Glissonian Approach Research Articles

Robotic Left Hepatectomy Using the Glissonean Approach and Saline-Linked Bipolar Clamp-Crush Technique.

We have previously reported a saline-linked bipolar clamp-crush technique as a novel robotic liver resection method. Herein, we present the surgical techniques and outcomes of robotic left hepatectomy using the Glissonean approach and our liver transection technique. The key procedures included the following: (1) encircling the left Glissonean pedicle using the Tip-Up fenestrated grasper, (2) dissecting the liver parenchyma using the saline-linked bipolar clamp-crush technique, (3) moving the endoscope one trocar to the right to facilitate visualisation of the liver transection plane, and (4) stapling the left pedicle and left hepatic vein. Seven robotic left hepatectomies were performed. The median operative time and estimated blood loss were 395min and 50mL, respectively. The median length of postoperative hospital stay was 9days. Pneumothorax was the only severe postoperative complication. Robotics left hepatectomy using the Glissonean approach and the saline-linked bipolar clamp-crush technique appears safe and feasible.

The Taping Game for the Complex G8 Glissonean Approach Is the Most Effective Technique for Laparoscopic Anatomic S8 Resection of Dandelion-Patterned Hepatic Pedicles.

Laparoscopic anatomic segment 8 resection (LAR-S8) remains a technical challenge due to the special location of S8 and the complex classification of the Glissonean pedicle of S8 (G8). Particularly for situations in which multiple grade 4 hepatic pedicles branch out from the same point at 360° in a dandelion pattern from the right anterior hepatic pedicle, effective methods for accurately locating the target G8 and the intersegmental plane between S8 and the adjacent hepatic segment remain lacking. This report describes a LAR-S8 guided by the indocyanine green (ICG) negative-staining method using the "taping game for complex G8 Glissonean approach" in a patient with a typical dandelion-patterned G8. The operative time was 150min, with a blood loss of 50mL and no complications. The patient was discharged 5 days postoperatively. Regular follow-up evaluation during 24 months showed no recurrence. The taping game is an effective method for S8 resection, especially for patients with complex G8 patterns such as the dandelion pattern.

P.372: Glissonean approach and parenchymal dissection with water jet scalpel for liver transplantation living donor.

P.372: Glissonean approach and parenchymal dissection with water jet scalpel for liver transplantation living donor.

Minimally Invasive Left Hepatectomy: Choosing the Suitable Surgical Strategy.

Numerous surgical techniques are currently available for minimally invasive left hepatic resection, each offering its own advantages and disadvantages. This multimedia manuscript delves into the primary approaches for minimally invasive left hepatectomy, with a focus on particular topics such as left hepatic vein approach, transection and middle hepatic vein exposure, and Glissonean approach. We examine key factors that surgeons should consider when choosing among these methods and provide practical recommendations. To enhance understanding, our article includes video footage from multiple centres, showcasing expertly executed surgeries for each approach along with their main considerations. This multimedia resource will serve as a valuable guide for surgeons, aiding in the selection of the most suitable strategy for minimally invasive left hepatectomies, tailored to the specific needs of the patient and the characteristics of the lesion.

ASO Author Reflections: Toward New Minimal AccessAnatomical Liver Resections: From Glissonean Approach to Compression Technique.

ASO Author Reflections: Toward New Minimal AccessAnatomical Liver Resections: From Glissonean Approach to Compression Technique.

Evaluation of ventral branches of segment VI portal vein relative to the right hepatic vein in laparoscopic right anterior sectionectomy.

The right intersectional plane and the right hepatic hilum were noted too often exhibit anatomical variations, making difficult the laparoscopic right anterior sectionectomy (LRAS). We analyzed the anatomical features employing 3D-CT images of 55 patients, and evaluated these features according to the course of ventral branches of segment VI of the portal vein (PV, P6a) relative to the right hepatic vein (RHV). P6a run on the dorsal side of RHV in 32 patients (58%, Dorsal-P6a) and the ventral side of RHV in 23 (42%, Ventral-P6a). Ventral-P6a had more patients with S6 partially drained by middle hepatic vein (MHV, 39% vs. 0%, P < 0001), the narrower angle between the anterior and posterior branches of PV (73.1° vs. 93.8°, P = 0.006), the wider angle between the RHV and inferior vena cava (54.3° vs. 44.3°, P < 0.001), and more steeply pitched angle between S6 and S7 along the RHV (140.6° vs. 162.0°, P < 0.001) compared to Dorsal-P6a. In LRAS for Dorsal-P6a patients, the transection surface was relatively flat. In LRAS for Ventral-P6a patients, the narrow space between anterior and posterior glissons makes difficult the glissonean approach. The transection plane was steeply pitched, and RHV was partially exposed. S6 was often partially drained to MHV in 39% of the Ventral-P6a patients, which triggers congestion during liver transection of a right intersectional plane after first splitting the confluence of this branch.

Right anatomical hepatectomy using extrahepatic glissonean pedicle approach combined liver hanging for hepatocellular carcinoma: Surgical approach in a developing country

Backgrounds/Aims: To evaluate the outcomes of hepatocellular carcinoma (HCC) patients who underwent right anatomical hepatectomy using the combination of the extrahepatic Glissonean pedicle approach (Takasaki’s technique) and liver hanging maneuver (LHM) (Belghiti’s technique). Patients and Methods: A retrospective analysis of 30 cases of HCC treated with right hepatectomy using extrahepatic Glissonean pedicle approach and liver hanging maneuver by only one surgeon at our department from March 2020 to August 2023. Clinical characteristics, pathological results, postoperative outcomes, and survival rate were analyzed. Results: Among the 30 HCC patients analyzed, males accounted for 96.7% of patients. The mean age was 54.9 ± 11 years. 96.7% had normal preoperative liver function (Child-Pugh A). LHM with an extrahepatic Glissonean approach was feasible in 100% of cases with minor blood loss, no blood transfusion, intraoperative complications, or perioperative mortality. The mean operative time was 123.8 ± 29.0 minutes. The mean hospital stay was 9.37 ± 4.02 days. Postoperative liver failure accounted for 6.7%. Pathological results: 63.3% moderately differentiated HCC; 36.7% poorly differentiated HCC. 1-, 2- and 3-year survival rates were 86.1%, 73.8% and 59.0%, respectively. Recurrence was witnessed in 13 (43.3%) cases, with 6 (20%) cases in remnant liver. 1-, 2-, and 3-year disease-free survival were 69.3%, 42.0%, and 28.0% respectively. Conclusion: Right anatomical hepatectomy using extrahepatic Glissonean pedicle approach combined LHM for hepatocellular carcinoma was feasible and safe at our high-volume oncology center in a developing country.

ICG-Enhanced Compression Anatomical Segment 7 Segmentectomy in Laparoscopic and Robotic Approach.

Minimally invasive anatomical resection (AR) for posterosuperior lesions is technically challenging.1,2 The Glissonean approach or puncture technique is generally selected.3,4 The tumor-feeding portal pedicle compression AR (C-AR) is an established procedure in open surgery.5 This technique has benefited from the association with indocyanine green (ICG) fluorescence, used to enhance the anatomical area to be resected.6 Recently, C-AR via the minimal access approach has been reported.7 Herein, we report the first cases of laparoscopic and robotic segment 7 (S7) segmentectomy using the ICG-enhanced compression technique. Two cases of CHILD-class A hepatocellular carcinoma (HCC) in segment 7 with a liver stiffness less than 7 kPa treated by laparoscopic and robotic anatomical S7 segmentectomies were reported. Using the intraoperative ultrasound (IOUS), the tumor-bearing portal pedicle and the level targeted for compression were identified. The right hemiliver was adequately mobilized to allow handling of the organ during dissection. Using the grasper and the probe itself, the S7 Glissonean pedicle was transparenchymally compressed under real-time IOUS control. To further enhance the visibility of the discolored S7, ICG was administered intravenously, obtaining the compressed area to be resected as a non-stained one. Dissection was performed under intermittent Pringle maneuver up to exposing the right hepatic vein, dividing the Glissonean pedicle to segment 7 and then completing the resection. Pathologic findings demonstrated a 4.9 cm and 7.3 cm HCC with a R0-resection margin (> 1 cm in both). Postoperative complications were nil. The patients were discharged 6 days after surgery. This preliminary experience shows that the C-AR is a feasible and reliable technique in laparoscopic and robotic approach for posterosuperior lesions. Further studies are needed to investigate its applicability and standardization.

ASO Author Reflections: How to Perform a Laparoscopic Right Anterior Sectionectomy with a Combination of a Transparenchymal Glissonean Approach and Indocyanine Green Fluorescence Imaging.

ASO Author Reflections: How to Perform a Laparoscopic Right Anterior Sectionectomy with a Combination of a Transparenchymal Glissonean Approach and Indocyanine Green Fluorescence Imaging.

ASO Author Reflections: How to Perform a Laparoscopic Right Posterior Sectionectomy with Glissonean Approach and Modified Hanging Maneuver, Guided by Indocyanine Green Fluorescence Imaging.

ASO Author Reflections: How to Perform a Laparoscopic Right Posterior Sectionectomy with Glissonean Approach and Modified Hanging Maneuver, Guided by Indocyanine Green Fluorescence Imaging.

Impact of Minimally Invasive Surgery on Anatomic Liver Segmentectomy Using the Extrahepatic Glissonean Approach.

Accurate minimally invasive anatomic liver (sub)segmentectomy (MIAS) is technically demanding and not yet standardized, and its surgical outcomes are undefined. To study the impact of the minimally invasive approach on perioperative outcomes of anatomic liver (sub)segmentectomy (AS), we retrospectively studied and compared perioperative outcomes of 99 open AS (OAS) and 112 MIAS (laparoscopic 77, robotic 35) cases using the extrahepatic Glissonean approach, based on the 1:1 propensity score matched analyses. After matching (71:71), MIAS was superior to OAS in terms of blood loss (p < 0.0001), maximum postoperative serum total bilirubin (p < 0.0001), C-reactive protein (p = 0.034) levels, R0 resection rate (p = 0.021), bile leak (p = 0.049), and length of hospital stay (p < 0.0001). The matched robotic and laparoscopic AS groups (30:30) had comparable outcomes in terms of operative time, blood loss, transfusion, open conversion, postoperative morbidity and mortality, R0 resection, and hospital stay, although the rate of Pringle maneuver application (p = 0.0002) and the postoperative aspartate aminotransferase level (p = 0.002) were higher in the robotic group. Comparing the matched posterosuperior (sub)segmentectomy cases or unmatched repeat hepatectomy cases between MIAS and OAS, we observed significantly less blood loss and shorter hospital stays in MIAS. Robotic AS yielded comparable outcomes with laparoscopic AS in the posterosuperior (sub)segmentectomy and repeat hepatectomy settings, despite the worse tumor and procedural backgrounds in robotic AS. In conclusion, various types of MIAS standardized by the extrahepatic Glissonean approach were feasible and safe with more favorable perioperative outcomes than those of OAS. Although robotic AS had almost comparable outcomes with laparoscopic AS, robotics may serve to decrease the surgical difficulty of MIAS in selected patients undergoing posterosuperior (sub)segmentectomy and repeat hepatectomy.

Anatomical liver resection using the ultrasound-guided compression technique in minimal access surgery.

Segmental or subsegmental anatomical resection (AR) of hepatocellular carcinoma (HCC) in minimal access liver surgery (MALS) has been technically proposed. The Glissonean approach or dye injection technique are generally adopted. The tumor-feeding portal pedicle compression technique (C-AR) is an established approach in open surgery, but its feasibility in the MALS environment has never been described. Eligible patients were prospectively enrolled to undergo laparoscopic or robotic ultrasound-guided C-AR based on HCC location and preoperative identification of a single tumor-feeding portal pedicle. Initial C-AR experience was gained with laparoscopic cases in the beginning of 2020. Following our progressive experience in laparoscopic C-AR, patients requiring AR for HCC were consecutively selected for robotic C-AR. A total of 10 patients underwent minimal access C-AR. All patients had Child-Pugh A HCC. The surgical procedures included 6 laparoscopic and 4 robotic C-AR. Median tumor size was 3.1cm (range 2-7cm). All procedures had R0 margin. Postoperative complications were nil. C-AR technique is a feasible and promising technique for patients eligible for laparoscopic and robotic AR for HCC. Further data are necessary to validate its applicability to more complex minimal access AR.

Glissonian Approach to Tertiary Pedicles in the Right Hemiliver

Glissonian Approach to Tertiary Pedicles in the Right Hemiliver

Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique.

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver resections, including less blood loss, reduced wound pain, and shorter hospital stays with a comparable oncological outcome. However, laparoscopic resection of lesions in the right posterior section of the liver is challenging due to difficulties in bleeding control and visualizing the surgical field. In the past, laparoscopic right posterior sectionectomy (LRPS) was still in the exploration phase, with undefined risks in the Second International Consensus Conference on LLR in 2014. However, recent technological advancements and increased surgical experience have shown that LRPS can be safe and feasible. It has been found to reduce hospital stay and blood loss compared to open surgery. This manuscript aims to provide a detailed description of the steps involved in LRPS. The key factors contributing to our success in this challenging procedure include proper liver retraction and exposure, the use of an intrahepatic Glissonian approach for inflow control, a technique called the 'ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)' for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy.

Laparoscopic anatomical liver resection of Segment 8 with Glissonean approach and ICG-guided negative counterstaining

Laparoscopic anatomical liver resection of Segment 8 with Glissonean approach and ICG-guided negative counterstaining

A novel Laennec's capsule tunnel approach for pure laparoscopic left hemihepatectomy: a propensity score matching study.

With the development of laparoscopic hepatectomy, there are different surgical approaches and pedicle anatomical methods for laparoscopic left hepatectomy. Combined with our practical experience, we proposed a method of transhepatic Laennec membrane tunnel for laparoscopic left hemihepatectomy (LT-LLH) and investigated the feasibility by comparison with the extrahepatic Glissonian approach for laparoscopic left hemihepatectomy (GA-LLH). The data of patients who underwent laparoscopic left hepatectomy in the Department of Hepatobiliary Pancreatic surgery of Fujian Provincial Hospital from December 2019 to March 2022 were analyzed retrospectively. Among them, 45 cases underwent laparoscopic left hemihepatectomy with an extrahepatic Glissonian approach, and 38 cases underwent laparoscopic left hemihepatectomy via transhepatic Laennec membrane tunnel approach. A 1:1 propensity score matching (PSM) method was performed to compare the perioperative indexes and long-term tumor prognosis between the two groups. After 1:1 PSM, 33 patients in each group were selected for further analysis. Compared with the GA-LLH group, the operation time of the LT-LLH group was shorter. There was no significant difference in the incidence of total complications between the two groups. Moreover, no statistical differences were found in disease-free survival and overall survival between the two groups. It is safe, faster, and convenient for selective appropriate cases to carry out laparoscopic left hemihepatectomy through the hepatic Laennec membrane tunnel, which is suitable for clinical promotion.

Intrahepatic Glissonean Approach for Robotic Anatomical Liver Resection of Segment 7 Using the Saline-Linked Monopolar Cautery Scissors (SLiC-Scissors) Method: A Technical Case Report With Videos.

Anatomical hepatectomy of segment 7 (S7) is technically difficult due to its difficult accessibility. Here, we present our experience of robotic anatomical S7 subsectionectomy of the liver employing the saline-linked cauteryscissors (SLiC-Scissors) technique. After the right lobe was fully mobilized, dissection of the Glissonean pedicle and hepatic venous branch of S7, as well as the liver parenchymal transection, were safely performed using the SLiC-Scissors method. Despite its technological complexity, the intrahepatic Glissonean approach for robotic anatomical S7 subsectionectomy of the liver employing the SLiC scissors method is safe and efficient.

Minimally Invasive Anatomic Liver Resection for Hepatocellular Carcinoma Using the Extrahepatic Glissonian Approach: Surgical Techniques and Comparison of Outcomes with the Open Approach and between the Laparoscopic and Robotic Approaches.

Surgical techniques and outcomes of minimally invasive anatomic liver resection (AR) using the extrahepatic Glissonian approach for hepatocellular carcinoma (HCC) are undefined. In 327 HCC cases undergoing 185 open (OAR) and 142 minimally invasive (MIAR; 102 laparoscopic and 40 robotic) ARs, perioperative and long-term outcomes were compared between the approaches, using propensity score matching. After matching (91:91), compared to OAR, MIAR was significantly associated with longer operative time (643 vs. 579 min, p = 0.028); less blood loss (274 vs. 955 g, p < 0.0001); a lower transfusion rate (17.6% vs. 47.3%, p < 0.0001); lower rates of major 90-day morbidity (4.4% vs. 20.9%, p = 0.0008), bile leak or collection (1.1% vs. 11.0%, p = 0.005), and 90-day mortality (0% vs. 4.4%, p = 0.043); and shorter hospital stay (15 vs. 29 days, p < 0.0001). On the other hand, laparoscopic and robotic AR cohorts after matching (31:31) had comparable perioperative outcomes. Overall and recurrence-free survivals after AR for newly developed HCC were comparable between OAR and MIAR, with potentially improved survivals in MIAR. The survivals were comparable between laparoscopic and robotic AR. MIAR was technically standardized using the extrahepatic Glissonian approach. MIAR was safe, feasible, and oncologically acceptable and would be the first choice of AR in selected HCC patients.

ASO Visual Abstract: Robotic Hepatic Bisegmentectomy (s4b+s5) and Hilar Lymphadenectomy for Incidental Gallbladder Cancer Using Glissonian Approach.

ASO Visual Abstract: Robotic Hepatic Bisegmentectomy (s4b+s5) and Hilar Lymphadenectomy for Incidental Gallbladder Cancer Using Glissonian Approach.

Laparoscopic Anatomic Segment III Procurement in Pediatric Living Donor Liver Transplantation Using Real-Time ICG Fluorescence In Situ Reduction by the Glissonean Approach

Nowadays, anatomic hepatectomy has been widely accepted and acknowledged as a feasible practice during laparoscopic procedure. We herein report the first case of laparoscopic anatomic segment III (S3) procurement in pediatric living donor liver transplantation using real-time indocyanine green (ICG) fluorescence in situ reduction by Glissonean approach. A 36-year-old father volunteered for living donation to his daughter who was diagnosed with liver cirrhosis and portal hypertension due to biliary atresia. Preoperative liver function was normal with mild fatty liver. Liver dynamic computed tomography showed a left lateral graft volume of 379.43 cm3 with a graft to recipient weight ratio (GRWR) of 4.77%. The ratio of the maximum thickness of the left lateral segment to the anteroposterior diameter of the recipient's abdominal cavity was 1.20. Hepatic veins of segment II (S2) and S3 separately flowed into the middle hepatic vein. The estimated S3 volume was 173.16 cm3 and GRWR was 2.18%. The estimated S2 volume was 118.54 cm3 and GRWR was 1.49%. Laparoscopic anatomic S3 procurement was scheduled. Liver parenchyma transection was divided into 2 steps. Step I: Anatomic in situ reduction of S2 by using real-time ICG fluorescence. Step II: Separating the S3 along the right side of sickle ligament. The left bile duct was identified and divided by ICG fluorescence cholangiography. The total operation time was 318 minutes without transfusion. The final graft weight was 208 g with GRWR of 2.62%. The donor was discharged uneventfully on postoperative day 4, and the graft function recovered to normal in the recipient without any graft related complication. Laparoscopic anatomic S3 procurement with in situ reduction is a feasible and safe procedure in selected donors in pediatric living donor liver transplantation.