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

Abstract

BACKGROUND: 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. METHODS: 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. RESULTS: 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 270 min (range, 190-310 min), and the median estimated blood loss was 130 mL (range, 30-700 mL). Postoperative morbidity occurred in three patients (16.7%). There were no deaths. CONCLUSION: The feasibility and safety of the Glissonean approach in lap-RPS could be increased through appropriate selection of extrahepatic, intrahepatic, and transfissural Glissonean approaches.

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