Laparoscopic Anatomical Liver Resection Using Glissonian Approach

Jai Young Cho, MD PhD, Ho-Seong Han, MD PhD, Yoo-Seok Yoon, MD PhD, Keun Soo Ahn, MD, Ji Hoon Kim, MD. Seoul National University Bundang Hospital, Department of Surgery, Seoul National University College of Medicine, Korea

Background: Laparoscopic liver resections have evolved rapidly but anatomical liver resection, especially in the right side of the liver is still rarely performed. The safety and reproducibility of laparoscopic anatomical liver resection using Glissonian approach was evaluated.
Methods: Of 265 consecutive laparoscopic liver resections performed from August 2004 to September 2010, twenty three laparoscopic anatomical liver resections using Glissonian approach for right sided resection were evaluated. For these patients, the Pringle maneuver in the contralateral liver was not used in any patient. When the Glissonian approach was adopted for right sided resection, hilar dissection was performed to isolate the right Glisson’s pedicles at the inferior surface of the quadrate lobe. For right posterior sectionectomy, the right Glisson’s pedicle was further dissected into the anterior and posterior pedicles. Each of these two Glisson’s pedicles was separately isolated. The posterior Glisson’s pedicle was extraparenchymally divided en masse with using a linear stapler. For central bisectionectomy, the Glisson’s pedicles to the left medial section were transected first, then after the parenchymal dissection along the superior side of the hilar plate toward the right, the Glissonian pedicle to the right anterior section was transected. For S5 segmentectomy, the Glissonian pedicle to S5 was isolated after hepatotomy along the right anterior pedicle.
Results: Using Glissonian approach, seven right hepatectomy, eleven right posterior sectionectomy, three central bisectionectomy, and one S5 segmentectomy was performed. One central bisectionectomy which was converted to open surgery was excluded. The mean patient age was 55.1 (range 33 ~ 75) years. Twelve patients had underlying cirrhosis. Indication for surgery was hepatocellular carcinoma (n = 14), hepatolithiasis (n = 5), and hepatic metastasis (n = 3). The mean tumor size was 3.3 (0.3 ~ 6.9) cm. The mean operating time was 485 (range 270 ~ 835) min. Mean blood loss was 808 (range 250 ~ 1800) ml. Transfusion was required in ten patients. There was no death. Four patients had postoperative complications (three ascites and one biloma). The mean postoperative stay was 11 (range 6 ~ 26) days.
Conclusion: Using Glissonian approach, safe and reproducible laparoscopic anatomical liver resection in the right side of the liver was feasible without any additional Pringle maneuver in this series.