hepatectomies at the Asan Medial Center between January 2006 and March 2009. Patient demographic, clinical, and surgical characteristics and outcomes were reviewed retrospectively. Seven females and one male patient underwent hepatectomies during the study period. The median age was 48.5 years (range, 33 to 58 years). Indications for surgical interventions were abdominal pain (62.5%), an abdominal mass (37.5%), Kasabach-Merritt syndrome (25%), and increased hemangioma size (25%). The hemangiomas were usually multiple (87.5%) and bilobar (75%) and had a median size of 14.5 cm (range, 7 to 29 cm). All patients underwent major hepatic resection with early vascular control using the Glissonean pedicle transection method (GPTM), the liver hanging maneuver (LHM), and preparation for total vascular exclusion (TVE). There was no major morbidity or mortality. The minor morbidity rate was 25 per cent with transfusion rate of 37.5 per cent. Early vascular control using the GPTM, the LHM, and preparation for TVE is essential for safe resection of large hepatic hemangiomas.

Three-dimensional CT angiography for preoperative evaluation of patients undergoing hepatic resection using the Glissonean pedicle transection method

Three-dimensional CT angiography for preoperative evaluation of patients undergoing hepatic resection using the Glissonean pedicle transection method

Glissonean pedicle transection method for hepatic resection: a new concept of liver segmentation.

A new concept of hepatic segmentation along with the Glissonean pedicle tree, and the basis of hepatic resection by the Glissonean pedicle transection method are presented. The portal triad continues from the hepato-duodenal ligament to the intra-hepatic portion as the Glissonean pedicle. That is, the artery, portal vein and bile duct, together with connective tissue, are sheathed by the peritoneum to form a fibroid bundle. The entire length of the primary branches of the Glissonean pedicle and the origin of the secondary branches are located outside the liver and the trunks of the secondary and more peripheral branches run inside the liver. The ramification pattern of the tertiary branches which branch out from each secondary branch is different from patient to patient. The liver is nourished by the secondary branches of the Glissonean pedicle. Each secondary branch feeds one segment. The liver can thus be separated into three segments and an additional caudate area. The area fed by each one of the tertiary branches is cone-shaped; fermed a "cone unit". Each segment conists of six to eight cone units. In limited resections, the number of cone units to be respected is adjusted and the tertiary branches which feed these areas must be transected selectively through a hilar or a parenchymal approach. To date we have experienced no complications with this procedure, employed for 832 patients with hepatocellular carcinoma.