Recent refinements of glissonean pedicle approach for liver resection
- VernacularTitle:Элэгний мэс заслын үе дэх глиссон техникийн сүүлийн үеийн ололтууд
- Author:
Yu Saito M.D.
;
Mitsuo Shimada M.D
;
Satoru Imura M.D
;
Yuji Morine M.D
;
Tetsuya Ikemoto M.D.
;
Yusuke Arakawa M.D.
;
Shuichi Iwahashi M.D.
;
Shinichiro Yamada M.D
;
Daichi Ichikawa M.D
;
Masato Yoshikawa M.D.
;
Hiroki Teraoku M.D.
- Collective Name:Institute of Health Biosciences, The University of Tokushima
- Publication Type:journal article
- From:Innovation
2014;8(4):142-143
- CountryMongolia
- Language:English
-
Abstract:
Background: The glissonean pedicle approach was introduced by Couinaud
and Takasaki in the early 1980s. The key of the glissonean pedicle approach is
clamping the pedicle first, secondly confirming the territory, and finally dissecting
the liver parenchyma. In this presentation, we introduced our recent refinements
of glissonean pedicle approach for liver resection.
“Approach to the glissonean pedicles at the hepatic hilus” Couinaud described
three approaches to the hepatic hilus. 1) Intra-fascial access (Control method):
The conventional dissection at the hilus or within the sheath is referred to as intrafascial
access However, dissection performed under the hilar plate is dangerous
and surgeons have to consider any variations of the hepatic artery and bile ducts.
2) Extra-fascial access (Glissonean pedicle approach): The glissonean pedicle is
dissected from the liver parenchyma at the hepatic hilus before dissecting the
liver parenchyma. This procedure prevents intrahepatic metastasis of HCC, which
spreads along the portal vein and improves the overall survival after surgery.
3) Extra-fascial and transfissural access: If the main portal fissure or the left
suprahepatic fissure is opened after dissecting the liver parenchyma, the surgeon
can confirm the pedicles that arise from the hilar plate or the umbilical plate.
“Operative techniques” 1) Preoperative 3D simulation of the precise anatomy
of portal vein, hepatic artery and bile duct at hepatic hilus should be performed.
2) Right glissonean pedicle: The hilar plate is detached from the quadrate lobe.
The assistant pulls the liver parenchyma cranially and the operator conversely
pulls the hepatoduodenal ligament caudally. Mayo scissors are inserted along the
liver parenchyma between the liver parenchyma and glissonean capsule (Fig.1).
Then forceps are inserted in the same way and the right main pedicle is taped
(Fig.2). The right anterior and posterior glissonean pedicles are taped as well. 3)
Left glissonean pedicle: The hilar plate is detached from the liver parenchyma.
Then, the Arantius duct is confirmed and the left pedicle is dissected along the left
pedicle at the ventral side of the Arantius duct.
“Pitfall of glissonean pedicle approach” The right pedicle should be dissected
in the liver side as much as possible to prevent the injury of left hepatic duct.
If possible, the right pedicle is recommended to be dissected at the level of the
second branches separately (Fig.3). The right posterior hepatic duct sometimes
branches from the left hepatic duct and the Arantius duct is confirmed and the left
pedicle should be dissected along the left pedicle at the ventral side of the Arantius
duct because the right posterior hepatic duct branches from the left hepatic duct
at the dorsal side of Arantius’ duct. In addition, the intraoperative cholangiogram
should be used in the case with the abnormal anatomy of bile duct.
Conclusions: Any anatomical hepatectomy can be performed using “glissonean
pedicle approach” which allows simple, safe and easy liver resection.
