Glissonian Approach Research Articles

Robotic Left Trisectionectomy with Glissonian Approach (with Video)

BackgroundLeft hepatic trisectionectomy consists of the removal of liver segments 2, 3, 4, 5, and 8. This difficult surgical procedure may be required when the left liver and right anterior sector (segments 5 and 8) are involved. We present a video of a robotic anatomic left trisectionectomy with Glissonian approach to the left and right anterior sector pedicles. MethodsA 77-year-old man presented at a routine ultrasound with a large liver mass. Magnetic resonance imaging showed a bulky hepatocellular carcinoma occupying liver segments 2, 3, 4, 5, and 8, with a portal tumor thrombus in the right anterior sector. The patient had multiple comorbidities, including obesity, diabetes, hypertension, and coronariopathy. The multidisciplinary team decided to use immunotherapy with atezolizumab and bevacizumab. After 12 cycles, the patient showed an objective response, and left trisectionectomy was indicated. A robotic approach was proposed and consent was obtained. The Glissonian approach was used for anatomic control of the left and right anterior sector pedicles. ResultsThe operative time was 390 min with an estimated blood loss of 410 ml, and no transfusion was required during or after the procedure. Recovery was uneventful and the patient was discharged on postoperative day 8. No bile leak was observed, and the drain was removed on postoperative day 8. ConclusionsRobotic left trisectionectomy is safe and feasible. The Glissonian approach is useful for anatomic left liver trisectionectomy. This video can help gastrointestinal surgeons perform this complex procedure in a minimally invasive manner.

Robotic radical resection for incidental gallbladder cancer using Glissonian approach

Background: Gallbladder cancer is suspected preoperatively in about 30 % of patients, while the remaining 70 % of cases are incidentally discovered. The increasing rate of cholecystectomies via laparoscopy has led to the detection of more gallbladder cancers in an early stage, and extended resection with regional lymph node dissection has been suggested. We present a video of a robotic liver resection (segments 4b and 5) with hilar lymphadenectomy in a patient with an incidental gallbladder cancer.

Minimally invasive isolated anatomic liver segmentectomy for hepatocellular carcinoma using extrahepatic Glissonian approach: surgical techniques and outcomes

Aim: To standardize surgical techniques for and define the safety, feasibility and oncologic validity of minimally invasive anatomic liver segmentectomy for hepatocellular carcinoma (HCC). Methods: We retrospectively studied perioperative and long-term outcomes of isolated anatomic segmentectomy (IA-Seg) using the extrahepatic Glissonian approach in 157 HCC cases, including 77 open and 80 minimally invasive (59 laparoscopic and 21 robotic) cases. Surgical outcomes were compared between the approaches using propensity score matching (PSM). Results: After matching (46:46), compared with open IA-Seg, minimally invasive IA-Seg was significantly associated with less blood loss (274 vs. 955 g), a lower transfusion rate (21.7% vs. 45.7%), the lower postoperative serum total bilirubin (TB) level (1.5 vs. 2.2 mg/dL) and shorter length of hospital stay (LOS) (17 vs. 27 days), while the latter had a significantly higher rate of Pringle maneuver application (15.2% vs. 2.2%) and a higher aspartate aminotransferase (AST) level (669 vs. 402 IU/L). Additionally, laparoscopic and robotic IA-Seg before and after matching (16:16) had comparable perioperative outcomes. Long-term outcomes after IA-Seg for newly developed HCC in matched cohorts were comparable, either between open and minimally invasive IA-Seg (36:36) or between laparoscopic and robotic IA-Seg (12:12). Conclusion: Although minimally invasive IA-Seg is technically demanding, it could be standardized using the extrahepatic Glissonian approach. This procedure for HCC was safe, feasible and oncologically acceptable, with several perioperative outcomes superior to those in open IA-Seg and with comparable long-term outcomes. By expert hands, the laparoscopic or robotic approach could be a reliable option for IA-Seg in selected HCC patients.

Standardized Procedures of Laparoscopic Anatomical Liver Resections of S7 and S8 Using ICG Fluorescence Guidance with Extrahepatic Glissonean Approach

Standardized Procedures of Laparoscopic Anatomical Liver Resections of S7 and S8 Using ICG Fluorescence Guidance with Extrahepatic Glissonean Approach

Pure laparoscopic left lateral graft procurement with removing segment 3 employing Glissonean approach, indocyanine green fluorescence imaging and in situ splitting for a small infant.

We report on a pure laparoscopic left lateral graft procurement with removing segment 3 that employs the Glissonean approach, indocyanine green (ICG) fluorescence imaging and in situ splitting. We first mobilised the liver and confirmed the root of the left hepatic vein (LHV). We then encircled the left Glissonean pedicle, and the segment 3 Glissonean pedicle (G3) was also individually encircled. We performed parenchymal transection of the left lateral segmentectomy using Pringle's manoeuvre. We clipped G3 and confirmed the demarcation line using ICG fluorescence imaging. The inflow in the S2 area was confirmed via intraoperative sonography, and we split segment 3 (S3) from the left lateral sector graft in situ. The left hepatic artery, left portal vein and left hepatic duct were also encircled and divided. The LHV was transected using a linear stapler, and the S2 monosegment liver graft and removed S3 were procured. Our technique reasonably prevents graft-related complications.

Standardization of laparoscopic anatomic liver resection of segment 2 by the Glissonean approach.

Anatomic liver resection (ALR) has been established to eliminate the tumor-bearing hepatic region with preservation of the remnant liver volume for liver malignancies. Recently, laparoscopic ALR has been widely applied; however, there are few reports on laparoscopic segmentectomy 2. This study aimed to present the standardization of laparoscopic segmentectomy 2 with surgical outcomes. This study included seven patients who underwent pure laparoscopic segmentectomy 2 by the Glissonean approach from January 2020 to December 2021. Four of them had hepatocellular carcinoma, two had colorectal liver metastasis, and one had hepatic angiomyolipoma, which was preoperatively diagnosed with hepatocellular carcinoma. In all patients, preoperative three-dimensional (3D) simulation images from dynamic CT were reconstructed using a 3D workstation. The layer between the hepatic parenchyma and the Glissonean pedicle of segment 2 (G2) was dissected to encircle the root of G2. After clamping or ligation of the G2, 2.5mg of indocyanine green was injected intravenously to identify the boundaries between segments 2 and 3 with a negative staining method under near-infrared light. Parenchymal transection was performed from the caudal side to the cranial side according to the demarcation on the liver surface, and the left hepatic vein was exposed on the cut surface if possible. The mean operative time for all patients was 281min. The mean blood loss was 37mL, and no transfusion was necessary. Estimated liver resection volumes significantly correlated with actual liver resection volumes (r = 0.61, P = 0.035). After the operation, one patient presented with asymptomatic deep venous and pulmonary thrombosis, which was treated with anticoagulant therapy. The mean length of hospital stay was 8.9days. Laparoscopic segmentectomy 2 by the Glissonean approach is a feasible and safe procedure with the preservation of the nontumor-bearing segment 3 for liver tumors in segment 2.

Laparoscopic isolated liver segmentectomy 8 for malignant tumors: techniques and comparison of surgical results with the open approach using a propensity score-matched study.

Anatomic isolated liver segmentectomy 8 (ILSeg8) for malignancies remains technically challenging. The feasibility, safety, and oncologic validity of laparoscopic ILSeg8 are undefined, and thus were evaluated in comparison with the open approach. This study enrolled 35 open and 29 laparoscopic ILSeg8 cases of hepatocellular carcinoma (n = 47), metastatic liver tumors (n = 16), and intrahepatic cholangiocarcinoma (n = 1) at our institution. The surgical techniques were based on the pre-hepatectomy extrahepatic Glissonian pedicle control, followed by cranial-to-caudal parenchymal dissection from the hepatic vein root side. The short- and long-term outcomes after ILSeg8 were retrospectively evaluated and compared between the open and laparoscopic approaches using 1:1 propensity score matching (PSM). Both before and after PSM, the laparoscopic ILSeg8 group had significantly less blood loss, lower postoperative serum bilirubin level, and a shorter postoperative hospital stay than the open group. The overall survival rates were comparable between the laparoscopic and open groups before (P = 0.017) and after (P = 0.043) PSM, with the similar recurrence-free survival rates between the groups. In a multivariable analysis of the cohort before PSM (n = 64), the laparoscopic approach was identified to be an independent factor for favorable overall survival (hazard ratio = 0.20, P = 0.039). Laparoscopic ILSeg8 using the extrahepatic Glissonian approach and hepatic vein root at first parenchymal dissection was feasible, safe, and oncologically acceptable. In ILSeg8 for malignancy, the laparoscopic approach potentially confers short-term advantages over the open approach with comparable long-term outcomes in select patients.

Laparoscopic left hemihepatectomy using the extrahepatic Glissonean approach: Technical tips for entering gaps.

There are two methods for selective inflow control from the liver hilum: individual hilar dissection and the Glissonean pedicle approach. The Glissonean pedicle approach has been increasingly used in laparoscopic anatomical liver resection. Recently, the extrahepatic Glissonean approach has been standardized due to the anatomical concept of Laennec's capsule. This article describes the technical details of entering gaps between the Laennec's capsule and Glissonean pedicle in laparoscopic left hemihepatectomy using the extrahepatic Glissonean approach. The key procedures of the laparoscopic left hemihepatectomy using the extrahepatic Glissonean approach included the following: (1) Dissection of left side of the hilar plate, (2) Dissection of ventral side of caudal end of the Arantius ligament, (3) Dissection and transection of left Glissonean pedicle. Our standardized technique is to create gap between the Laennec's capsule and Glissonean pedicle through appropriate traction and countertraction at the anatomical landmarks. Our procedure helps the surgeons to reproduce the extrahepatic Glissonean approach without parenchymal transection.

ASO Visual Abstract: Glissonian Approach During Robotic Mesohepatectomy for Recurrent Colorectal Liver Metastasis.

ASO Visual Abstract: Glissonian Approach During Robotic Mesohepatectomy for Recurrent Colorectal Liver Metastasis.

The APR triangle: A practical zone in the Glissonean approach to laparoscopic anatomical right hepatectomy

An understanding of vascular anatomy is crucial for the safe performance of laparoscopic anatomical liver excision. We discovered a triangular zone during the laparoscopic right liver surgery and termed this zone the APR triangle. The purpose of this study was to determine the probability of the existence of the APR triangle and elucidate its various forms. Analyzed three-dimensional image reconstructions of 66 individuals who underwent liver surgery and calculated the statistics for various types of APR triangles under various grouping settings. The APR triangle was present in the majority of cases, with right hepatic vein trunk type in 68% and right hepatic vein branch type in 21%, respectively. The angle between the right anterior and right posterior hepatic pedicles (AP&PP) was at most between 45 and 90° (74%). There was a 35% chance that at least one of the AP&PP was longer than 2 cm, and a 39% chance that both were. The right posterior pedicle first branch would appear at the bifurcation of AP&PP in 13% only. The APR triangle is objectively present and may represent a practical zone for performing laparoscopic right hepatic anatomical resection more simply and safely.

ASO Author Reflections: Glissonian Approach is Useful in Robotic Liver Resections.

ASO Author Reflections: Glissonian Approach is Useful in Robotic Liver Resections.

Standardized upfront Glissonean approach and liver hanging maneuver reduces bile leakage from the hepatic hilum in living donors.

Biliary complications after hepatectomy in living donors have yet to be eradicated. We hypothesized that a standardized upfront Glissonean approach and liver hanging maneuver (GH) would prevent mechanical and thermal injuries to the hilar plate of the remnant liver by determining the point of bile duct division and the final destination of hepatectomy preceding liver parenchymal transection (safety) and facilitate liver transection deep within the parenchyma and allow maximum length of hilar structures (rationality). GH was implemented in 2016 and its incidence of bile leakage was retrospectively compared against the conventional technique. GH comprises six steps: (1) development of the retrohepatic avascular plane between the right hepatic vein (RHV) and the middle hepatic vein (MHV) and isolation of the hepatic vein(s); (2) isolation of the right or left Glissonean pedicle with the corresponding Glissonean pedicles of the caudate lobe; (3) for right liver grafts and left liver grafts with the caudate lobe, passage of the tape for the liver hanging maneuver along the retrohepatic avascular plane and above the hilar plate, and for left liver grafts without the caudate lobe and for left lateral section grafts, passage of the tape from between the RHV and the MHV, along the Arantius ligament, and to the right of the umbilical portion; (4) liver transection; (5) isolation of hilar structures; and (6) graft procurement. Until 2020, 62 consecutive living donors underwent GH (success rate, 100%). The incidence of bile leakage from the hepatic hilum (0%) was significantly lower than that among 59 donors who underwent the conventional technique in 2011-2015 (9%; p = 0.01). In conclusion, GH is highly effective in reducing bile leakage from the hepatic hilum in living donors.

Glissonian Approach During Robotic Mesohepatectomy for Recurrent Colorectal Liver Metastasis.

Glissonian Approach During Robotic Mesohepatectomy for Recurrent Colorectal Liver Metastasis.

Laparoscopic Left Hemihepatectomy Using the Hilar Plate-First Approach (with Video).

Effective inflow and outflow control of the liver is essential for a safe hepatectomy. Detachment of the hilar plate is a fundamental technique in the Glissonean approach. The hilar plate is situated near the middle hepatic vein, which runs in the midplane of the liver, and serves as a landmark during hemihepatectomy. In this study, we describe the technical details and surgical outcomes of laparoscopic left hemihepatectomy using the hilar plate-first approach. The key procedures of the hilar plate-first approach included the following: (1) detachment of the hilar plate for the left Glissonean approach, (2) the middle hepatic vein approach from the hilar plate, (3) parenchymal transection along the ischemic line and middle hepatic vein, and (4) transection of the left Glissonean pedicle at the ventral aspect of the Arantius ligament. Between September 2020 and September 2021, 12 patients underwent laparoscopic left hemihepatectomy using the hilar plate-first approach. The median operation time was 227min (range 140-350min), and the median estimated blood loss was 82.5ml (range 50-150ml). The median length of postoperative hospital stay was 7days (range 5-10days). No major complications, including biliary complications, were observed. The hilar plate-first approach contributes to the standardization of surgical techniques for laparoscopic left hemihepatectomy. This technique is a safe and effective approach for the inflow and outflow systems of the left hemiliver.

Extra‐hepatic Glissonean approach allows safe segmental liver resection in patients with cirrhosis with hepatocellular carcinoma

AbstractAimThis study aims to report our experience with the extra‐hepatic Glissonean approach (EHGA) in liver resection in patients with cirrhosis.Patients and MethodsFrom a prospectively maintained database in Al‐Rajhi Liver Hospital, Assiut University, Egypt, all patients with cirrhosis with hepatocellular carcinoma (HCC) who had open liver resections of two or more segments from January 2014 to December 2016 were identified. As many as 49 patients received resection via the classical pedicle dissection technique (PDT) and 38 by EHGA.ResultsThere was no difference in age, sex, American Society of Anesthesiologists grade, aetiology of liver disease, alpha‐fetoprotein, tumour number, size, Child‐Turcotte‐Pugh or Model for End‐stage Liver Disease scores between groups. Patients in the EHGA group had shorter operative time (214 ± 54 vs. 249 ± 44 minutes in PDT; P = .001), lesser blood loss (647 ± 140 ml vs. 741 ± 192 ml, respectively; P = .010), wider safety margin (14 ± 3.5 mm vs. 11.5 ± 5.8 mm, respectively; P = .029), lesser decompensation (18.4% vs. 40.8%, respectively; P = .026) and shorter hospital stay (8, range 3‐26 vs. 9, range 4‐36 days, respectively; P = .015). There was no 30‐day mortalities in the EHGA group compared with two in the PDT group. There were no differences between groups in 1‐ and 3‐year overall and recurrence‐free survival rates.ConclusionsEHGA is a rapid, safe and oncologically sound approach for segmental anatomical liver resections of HCC in patients with cirrhosis.

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

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.

Tailored strategy of glissonean approach using the 3D flexible scope

Tailored strategy of glissonean approach using the 3D flexible scope

Crucial Roles of the Assistant Surgeon During Laparoscopic Left Hemihepatectomy.

BackgroundAlthough left hemihepatectomy has been widely performed via the laparoscopic approach, the roles of the assistant surgeon have not been well-documented so far. We herein present our standardized procedures of laparoscopic left hemihepatectomy without Spiegel’s lobe resection, focusing on the crucial roles of the assistant surgeon.MethodsDuring laparoscopic left hemihepatectomy without Spiegel’s lobe resection, countertraction by the assistant surgeon is quite important especially during isolating the left Glissonean pedicle and transecting liver parenchyma. When securing the left hepatic pedicle using the Glissonean approach, the assistant surgeon pushes Segment 4 of the liver cranially and pulls the tape encircling the hepatoduodenal ligament caudally in the opposite way, orthogonal to the direction of the laparoscopic forceps toward the left portal triad. During liver parenchymal transection, the assistant surgeon pulls the hanging tape across the left lobe of the liver in order to provide a wide and stable liver transection plane.With this standardized technique, nine cases of laparoscopic left hemihepatectomy were performed over the last two years in our department, and the perioperative data were retrospectively analyzed.ResultsThe median age of the nine patients was 70 years (range: 58 - 84 years). Most of the patients were males (77.8%). Five of nine patients were diagnosed with colorectal liver metastasis, two with hepatocellular carcinoma (HCC), one with inflammatory pseudotumor, and the other one with hepaticolithiasis. There were no conversions to open surgery. The median operative time and estimated blood loss were 337 minutes (range: 219 - 478 minutes) and 100 ml (range: 41 - 375 ml), respectively. The median length of postoperative hospital stay was nine days (range: 7 - 16 days). Major complications (Clavien-Dindo classification grade III or more) were not encountered in our cohort postoperatively.ConclusionWe presented here our standardized assistant roles during laparoscopic left hemihepatectomy without Spiegel’s lobe resection, which was revealed to be safe and feasible in our cohort.

Laparoscopic resection of the ventral area of segment 8 and segment 4a by intrahepatic Glissonean approach

Laparoscopic resection of the ventral area of segment 8 and segment 4a by intrahepatic Glissonean approach

Laparoscopic resection of the segment 7 and dorsal area of segment 8 in a cirrhotic patient with big inferior right hepatic veins by intrahepatic Glissonean approach

Laparoscopic resection of the segment 7 and dorsal area of segment 8 in a cirrhotic patient with big inferior right hepatic veins by intrahepatic Glissonean approach