Ann Surg Treat Res.  2017 May;92(5):383-386. 10.4174/astr.2017.92.5.383.

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

• Lee N
• Cho CW
• Kim JM
• Choi GS
• Kwon CH
• Joh JW

• KMID: 2377712
• DOI: http://doi.org/10.4174/astr.2017.92.5.383

Abstract

The Glissonian approach, due to its simplicity of procedure, is a technical procedure widely used in open hepatectomy. However, it is not easily applicable in the setting of the total laparoscopic approach because of movement restriction. We herein propose a new and simple method of performing hemihepatectomy by Glissonian approach called temporary inflow control of the Glissonian pedicle (TICGL) technique. Dissection of the Glisson pedicle from the liver parenchyma is done until the posterior margin of the pedicle is visualized, and is clamped with bulldog clamps. Encircling the pedicle is not necessary. Resection of the liver parenchyma is performed under inflow control of the resected side liver providing less bleeding. After sufficient resection is done so that the whole Glissonian pedicle structures are visualized, the pedicle is encircled, often very easily without the fear of bleeding from the posterior side of the pedicle, which is a common problem when encircling is done before parenchymal resection. The staplers may then be applied safely without injuring the major hepatic veins since they have been already exposed. Stapling is done while the tape is retracted toward the contralateral side. This retraction prevents injury or stricture of the contralateral Glissonian pedicle branch. The remnant liver parenchyma is resected and hepatectomy finalized. The TICGL technique provides a safe and easy way of performing major hemihepatectomies, not only by expert laparoscopic surgeons but by less experienced surgeons. It can therefore become a standard method of performing hemihepatectomy by Glissonian approach.

Keyword

Laparoscopic surgical procedures; Hepatectomy; Hepatocellular carcinoma; Glissonian approach

MeSH Terms

Carcinoma, Hepatocellular
Constriction, Pathologic
Hemorrhage
Hepatectomy
Hepatic Veins
Laparoscopy
Liver
Methods*
Surgeons

Figure

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  Fig. 1 The right Glissonean pedicle (black arrow) is detached from the liver surface (white arrow) by blunt dissection using bipolar clamp and suction at the superior (A) and inferior plane (B).

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  Fig. 2 (A) Arterial bulldog is applied on the Glissonean pedicle. (B) Additional bulldog may be applied for maximal inflow control especially in cirrhotic livers with thick pedicle. Hemostasis of minor bleeding is easily achieved with hemostatic agents.

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  Fig. 3 After sufficient parenchymal resection is done, bifurcation of Glissonean pedicle is well exposed. A nylon tape is easily and safely encircled around the pedicle using the Goldfinger without fear of injury to the parenchyma or middle hepatic vein (white arrow).

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  Fig. 4 The stapling of the whole Glissonean pedicle is done. A leftward traction of the nylon tape (white arrow) during stapling enables the stapling line to be positioned sufficiently to the right side so that the left side portal vein or bile duct is not compromised making the stapling very safe.

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