Hilar Glissonean Access in Laparoscopic Liver Resection

Laparoscopy for liver resection is a highly specialized field, as laparoscopic liver surgery presents severe technical difficulties. However, the recent rapid development of technological innovations, improvements in surgical skills and the accumulation of extensive experience by surgeons have improved the feasibility and safety of a laparoscopic approach for properly selected patients [1]. Since the first report of laparoscopic anatomical left lateral sectionectomy in 1996 [2], increasing numbers of laparoscopic anatomical liver resections have been reported [3-6]. However, laparoscopic anatomical resection has not been widely accepted because major technical difficulties remain, such as hilar dissection and pedicle control. During open anatomical liver resections, each Glissonean pedicle is often ligated and divided en bloc extrahepatically [7, 8]. Using the same concept, we describe herein a novel technique by which each Glissonean pedicle can be easily and safely encircled and divided en bloc extrahepatically during laparoscopic anatomical liver resection.

presents severe technical difficulties.However, the recent rapid development of technological innovations, improvements in surgical skills and the accumulation of extensive experience by surgeons have improved the feasibility and safety of a laparoscopic approach for properly selected patients [1].Since the first report of laparoscopic anatomical left lateral sectionectomy in 1996 [2], increasing numbers of laparoscopic anatomical liver resections have been reported [3][4][5][6].However, laparoscopic anatomical resection has not been widely accepted because major technical difficulties remain, such as hilar dissection and pedicle control.During open anatomical liver resections, each Glissonean pedicle is often ligated and divided en bloc extrahepatically [7,8].Using the same concept, we describe herein a novel technique by which each Glissonean pedicle can be easily and safely encircled and divided en bloc extrahepatically during laparoscopic anatomical liver resection.

Surgical technique
Laparoscopic encircling of the hepatoduodenal ligament is usually performed using an Endo Retract Maxi (Fig. 1) or Endo Mini-Retract (Covidien Japan, Tokyo, Japan) to be used as a tourniquet for complete interruption of blood inflow to the liver only if necessary [9].Fig. 1.Endo Retract Maxi in activated position.Vessel tape is preliminarily fixed to the tip of the metallic arch.

Encircling right-sided Glissonean pedicles, including the right, anterior, and posterior pedicles
After dividing the cystic artery and duct and dissecting the gallbladder neck, the peritoneum of the hepatoduodenal ligament is dissected at the hepatic hilum (Fig. 2).Retracting the round ligament and gallbladder allows a good operative field of view, facilitating the encircling of each Glissonean pedicle.The metallic arch of an Endo Retract Maxi or Endo Mini-Retract is then meticulously extended between the hepatic parenchyma and the bifurcation of the right and left Glissonean pedicles, so the tip of the metallic arch is visualized (Fig. 3).Although the metallic arch is blindly deployed behind the Glissonean bifurcation, the tip can be safely delivered into the dorsal side of the hepatoduodenal ligament because the blade is blunt.The right Glisonean pedicle is encircled extrahepatically (Fig. 4).In the same way, the metallic arch of Endo Mini-Retract is meticulously extended between the hepatic parenchyma and the bifurcation of the anterior and posterior Glissonean pedicles, then the anterior or posterior Glisonean pedicle is extrahepatically encircled (Fig. 5) [10,11].Hepatic parenchymal dissection along the Cantle line facilitates inserting an endocopic stapler and dividing the right anterior and posterior Glissonean pedicles respectively (Fig. 6).

Encircling left-sided Glissonean pedicles, including the left, medial, and lateral pedicles
Dividing the ligamentum venosum (Fig. 7) and retracting the round ligament upward extends the umbilical portion, facilitating isolation of its root.A parenchymal bridge is divided if present.Dissection between the hepatic parenchyma and umbilical plate is performed.The metallic arch of an Endo Retract Maxi or Endo Mini-Retract is meticulously extended behind the umbilical plate, so the left Glisonean pedicle is encircled extrahepatically (Fig. 8).Hepatic parenchyma is divided along the main portal fissure, which facilitates dividing the left Glissonean pedicle using an endoscopic stapler.A little dissection of the hepatic parenchyma along the umbilical fissure facilitates isolation of the root of the medial Glissonean pedicle (G4) or lateral Glissonean pedicles (G2, G3).Dissection between the hepatic parenchyma and umbilical plate is performed, and G2, G3, or G4 is extrahepatically encircled using Endo Mini-Retract (Fig. 9) and divided using an endoscopic stapler based on resection type (Fig. 10).

Comments
Laparoscopic anatomical segmental resection has not been widely accepted due to technical difficulties in controlling each Glissonean pedicle laparoscopically.Previous reports relating to laparoscopic hemihepatectomy have described separate dissection and division of each of the hepatic artery, duct and portal vein [3][4][5][6], or an intrahepatic Glissonean approach [12,13].The entire length of primary branches of the Glissonean pedicle and the origin of secondary branches are located outside the liver and the trunks of the secondary and more peripheral branches run inside the liver [8].Therefore, the right, left, anterior, posterior, medial, or lateral Glissonean pedicle can be encircled and divided en bloc extrahepatically.Using an Endo Retract Maxi or Endo Mini-Retract, an extrahepatic Glissonean approach can be safe and feasible.However, each Glissonean pedicles should be divided as distally as possible to avoid biliary injury.The right Glissonean pedicle should not be transacted en bloc but the right anterior and posterior Glissonean branches should be divided respectively.The left Glissonean pedicle should be divided at the root of the umbilical portion to avoid injury of the right hepatic duct.Therefore, the pedicle should be encircled left to the Spiegel branch.In addition, each pedicles show shorter extrahepatic courses, and thus are better divided after some amount of parenchymal dissection.

Fig. 8 .
Fig.8.The metallic arch of an Endo Retract Maxi is meticulously extended behind the umbilical plate, so the left Glisonean pedicle is encircled extrahepatically.