Tailored Strategy for Dissecting the Glissonean Pedicle in Laparoscopic Right Posterior Sectionectomy: Extrahepatic, Intrahepatic, and Transfissural Glissonean Approaches (with Video)

Laparoscopic Anatomical Resection of the Dorsal Segment of the Right Anterior Section Using an Extrahepatic Glissonean Approach: 3D Reconstruction Simulation and ICG Fluorescent Navigation

BACKGROUND

Advances in laparoscopic techniques and technology have led to the increased performance of laparoscopic hepatectomy. Laparoscopic anatomical resection of the dorsal segment of the right anterior section (RAS) of the liver, however, remains complex and is infrequently performed because of its technical challenges. This study describes the laparoscopic anatomical resection of the dorsal segment of the RAS using an extrahepatic Glissonean approach, guided by preoperative 3D reconstruction and intraoperative indocyanine green (ICG) fluorescent imaging.

METHODS

A 3D reconstruction image was generated preoperatively for surgical planning, and the patient was placed in the lithotomy position with five trocars. The target dorsal Glissonean pedicle was isolated via an extrahepatic Glissonean approach. ICG fluorescent imaging provided real-time guidance, allowing for precise delineation of the dorsal segment. Parenchymal transection was completed under ICG guidance to maintain a clear intersegmental plane.

RESULTS

The operation time was 220 minutes, with an estimated blood loss of 80 mL and no blood transfusion required. Pathologic examination showed a 22-mm hepatocellular carcinoma with a 21-mm margin. No bile leakage was observed, and the patient was discharged on postoperative day 6 without complications.

CONCLUSIONS

Findings in this patient demonstrate that the extrahepatic Glissonean approach, combined with 3D image reconstruction and ICG fluorescent imaging, enables precise, safe, and effective laparoscopic anatomical resection of the dorsal RAS segment. This approach has promise for the use of minimally invasive surgical techniques in advanced anatomical liver resection.

Anatomical insights into Rouviere's Sulcus through the Glissonean approach in minimally invasive right-sided sepatectomy

BACKGROUND

Understanding the liver anatomy, particularly the Rouviere sulcus (RS), is crucial for safely performing cholecystectomy and hepatectomy. As surgical interest in right-sided hepatectomies using the Glissonean pedicle approach has increased, a thorough understanding of the RS anatomy is becoming increasingly important. This study aimed to investigate the presence and anatomical contents of the RS during right-sided hepatectomy and to develop a preoperative assessment method to improve surgical safety and precision.

METHODS

Patients who underwent laparoscopic or robotic right-sided hepatectomy with RS dissection were included in the study. The RS was categorized into open and closed types, and its contents were examined to identify the presence of Glissonean pedicles. The findings were compared with simulations generated from 3-dimensional reconstruction imaging for further analysis.

RESULTS

Of the 83 patients, 62 (74.7%) had open-type RS, and 21 (25.3%) had closed-type RS. Among the open-type RS cases, 38 patients (61.3%) involved the right posterior Glissonean pedicle within the RS, whereas 19 patients (30.7%) involved segment 6 Glissonean pedicle. Preoperative imaging revealed that when the right posterior Glissonean pedicle did not form a common trunk with segments 6 and 7, the Glissonean pedicle of segment 6 was located within the RS. The variation observed in 5 cases (8.1%) with the right main Glissonean pedicle in the RS was significant and should be carefully considered during surgery.

CONCLUSION

A thorough understanding of the RS anatomy is essential for safe and precise right-sided hepatectomy. Our findings emphasize the variability of RS, particularly concerning the presence of different Glissonean pedicles, including the right posterior segment 6 and, in rare cases, the right main Glissonean pedicle. Our findings highlight the necessity for individualized preoperative imaging and careful consideration of anatomical variations to minimize complications during right-sided hepatectomy.

Intrahepatic Glisson Intrathecal Dissection via a Hepatic Parenchymal Transection-First Approach for Laparoscopic Anatomical Hemihepatectomy in Patients with Left/Right Glisson Pedicle Involvement

Background: Because of lack of an appropriate surgical approach, laparoscopic surgery in patients with left/right Glisson pedicle involvement is still rarely conducted. This study aimed to discusses the methods of intrahepatic Glisson intrathecal dissection via a hepatic parenchymal transection-first approach for laparoscopic hemihepatectomy in patients with left/right Glisson pedicle involvement. Materials and Methods: We retrospectively analyzed the clinical data of 21 patients who underwent laparoscopic hepatectomy in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from March 2021 to May 2022. Results: The mean age of the patients was 53.1 ± 11.6 years; mean operation time, 191.9 ± 22.3 minutes; median intraoperative blood loss, 205 mL (160-300 mL); and median length of hospital stay, 8 days (7-9 days). None of the patients underwent conversion to open procedure. Thirteen patients had pathologically confirmed hepatocellular carcinoma (HCC) with portal tumor thrombi (PVTT), and 8 was confirmed hepatolithiasis. Intraoperative frozen pathology and final pathology showed tumor free surgical margins in HCC with PVTT patients. After conservative treatment, all the complications such as postoperative liver section effusion, pleural effusion, pneumonia, intra-abdomen bleeding, and bile leak were cured. During outpatient follow-up examination, no other abnormality was detected. All HCC with PVTT patients were treated with a tyrosine kinase inhibitor after the operation and survived tumor-free. Conclusions: Proposed here is a more safe and feasible method of laparoscopic hemihepatectomy in patients with left/right Glisson pedicle involvement, but many problems still needs further exploration.

Roboter-assistierte Hemihepatektomie links mittels Glissonean pedicle approach bei Caroli Syndrom

Zielsetzung Das Caroli-Syndrom ist eine seltene Gallenwegserkrankung, die durch eine nicht obstruktive Dilatation der intrahepatischen Gallenwege, Leberfibrose und ein erhöhtes Risiko für ein cholangiozelluläres Karzinom charakterisiert ist. Eine Leberresektion ist beim lokalen Befund die Therapie der Wahl und wird in der Literatur zunehmend minimalinvasiv durchgeführt. Allerdings wurde in der Literatur bisher eine roboterassistierte Leberresektion beim Caroli-Syndrom nicht beschrieben. Indikation Eine 72-jährige asiatische Patientin wurde mit einer multifokalen zystischen Dilatation der Lebersegmente II, III und IV unserer Klinik vorgestellt. Bis auf eine konventionelle Appendektomie waren keine weiteren Voroperationen und Vorerkrankungen, insbesondere keine kongenitalen Zysten, bekannt. Die Leberfunktionsparameter waren unauffällig und die Echinokokkus-Serologie fiel negativ aus. Die MRT-Schnittbildgebung zeigte eine reguläre Gallenwegsanatomie der rechten Leber. Eine roboterassistierte Hemihepatektomie links mit dem Da Vinci Xi-System wurde geplant. Methode Die roboterassistierte Hemihepatektomie links wurde in einer Französischlagerung durchgeführt. Zunächst erfolgte eine Adhäsiolyse und Cholezystektomie. Eine aberrante Leberarterie aus der A. gastrica sinistra wurde mithilfe von Clips abgesetzt. Nach Senkung der hilären Platte wurde der linke Pedikel en bloc mittels Glissonean Pedicle Approach umfahren und mit einer Bulldog-Klemme ausgeklemmt. Eine ischämische Demarkationslinie zur rechten Leber zeichnete sich auf der Leberoberfläche ab. Die Parenchymdissektion wurde mittels bipolarer Pinzette durchgeführt. Ein Pringle-Manöver wurde nicht angewendet. Der linke Pedikel und die linke Lebervene wurden mit einem robotischen Linearstapler abgesetzt und die mittlere Lebervene erhalten. Die regelrechte Perfusion der Restleber inkl. Segment I wurde mittels intravenöser Indocyaningrünapplikation (ICG) in einer Dosierung von 0,2 mg/kg Körpergewicht bestätigt. Das Resektat wurde in einen Bergebeutel verbracht und über einen Pfannenstiel-Schnitt geborgen. Die OP-Zeit betrug 239 min mit einem Gesamtblutverlust von 100 ml. Die Patientin wurde am 5. postoperativen Tag entlassen. Der histologische Befund bestätigte ein Caroli-Syndrom. In der 6-Monats-Verlaufskontrolle hatte die Patientin eine regelrechte Leberfunktion ohne Zeichen einer rezidivierenden Erkrankung. Schlussfolgerung Eine Hemihepatektomie links ist in der Glissonean-Pedicle-Approach-Technik sicher roboterassistiert durchführbar und ein geeignetes Verfahren für die Therapie des Caroli-Syndroms.