Application of temporary inflow control of the Glissonean pedicle method provides a safe and easy technique for totally laparoscopic hemihepatectomy by Glissonean approach

With the recent advances in laparoscopic procedures, laparoscopic liver resection has been performed more widely during the last decade [1]. However, major hepatectomies, such as right or left hemihepatectomy, still remain a challenge to many, due to its technical difficulty. The Glissonian approach, due to its simplicity of procedure, is a technical procedure widely used among liver surgeons performing open hepatectomies [2, 3]. However, because of movement limitations of the instruments during laparoscopic procedures, the Glissonian approach still remains a surgical challenge. Cho et al. [4] proposed the method of a extrahepatic Glissonian approach using Endo Retract Maxi (Covidien Japan, Tokyo, Japan) to encircle the Glisson pedicle and concluded that it is a feasible method. However, despite the aid of the Endo Retract Maxi, many surgeons, especially those with less experience, find it difficult due to the fear of bleeding at the posterior side of the Glissonian pedicle since the dissection has the be done blindly. Machado et al. [5] proposed another method of Glissonian approach by adding 2 small incisions on both sides of the Glissonian pedicle in which to insert the stapler. Although feasible in many circumstances, this approach has 2 potential dangers. First, all major hepatic veins lie between the major Glissonian pedicles and an incision at this area may injure the hepatic vein causing troublesome bleeding. Secondly, applying the stapler before parenchymal dissection and exposure of the Glissonian structures may result in injury of the remnant pedicle due to the restriction of vision and motion.

We herein propose a new method of liver resection by Glissonian approach called temporary inflow control of the Glissonian pedicle (TICGL) technique. This technique provides easy Glissonian approach, allows inflow control during parenchymal dissection thus reducing bleeding, and offers maximal safety during stapling. Due to its technical simplicity, it may be performed quickly, easily and safely even by less experienced surgeons.

Controlled hepatectomy, proposed by Lortat-Jacob and Robert [6] and Honjo and Araki [7] in the 1950s, consisted of division of hepatic inflow first followed by parenchymal resection. This method allows for less blood loss during parenchymal resection because the inflow is controlled before parenchymal resection, and has been a preferred method compared to parenchymal resection first, followed by inflow control proposed Lin et al. [8]. Complete inflow control before parenchymal division requires either individual ligation of hepatic artery and portal vein or complete encircling of the Glissonian pedicle as proposed by Cho et al. [4], but both procedures necessitate technical expertise and are not easy to perform for relatively less experienced surgeons. The TICGL method not only allows inflow control before parenchymal division providing less bleeding, but also incorporates the Glissonian approach, which is less time consuming than individual ligation. Moreover, since the dissection of the posterior part of the Glisson pedicle, often done blindly, is not done before full exposure of the Glissonian structure, it is less technically demanding with less chance of troublesome bleeding. Another advantage of the TICGL method is that the stapling is done after full view of the Glissonian structure providing for safe stapling. It is important to retract the tape leftward during right hepatectomy and rightward during left hepatectomy to not injure the pedicle of the remnant liver.

We believe that the TICGL method, due to its technical simplicity and safety, and ease of reproduction, will provide a way for less experienced surgeons to be able to perform hemihepatectomies with reduced operative time.