Peripheral Subtractive Dissection of Glissonean Pedicles in Minimally Invasive Anatomic Liver Resection for Right Posterior Lobe Tumors

Summary

Minimally invasive anatomic liver resection (MIALR) involving Glissonean pedicle ligation for the right posterior hepatic lobe may cause tumor rupture, hemorrhage, and ischemia-reperfusion injury (IRI). This study proposes a novel surgical approach, peripheral subtractive dissection of the Glissonean pedicle (PSDGP), aimed at mitigating these risks.

Abstract

Minimally invasive anatomic liver resection (MIALR) has recently garnered significant attention and has rapidly advanced in the field of hepatobiliary surgery. In particular, the dissection of the Glissonean pedicle, such as in Atsushi Sugioka's Gate Theory, represents a fundamental operative technique within MIALR. This technique is based on the anatomical structure of the Laennec capsule, thereby promoting and implementing MIALR in a scientifically rigorous manner. However, potential risks such as hemorrhage, ischemia-reperfusion injury (IRI), and tumor rupture may arise during MIALR in clinical practice, particularly when it is applied to tumors located in the right posterior hepatic lobe near the bifurcation of the Glissonean pedicles (excluding hilar cholangiocarcinoma). To address these challenges, this study introduces a unique surgical approach, termed peripheral subtractive dissection of the Glissonean pedicle (PSDGP), designed to mitigate these potential complications. During the PSDGP procedure in MIALR for liver tumors, the cystic plate approach is utilized to facilitate extrahepatic dissection. Initially, a non-absorbable suture is threaded from Gate VI to Gate IV under the guidance of non-traumatic forceps (or similar instruments). Subsequently, the non-traumatic forceps are passed through Gate V again to retrieve the non-absorbable suture from Gate IV. Finally, both Gate V and Gate VI are used to achieve the separation of the right posterior Glissonean pedicle. This method may improve surgical success rates and yield better oncological outcomes due to its strict adherence to the no-touch and en-bloc principles of tumor resection.

Introduction

Laparoscopic hepatic surgery has been continuously explored and developed for more than three decades, evolving from sporadic liver resections to precise minimally invasive anatomic liver resection (MIALR). It has become a prominent area within hepatobiliary surgery, gaining considerable attention in recent years^1,2,3,4,5. This technique offers several advantages, including enhanced visualization and magnification of the surgical field, enabling precise surgical operations. Accurate understanding and refine....

Protocol

1. Patient selection

1. Select patients based on the following inclusion criteria: tumor in the right posterior lobe (both benign and malignant tumors).
2. Exclude patients based on the following exclusion criteria: hilar cholangiocarcinoma and hepatic neoplasm without metastasis.

2. Surgical procedure

1. Place patients in the lithotomy position after combined intravenous-inhalational anesthesia (following institutionally approved protocols). Insert five trocars into the upper abdomen. Maintain intra-abdominal pressure at 13 mmHg. Insert an umbilical tape to encircle the hepa....

Results

The surgery was completed in 176 min, with minimal intraoperative bleeding of 50 mL and no need for a blood transfusion. The right Glissonean pedicle was occluded twice, with the first occlusion lasting 15 min and the second lasting 20 min. The hepatoduodenal ligament was not occluded during the procedure, and an adequate blood supply to the left liver was maintained while preserving the right hepatic vein (Figure 4C). No short-term complications occurred, and the patient's post-operative re.......

Discussion

The extracorporeal dissection method of the Glissonean pedicles is safe, effective, and expedient, making it a fundamental technique for MIALR^2,3,7,13. The Glissonean pedicles and their branches provide blood supply to the hepatic lobes and facilitate bile outflow. Safe and efficient dissection of the Glissonean pedicles during surgery is essential for the successful implementation of MIALR.

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Electrocantery	Hangzhou Kangji Medical Instrument Co., Ltd	KJ-SJ0205	Sterile,dry heat sterilized, reusable
Gold finger	Hangzhou Kangji Medical Instrument Co., Ltd	101.237Φ10*350mm	Sterile,dry heat sterilized, reusable
Non-absorbable suture	Johnson & Johnson MEDICAL (CHINA) Ltd	2-0/W2512	Sterile, ethylene oxide sterilized, disposable
Non-traumatic forceps	Hangzhou Kangji Medical Instrument Co., Ltd	Φ10×260	Sterile,dry heat sterilized, reusable
Soft rubber ureteric catheter	Yangzhou Jinhuan Medical  Appliance factory	Type A 5.3mm(16Fr)	Sterile, ethylene oxide sterilized, disposable
Trocar	Zhejiang Geyi Medical Instrument Co.,Ltd	GYTR-I Φ5/Φ10/Φ12	Sterile, ethylene oxide sterilized, disposable