Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

Here, we present a protocol to perform laparoscopic right posterior sectionectomy, focusing on two key aspects: the intrahepatic Glissonian approach for inflow control and a parenchymal transection technique using an ultrasonic surgical aspirator.

After inserting the laparoscope ports in the patient, complete the division of the triangular ligament until the bare area of the liver is exposed. Expose the groove that lies between the right hepatic veins and the common trunk of the middle and left hepatic veins. Then, incise the inferior peritoneal attachment and gently lower the adrenal gland to the retroperitoneum.

Divide the short hepatic veins and the ligament connecting to the vena cava until the inferior border of the right hepatic vein becomes visible. Carefully dissect along the superior border of the right posterior Glissonean pedicle along the Rouviere's sulcus, while ensuring the integrity of the Laennec capsule. Then transect the caudate process to reveal the inferior margin of the right posterior Glissonean pedicle.

Dissect along the inferior border of the right posterior Glissonean pedicle along the Rouviere's sulcus. Using a bulldog clamp, control the right posterior pedicle. With the help of an ultrasonic scalpel, carefully open the liver capsule.

Make the incision at the dome of the liver, precisely along the left margin of the right hepatic vein, ensuring a secure and accurate transection plane. Then use diathermy to mark the remainder of the transection line along the ischemic line. Using Huang's loop and a shortened Foley catheter, prepare an intracorporeal tourniquet for the laparoscopic Pringle maneuver.

Carefully open the liver capsule along the predetermined transection line. Heat both arms of the ultrasonic scalpel in the open position. Utilize the active blade of the ultrasonic scalpel for tissue dissection.

Activate the ultrasonic scalpel at its maximum power setting, and move the active blade in a horizontal swinging motion parallel to the vasculobiliary structures. Then dissect the liver parenchyma while exposing individual intrahepatic vessels and ensuring their preservation. Employ a suction device with the left hand to maintain a dry surgical field continually.

And then use either plastic clips or metal clips to divide large vessels or pedicle structures. Use an ultrasonic scalpel to divide small vessels. To address bleeding, use bipolar diathermy while simultaneously using suction to maintain a clear surgical field.

Wrap vascular tape around the right posterior pedicle before cutting with a vascular stapler. Use intracorporeal sutures for significant bleeding, such as bleeding from the right hepatic vein. Transect the right hepatic vein using a vascular stapler.

Finally, place the specimen into a plastic bag and retrieve the specimen through the Pfannenstiel incision. In the representative case, the total operative time was 738 minutes, with an estimated blood loss of 400 milliliters. The patient was discharged on post-operative day five.

The resection margin was 14 millimeters.