Glissonian Approach Research Articles

Application and utility of surgical techniques for cystic plate isolation in liver surgery.

One of the most important areas of anatomical knowledge for liver surgery is the plate system in the hilar area. Four plates comprise the hilar area plate system: the hilar plate, cystic plate, umbilical plate, and Arantian plate. Based on the theory that the cystic plate is continuous with the hilar plate, isolation of the cystic plate can be applicable to various scenarios in liver surgery. We describe herein the procedure and usefulness of cystic plate isolation to approach the hilar plate, in both open and laparoscopic surgeries. This isolation can be applied in various manners. First, cystic plate traction can facilitate the Glissonian approach, drawing out the extrahepatic Glissonian pedicles and thus lengthening the pedicle, and facilitate isolation of these pedicles. Second, inflow control can be obtained by applying the cystic plate traction method to the Glissonian approach. This is suitable to control hepatic inflow when there is no need to divide vessels such as lymph node dissection or vascular resection and reconstruction. Third, the Glissonian approach can be used in surgery for hepatocellular carcinoma patients with portal thrombosis. The cystic plate traction method potentially avoids injury to the Glissonian pedicle that would cause unnecessary bleeding, and is thus particularly efficient for advanced cancers such as hepatocellular carcinoma patients with portal thrombosis and collateral vessels around the area of obstruction in the Glissonian sheath. In this article, we focused on our anatomical knowledge and technical tips for making use of cystic plate isolation in liver surgery.

Bases anatómicas y aplicación clínica inicial del abordaje glissoniano intrahepático en las hepatectomías

Introducción: El control pedicular durante las resecciones hepáticas puede hacerse mediante disección hiliar extrahepática (DHE) o abordaje glissoniano (AG). El AG intrahepático (AGI) según técnica de Machado puede brindar ciertas ventajas, especialmente en disecciones difíciles. Sin embargo, es menos empleado que la DHE.Objetivo: Analizar las bases anatómicas del AGI y comunicar nuestra experiencia clínica inicial.Material y métodos: El AGI según técnica de Machado se practicó en seis (6) hígados cadavéricos. Luego se hizo la disección hepática para valorar la efectividad del cargado pedicular y medir la profundidad de los diferentes pedículos glissonianos. La aplicación clínica de la técnica fue gradual y selectiva, aplicándola cuando nos parecía factible y que aportaba alguna ventaja sobre la DHE.Resultados: en los 6 hígados cadavéricos fue posible realizar el cargado de todos los pedículos glissonianos (lobares y sectoriales bilateralmente, así como los segmentarios izquierdos). Estos se encuentran a una profundidad menor a 2 cm de la capsula hepática, siendo accesibles para su control mediante AGI. La principal excepción es el pedículo anterior derecho, cuyo nacimiento es más profundo, lo que asociado a su origen en sentido cefálico y a veces ramificado, puede hacer más difícil su cargado. La aplicación del AGI se llevo a cabo en 5 pacientes, en todos fue efectiva, insumió poco tiempo y no tuvo complicaciones intraoperatorias.Conclusiones: el AGI según técnica de Machado es un procedimiento sistematizado, reproducible, factible y seguro, aún en su aplicación clínica inicial. El conocimiento anatómico de los pedículos glissonianos es fundamental para llevarlo a cabo con éxito.

‘Inside-Out’ Transection: Simple and Safe Way of Laparoscopic Anatomical Liver Resection

Introduction: In open anatomical liver resection, liver parenchymal transection from the peripheral part to the hilum because of restricted surgical view. Confirmation of transection line as a demarcation line using dye-injection method or extrahepatic glissonian approach, Modification of disorientation during liver parenchymal transection by intraoperative ultrasonography are too complicated and technical-demanding procedures for laparoscopic approach. Theoretically considering the directions of branched Glissonian pedicles and hepatic veins, parenchymal transection should be done from the hilum to the the peripheral, in other words, ‘inside-out’. We recently perform laparoscopic anatomical ‘inside-out’ liver resection utilizing laparoscopic caudal view. Methods: Anatomical resection starts from parenchymal transection around the root of the corresponding Glissonian pedicle and a tip of CUSA is moved inside-out to the direction with low resistance between the glissonian pedicles, which leads to the right intersegmental plane. The direction of transection can also be corrected by visually checking the ramification of branched Glissonian pedicles that are clearly recognizable in laparoscopic view. The corresponding Glissonian pedicle is dissected on the way of paremchymal transection when surgical space is made for safe procesures. ‘Inside-out’ transection also prevents from bleeding from the root of branched hepatic veins and enables to keep a good surgical view and tension on the dissection point. Liver peripheral parenchyma is dissected in the end. The process of laparoscopic anatomical ‘inside-out’ liver resection is so simple because all procesures is completed on one direction way. Conclusions: Laparoscopic anatomical ‘inside-out’ liver resection is simple and safe utilizing the advantages of laparoscopic approach.

Repeat laparoscopic anatomical liver resection in a hepatocellular carcinoma patient: a case report

Anatomical resection (AR) has been reported to achieve better long-term outcomes than non-anatomical resection for the treatment of hepatocellular carcinoma (HCC). The surgical feasibility and oncological significance of laparoscopic AR (LAR), especially “subsegment resection”, “cone unit resection”, and repeat LAR for HCC, remain unproven. We present a 67-year-old patient with alcoholic liver cirrhosis and HCC who underwent full LAR three times, focusing on the technical aspects of the Glissonean approach. Repeating LAR for recurrent HCC could be a safe and feasible procedure. However, HCC recurred in the neighboring segment twice, even though pathological vascular invasion and marginal remnants were not confirmed. We should investigate the oncological significance and advancements in subsegmentectomy and cone unit resection, in the future.

Advantages of Extrahepatic Glissonean Approach in the Donor Operation in Living Donor Liver Transplantation

Introduction: To eliminate biliary complications in living donor hepatectomy, we introduced the extrahepatic glissonean approach combined with liver hanging maneuver (GA+LHM) since 2017. Method: Surgical procedures are as follows: Prior to liver transection, we encircle the extrahepatic Glissonean pedicle at the graft liver side with a tape. Then, we introduce a hanging tape from the encircled Glissonean pedicle to the groove between middle hepatic vein and right hepatic vein. Liver parenchymal transection is facilitated with the LHM. After the completion of transection, hepatic artery and portal vein of the graft liver are isolated in the hilum. The remaining structure is the hilar plate including the hepatic duct(s). After intraoperative cholangiography, bile duct, hepatic artery, portal vein, and hepatic vein are divided in this order and the graft liver is procured. We analyzed the short-term outcomes of the donor using Clavien–Dindo classification: For bile leakage, the International Study Group of Liver Surgery definition was used. Results: GA+LHM was successfully performed in a total of 44 consecutive living donor hepatectomy (right lobe graft in 28, left lobe graft in 15, and left trisegmental lobe +S1 graft in 1). There were no Grade Ⅲa≦ complications and bile leakage until discharge. Biliary stricture occurred in 1 (2%) patient who was readmitted and required endoscopic biliary stent placement. Conclusions: GA+LHM presumably prevents heat and mechanical injury of the bile ducts of the remnant liver by minimization of hilar dissection, thereby contributes to eliminating bile leakage in living donor hepatectomy.

Minimally invasive anatomic liver resection: Results of a survey of world experts

Although the number of minimally invasive liver resections (MILRs) has been steadily increasing in many institutions, minimally invasive anatomic liver resection (MIALR) remains a complicated procedure that has not been standardized. We present the results of a survey among expert liver surgeons as a benchmark for standardizing MIALR. We administered this survey to 34 expert liver surgeons who routinely perform MIALR. The survey contained questions on personal experience with liver resection, inflow/outflow control methods, and identification techniques of intersegmental/sectional planes (IPs). All 34 participants completed the survey; 24 experts (70%) had more than 11years of experience with MILR, and over 80% of experts had performed over 100 open resections and MILRs each. Regarding the methods used for laparoscopic or robotic anatomic resection, the Glissonean approach (GA) was a more frequent procedure than the hilar approach (HA). Although hepatic veins were considered essential landmarks, the exposure methods varied. The top three techniques that the experts recommended for identifying IPs were creating a demarcation line, indocyanine green negative staining method, and intraoperative ultrasound. Minimally invasive anatomic liver resection remains a challenging procedure; however, a certain degree of consensus exists among expert liver surgeons.

Handling of Hilar Vasculature in Living Donor Right Hepatectomy Using Extrahepatic Glissonean Approach

Donor hepatectomy is one of the most important procedures in LDLT because it affects the safety of donors and the outcome of the recipients. We standardized a method of securing the important vessels at the hepatic hilum while advancing the dissection toward the central direction. This research introduces our technique of handling hilar vasculature in living donor hepatectomy, using the extrahepatic Glissonean approach, and discusses its efficacy. At first, after the extrahepatic right Glissonean approach, the resected hepatic artery and portal vein are secured on the same line as with the secured Glisson. The resected hepatic artery and portal vein are followed in the central direction, and the surrounding area is dissected. The dissection is continued up to the main brunch of the hepatic artery and portal vein. The bile duct can be secured by subtracting the hepatic artery and portal vein from the tape that secured the Glissonean pedicle. The bile duct, hepatic artery, and the portal vein are dissected in this order, before dissecting the right hepatic vein, completing the surgery. This method of dissection approaching the extrahepatic Glisson carried out toward the central direction suggests to acquire minimal tissue removal and to shorten operative time. This could result in adequate perfusion to the remaining liver and donor safety, taken together effective results on the recipient.

Intrahepatic Glissonean Approach for Laparoscopic Bisegmentectomy 7 and 8 With Root-Side Hepatic Vein Exposure.

Laparoscopic anatomic liver resections of the posterosuperior segments are technically demanding procedures.1-5 The segments are located in a deep-seated area of the liver surrounded by the ribs and the diaphragm, making forceps manipulation difficult. To overcome this limitation, an intrahepatic Glissonean approach and exposure of the hepatic veins from the root side was applied.6-10 The authors describe the technical aspects of performing a bisegmentectomy 7-8. Liver parenchymal transection was initiated from the ventral aspect of the root of the middle hepatic vein, which often runs in the intersegmental plane, identifying the Glissonean pedicle of segment 8 (G8). After dissection of the G8, segmentectomy 8 was performed through identification of the ischemic area. After complete mobilization of the right lobe, the Glissonean pedicle of segment 7 (G7), which runs relatively near the liver surface,9, 10 was marked using ultrasonography. After division of the G7, a wide dissection between the caudate lobe and segment 7 was performed and connected to the previously dissected plane from the dorsal side of the right hepatic vein (RHV). Finally, bisegmentectomy 7-8 was performed with RHV resection because of tumor invasion. The operation time was 510 min, and the estimated blood loss was 150 ml. The patient was discharged on postoperative day 10 without any complications. Application of the intrahepatic Glissonean approach and exposure of the major hepatic veins from their roots using unique laparoscopic principles allows a safe performance of bisegmentectomy 7-8.

ROBOTIC LIVER RESECTION. REPORT OF THE FIRST 50 CASES.

Robotic surgery has gained growing acceptance in recent years, expanding to liver resection. The aim of this paper is to report the experience with our first fifty robotic liver resections. This was a single-cohort, retrospective study. From May 2018 to December 2020, 50 consecutive patients underwent robotic liver resection in a single center. All patients with indication for minimally invasive liver resection underwent robotic hepatectomy. The indication for the use of minimally invasive technique followed practical guidelines based on the second international laparoscopic liver consensus conference. The proportion of robotic liver resection was 58.8% of all liver resections. Thirty women and 20 men with median age of 61 years underwent robotic liver resection. Forty-two patients were operated on for malignant diseases. Major liver resection was performed in 16 (32%) patients. Intrahepatic Glissonian approach was used in 28 patients for anatomical resection. In sixteen patients, the robotic liver resection was a redo hepatectomy. In 10 patients, previous liver resection was an open resection and in six it was minimally invasive resection. Simultaneous colon resection was done in three patients. One patient was converted to open resection. Two patients received blood transfusion. Four (8%) patients presented postoperative complications. No 90-day mortality was observed. The use of the robot for liver surgery allowed to perform increasingly difficult procedures with similar outcomes of less difficult liver resections.

How-I-do-it: laparoscopic left medial sectionectomy utilizing a cranial approach to the middle hepatic vein and Laennec\u2019s capsule

BackgroundLaparoscopic anatomic liver resection is technically demanding, given the need to safely isolate the Glissonean pedicles and expose the hepatic veins (HVs) on the liver parenchyma cut surface. Laennec’s capsule is observed around the Glissonean pedicles and root of the HVs. However, its existence, particularly on the peripheral side of the HVs, remains controversial. Herein, we describe Laennec’s capsule-related histopathological findings around the HVs and a safe laparoscopic left medial sectionectomy utilizing Laennec’s capsule.MethodsThe extrahepatic Glissonean approach was performed by connecting Gates II and III, in accordance with Sugioka’s Gate theory. Liver parenchymal transection commenced along the demarcation line, which is between the medial and lateral sections, and the G4 was dissected during transection. Subsequently, via the outer-Laennec approach, the middle hepatic vein (MHV) was exposed from the root side in cranial view, while Laennec’s capsule was preserved. Parenchymal transection was completed while connecting the MHV with the demarcation line. We obtained the membrane surrounding the HVs and performed histopathological examinations.ResultsSix patients underwent laparoscopic left medial sectionectomy from February 2012 to November 2020. There were no cases involving complications (Clavien–Dindo classification; grade II or higher), open-surgery conversion, transfusion, or surgery-related death. The histopathological findings showed Laennec’s capsule surrounding both the trunk of the major HVs and the peripheral side of the HVs.ConclusionsA cranial approach to the major HVs utilizing Laennec’s capsule is a feasible and advantageous procedure for laparoscopic left medial sectionectomy. We propose that Laennec’s capsule surrounds the entire length of the HVs.

Laparoscopic anatomical S8 segmentectomy by Glissonian approach after dissection of the midplane of the liver

Anatomical resection of the liver in HCC is important in terms of oncologic benefit. However, laparoscopic anatomical segment 8 (S8) resection is anatomically complex and technically difficult. Ultrasonography guided dye or ICG injection technique can be a good option, but it is technically demanding and experience dependent. A 56-year-old female with underlying chronic hepatitis B virus was diagnosed with 1.8 cm sized HCC in S8. The tumor was suspected of the microvascular invasion near the middle hepatic vein (MHV) in MRI. Laparoscopic ultrasonography was used to identify the location of mass and the relation to the vasculature. The lower 2/3 of the midplane of the liver was dissected. The branches of MHV draining S4 were divided to get resection margin. After dissection around the right anterior Glissonian pedicle, ligation of S8 pedicle was done. Then, lateral border of S8 was dissected along the ischemic line. MHV was crossed over during the dissection of the upper 1/3 of the midplane of the liver. S8 was anatomically resected. The operative time was 185 minutes, and the estimated blood loss was 100 mL. The final pathology was HCC and the size of tumor was 18 mm with 2 cm safety margin. Follow up CT scan showed congestion in S4 and S5, but no other problems. The patient was discharged on postoperative day 5 without complication. Laparoscopic anatomical resection of S8 using Glissonian approach after dissection of the midplane of the liver was feasible and it is simpler and easier to apply than dye injection technique.

Laparoscopic right posterior sectionectomy (LRPS) in semi prone position: surgical aspects and results

Laparoscopic hepatectomy has been accepted widely due to its advantages as a minimally invasive surgery, but laparoscopic right posterior sectionectomy (LRPS) has rarely been reported. Tumors located over the right posterior section are considered to be difficult for laparoscopic resection. The Glissonean approach is our technique of choice. The aim of this work is to present our experience in LRPS in semi prone position and to show surgical technical aspects. For six years period we were performed 12 LRPS procedures. Patient's data were prospectively collected. Demographics data, tumor characteristics, operative data, and postoperative outcome were collected and analyzed. There were 8 patients with colorectal liver metastasis, 2 HCC, one melanoma metastasis and one breast cancer liver metastasis. During the period of 2014-2020, we performed 12 LRPS. Median operative time was 200 minutes, median blood loss was 300 ml. Significant bleeding occurred in 1 cirrhotic liver patients. The median size of the tumor resected was 3.5 cm, and the median resection margin was 7 mm. Nine patients show single tumor nodule, 2 patients had two metastases and 1 with 3 metastases. There was no postoperative mortality. Median hospital stay was 6 days. LRPS is a technically demanding procedure. LRPS in semi prone position is feasible and safe. Semi prone position offers a maximum amount of working space. A proper inflow control is mandatory for excellence of anatomical resection. The Glissonean approach allows safe and masse control of the portal structures of the posterior sector and resulting in less blood loss during transection.

Initial experience of robotic extrahepatic Glissonean pedicle approach for anatomical liver resection: techniques and short term perioperative outcomes

Anyone who is a Liver surgeon and performs minimally invasive surgery will try to shorten the surgery time. And we will seek to simplify the operation to make it simpler. In this study, we introduce our initial experience and technique of the extrahepatic Glissonean approach for anatomic liver resections, using a robotic system, and report on short-term perioperative outcomes. From August 2016 to December 2020, 10 patients underwent robotic anatomic liver resection using extrahepatic Glissonean approach. The procedure is as follows: (1) mobilization of the liver and isolation and clamping of a selected Glissonean pedicle; (2) transection of the liver parenchyma using a rubber band retraction technique; (3) division of the Glissonean pedicle after full exposure, followed by completion of parenchymal transection. The median age of the patients was 59.0 (range 42-70) years, and eight were male. Nine patients had hepatocellular carcinoma and the other was liver metastasis. The types of resections performed were as follows: segmentectomy S4 (n = 1), left lateral sectionectomy + segmentectomy S6 (n = 1), right posterior sectionectomy + Wedge resection S2 (n = 1), right hepatectomy (n = 2), left heaptectomy (n = 1), bisectionectomy S5 + 6 (n = 2), and central bisectionectomy (n = 2). The overall complication rate was 20 % (grade I, 2; grade II, 0; grade III, 0; grade. Robotic surgery allowed for successful anatomic liver resections via an extrahepatic Glissonean pedicle approach in the right liver and can be safely performed in selected patients.

A Combined "Hanging Liver Maneuver" and "Intrahepatic Extra-Glissonian Approach" for Anatomical Right Hepatectomy: Technique Standardization, Results, and Correlation With Portal Pedicle Anatomy.

Background: The hanging liver maneuver and intrahepatic extra-Glissonian approach are distinct modalities to facilitate safe anatomical liver resections. This study reports a standardized combination of these techniques focusing on safety, results and correlation with portal pedicle anatomy in oncological patients.Method: Combined hanging liver maneuver and intrahepatic extra-Glissonian approach for anatomic right hepatectomy was described stepwise. Portal pedicle anatomy was correlated with the Glissonian approach failure and complications. Clinical characteristics of patients, perioperative outcomes, short and long-term survival rates were analyzed.Results: Thirty colorectal liver metastases patients submitted to the combined approach were evaluated. Anatomical variations of the right portal pedicle were present in 26.6%. Hanging liver maneuver was feasible in 100%, and Glissonian approach in 96.7% despite portal pedicle variations. Mean operative time was 326 min. Mean blood loss was 507 ml. Mean hospital stay was 8 days. There was no 90-day operative mortality and no significant morbidity. Oncological surgical margins were free. Overall and disease-free 5-year survival were 59 and 37%.Conclusion: Regardless of frequent anatomical variations of the right portal pedicle, the hanging liver maneuver, and intrahepatic extra-Glissonian approach can be combined, being useful for anatomical right hepatectomies in a safe and reproducible way in most patients.

A snapshot of the 2020 conception of anatomic liver resections and their applicability on minimally invasive liver surgery. A preparatory survey for the Expert Consensus Meeting on Precision Anatomy for Minimally Invasive HBP Surgery.

The main aim of this survey was to analyze how liver surgeons perform liver resections and to define their conception of anatomic procedures within the incorporation of minimally invasive liver surgery (MILS). The survey was distributed among liver surgeons. It mainly focused on personal experience on open and MILS, methods and landmarks, and experience on anatomic resections and Glissonean approach. A total of 445 valid answers from 54 countries was obtained. Surgeons performing MILS mainly have below 10years of experience (81.8% of responders) and one third has never done complex MILS. New techniques, including indocyanine green demarcation are marginally used (<25%). More than 60% of surgeons do not make a full exposure of hepatic veins during MILS, mainly due to the risk of injury or not considering it to be of utility. Although 88% of responders agreed with the concept of anatomic resection as the "resection along the border/watersheds of each order division identified by the portal vein flow", only 55% of surgeons have ever performed MILS Glissonean approaches. Liver anatomy is not a static concept. Anatomic resections need training and precision. Standardization of complex anatomic resections by a minimally invasive approach should be encouraged.

Laparoscopic anatomical segment III resection for a giant focal nodular hyperplasia (FNH): advantages of the extraglissonean approach—a case report

: In recent years the laparoscopic approach in liver surgery has gained wide acceptance compared to open surgery, especially in cases of benign liver lesions. Many of these, i.e., focal nodular hyperplasia (FNH), have an important vascular inflow depending from nutrient vessels, which hamper sometimes a proper resection. We report in this video a 24-year-old male with a fortuitous diagnosis of a 10×8×7 cm FNH in the left hepatic lobe, with its characteristic central nutrient vessel. Given the size of the lesion, surgical excision was indicated and performed a laparoscopic resection of segment III following an extraglissonean approach. This approach enables an intrahepatic identification of the targeted glissonean pedicle for segment III without dissecting the hepatoduodenal ligament. It also permits the localization and clamp of the vascular inflow of the tumor leading to tumor shrinkage, which facilitates the resection without invading the tumor capsule and thus respecting the portal pedicles for the other segments. The patient did not present postoperative complications and was discharged on the third postoperative day. The definitive pathology confirmed the diagnosis of FNH. A detailed preoperative anatomical study of the liver segments allows a better planning of liver surgeries. More specifically, this selective transfisural glissonean approach avoids a dissection of the hepatoduodenal ligament and therefore the risk of a postoperative bile leak.

Dorsal approach with Glissonian approach for laparoscopic right anatomic liver resections

BackgroundLaparoscopic anatomic hepatectomy (LAH) has gradually become a routine surgical procedure. However, how to expose the whole hepatic vein and avoid the hepatic vein laceration is still a challenge because of the caudate lobe, particularly in right hepatectomy. We adopted a dorsal approach combined with Glissionian appraoch to perform laparoscopic right anatomic hepatectomy (LRAH).MethodsTwenty patients who underwent LRAH from January 2017 to November 2018 were retrospectively analysed. Of these patients, seven patients underwent laparoscopic right hemihepatectomy (LRH group), seven patients who underwent laparoscopic right posterior hepatectomy (LRPH group), and six patients who underwent laparoscopic hepatectomy for segment 7 (LS7 group). The paracaval portion of caudate lobe could be transected firstly through dorsal approach and the corresponding major hepatic vein could be exposed from its root to the peripheral branches safely. Due to exposure along the major hepatic vein trunk, the remaining liver parenchyma could be quickly transected from dorsal to cranial side.ResultsThe mean age of the patients was 53.8 years and the male: female ratio was 8:12. The median operation time was 306.0 ± 58.2 min and the mean estimated volume of blood loss was 412.5 ± 255.4 mL. The mean duration of postoperative hospital stay was 10.2 days. The mean Pringle maneuver time was 64.8 ± 27.7 min. Five patients received transfusion of 2–4 U of red blood cells. Two patients suffered from transient hepatic dysfunction and one suffered from pleural effusion. None of the patients underwent conversion to an open procedure. The operative duration, volume of the blood loss, Pringle maneuver time, and postoperative hospital stay duration did not differ significantly among the LRH, LRPH, and LS7 groups (P > 0.05).ConclusionsDorsal approach combined with Glissonian approach for right lobe is feasible and effective in laparoscopic right anatomic liver resections.

Evaluation of accuracy of laparoscopic liver mono-segmentectomy using the Glissonian approach with indocyanine green fluorescence negative staining by comparing estimated and actual resection volumes: A single-center retrospective cohort study.

Laparoscopic liver mono-segmentectomy (LLMS) may improve patient outcomes, but it is difficult and its accuracy and safety are unknown. We evaluated the accuracy of LLMS using Glissonian approach with indocyanine green fluorescence (ICG) negative staining. Seventy-four patients eligible for LLMS except for segment 1 were enrolled. Preoperative three-dimensional CT-based surgical simulation was used to determine estimated liver resection volume (ELRV), which was compared with modified actual liver resection volume (ALRV) obtained from actual liver resection mass. The LLMS accuracy was also evaluated based on operator's experience (attending surgeon [AS] or trainee surgeon [TS]). Estimated liver resection volumes significantly correlated with ALRVs (r=.82) in all cases. Moreover, TS-conducted LLMS also showed acceptable difference between ELRV and ALRV compared with AS-conducted LLMS. There were no intergroup differences in estimated blood loss, operation time, time of Pringle maneuver, postoperative complications, and length of postoperative hospitalization (P<.05). Moreover, R0 resection was comparable between the AS and TS groups. Laparoscopic liver mono-segmentectomy with Glissonian approach using ICG negative imaging ensured safe and accurate procedure owing to facilitated visualization of the resection line. Our approach was effective in avoiding postoperative liver dysfunction and securing radical resection. In addition, it might be helpful in TS education of LLMS.

Robotic anatomical resection of liver segment 4 with glissonian approach and selective hepatic artery clamping

Robotic anatomical resection of liver segment 4 with glissonian approach and selective hepatic artery clamping

Glissonean approach for hepatic inflow control in minimally invasive anatomic liver resection: A systematic review.

The Glissonean approach has been widely validated for both open and minimally invasive anatomic liver resection (MIALR). However, the possible advantages compared to the conventional hilar approach are still under debate. The aim of this systematic review was to evaluate the application of the Glissonean approach in MIALR. A systematic review of the literature was conducted on PubMed and Ichushi databases. Articles written in English or Japanese were included. From 2,390 English manuscripts evaluated by title and abstract, 43 were included. Additionally, 23 out of 463 Japanese manuscripts were selected. Duplicates were removed, including the most recent manuscript. The Glissonean approach is reported for both major and minor MIALR. The 1st, 2nd and 3rd order divisions of both right and left portal pedicles can be reached following defined anatomical landmarks. Compared to the conventional hilar approach, the Glissonean approach is associated with shorter operative time, lower blood loss, and better peri-operative outcomes. Glissonean approach is safe and feasible for MIALR with several reported advantages compared to the conventional hilar approach. Clear knowledge of Laennec's capsule anatomy is necessary and serves as a guide for the dissection. However, the best surgical approach to be performed depends on surgeon experience and patients' characteristics. Standardization of the Glissonean approach for MIALR is important.