Anatomical bases and initial clinical application of the intrahepatic Glissonian approach in hepatectomies.
DOI:
https://doi.org/10.31837/cir.urug.6.1.8Keywords:
Glissonian approach, hepatic vascular control, hepatectomiesAbstract
Introduction: Pedicle control during liver resections can be done by extrahepatic hilar dissection (EHD) or the Glissonian approach (GA). Intrahepatic GA (IGA) according to the Machado technique can offer certain advantages, especially in difficult dissections. However, it is used less than the DHE.
Objective: to analyze the anatomical bases of the IGA and to communicate our initial clinical experience.
Material and methods: IGA according to the Machado technique was performed on six (6) cadaveric livers. Liver dissection was then performed to assess the effectiveness of pedicle loading and measure the depth of the different Glissonian pedicles. The clinical application of the technique was gradual and selective, applying it when it seemed feasible and that it provided some advantage over DUS.
Results: in the 6 cadaveric livers it was possible to load all the Glissonian pedicles (lobar and sectoral bilaterally, as well as the left segmental ones). These are found at a depth of less than 2 cm from the hepatic capsule, being accessible for control by IGA. The main exception is the right anterior pedicle, whose origin is deeper, which, associated with its cephalad and sometimes branched origin, can make it more difficult to load. The application of the IGA was carried out in 5 patients, in all of them it was effective, it took little time and there were no intraoperative complications.
Conclusions: the IGA according to the Machado technique is a systematic, reproducible, feasible and safe procedure, even in its initial clinical application. The anatomical knowledge of the Glissonian pedicles is essential to carry it out successfully
Downloads
References
Pringle JH. Notes on the Arrest of Hepatic Hemorrhage Due to Trauma. Ann Surg. 1908; 48:541-9. doi: 10.1097/00000658-190810000-00005.
Lortat-Jacob JL, Robert HG, Henry C. Case of right segmentectomy. Mem Acad Chir.1952;78:244-51.
Takasaki K, Kobayashi S, Tanaka S, Saito A, Yamamoto M, Hanyu F. Highly anatomically systematized hepatic resection with Glissonean sheath code transection at the hepatic hilus. Int Surg. 1990; 75:73-7.
Strasberg S, Linehan D, Hawkins W. Isolation of Right Main and Right Sectional Portal Pedicles for Liver Resection Without Hepatotomy or Inflow Occlusion. J Am Col Surg. 2008;206:390-6. doi: 10.1016/j.jamcollsurg.2007.06.317
Sugioka A, Kato Y, Tanahashi Y. Systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection based on Laennec’s capsule: proposal of a novel comprehensive surgical anatomy of the liver. J Hepatobiliary Pancreat Sci. 2017;24:17-23. doi: 10.1002/jhbp.410.
Ton-That-Tung, Nguyen-Duong-Quang. Segmentary hepatectomy by transparenchymatous vascular ligation. Presse Med. 1965;73:3015-7
Galperin EI, Karagiulian SR. A new simplified method of selective exposure of hepatic pedicles for controlled hepatectomies. HPB Surgery. 1989;1:119-30. doi: 10.1155/1989/28161.
Launois B, Sutherland FR, Harissis HA. New technique of Hepp-Couinaud hepaticojejunostomy using the posterior approach to the hepatic hilum. J Am Coll Surg. 1999;188:59-62.
Machado MA, Herman P, Machado MC. A Standardized Technique for Right Segmental Liver Resections. Arch Surg. 2003;138:918-20 doi: 10.1001/archsurg.138.8.918
Machado MA, Herman P, Machado MC. Anatomical Resection of Left Liver Segments. Arch Surg. 2004;139:1346-9.
Koch M; Garden J, Padbury R, Rahbari N, Adam R, Capussotti L, et al . Bile leakage after hepatobiliary and pancreatic surgery: A definition and grading of severity by the International Study Group of Liver Surgery. Surgery. 2011;149:680-8. doi: 10.1016/j.surg.2010.12.002
Dindo D, Demartines N, Clavien P-A: Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13. doi: 10.1097/01.sla.0000133083.54934.ae
Surjan R, Makdissi F, Machado MA. Anatomical basis for the intrahepatic glissonian approach during hepatectomies. Arq Bras Cir Dig. 2015;28(2):128-31. doi: 10.1590/S0102-67202015000200011
Nakai T, Koh K, Funai S, Kawabe T, Okuno K, Yasutomi M. Comparison of controlled and Glisson's pedicle transections of hepatic hilum occlusion for hepatic resection. J Am Coll Surg.1999;189:300-04. doi: 10.1016/s1072-7515(99)00127-1.
Machado MA, Herman P, Figueira E, Bacchella T, Machado MC. Intrahepatic Glissonian access for segmental liver resection in cirrhotic patients. Am J Surg. 2006;192:388-92. doi: 10.1016/j.amjsurg.2006.01.017
Ji B, Wang Y, Wang G, Liu Y. Curative Resection of Hepatocellular Carcinoma Using Modified Glissonean Pedicle Transection versus the Pringle Maneuver: A Case Control Study. Int. J. Med. Sci. 2012; 9:843-52. doi: 10.7150/ijms.4870.
Giordano M, Lopez-Ben S, Codina-Barreras A, Pardina B, Falgueras L, Torres-Bahi S, et al. Extra-Glissonian approach in liver resection. HPB. 2010;12:94-100. doi: 10.1111/j.1477-2574.2009.00135.x
Mouly C, Fuks D, Browet F, Mauvais F, Potier A, Yzet T, et al. Feasibility of the Glissonian approach during right hepatectomy. HPB. 2013;15: 638-45. doi: 10.1111/hpb.12035.
Figueras J, Lopez-Ben S, Lladó L, Rafecas A, Torras J, Ramos E, et al. Hilar Dissection versus the “Glissonean” Approach and Stapling of the Pedicle for Major Hepatectomies: A Prospective, Randomized Trial. Ann Surg. 2003;238: 111-9. doi: 10.1097/01.SLA.0000074981.02000.69.
Smyrniotis V, Arkadopoulos N, Theodoraki K, Voros D, Vassiliou I, Polydorou A, et al. Association between biliary complications and technique of hilar division (extrahepatic vs. intrahepatic) in major liver resections. World J Surg Oncol. 2006;4:59. doi:10.1186/1477-7819-4-59.
Karamarkovic? A, Doklestic? K, Milic? N, Djukic? V, Bumbasirevic? V, Sijac?ki A, et al. Glissonean pedicle approach in major liver resections. Hepatogastroenterology. 2012;59(118):1896-901. doi: 10.5754/hge12198
Machado MA, Surjan R, Basseres T, Schadde E, Costa F, Maldissi F. The laparoscopic Glissonian approach is safe and efficient when compared with standard laparoscopic liver resection: Results of an observational study over 7 years. Surgery. 2016;160(3):643-51. doi: 10.1016/j.surg.2016.01.017.
D’Amico F, Allen P, Eaton A, DeMatteo R, Fong Y, Kingham T, et al. Vascular inflow control during hemi-hepatectomy: a comparison between intrahepatic pedicle ligation and extrahepatic vascular ligation. HPB (Oxford). 2013;15:449-56. doi: 10.1111/j.1477-2574.2012.00618.x.
Cresswell A, Welsh F, John T, Rees M. Evaluation of intrahepatic, extra-Glissonian stapling of the right porta hepatis vs. classical extrahepatic dissection during right hepatectomy. HPB (Oxford). 2009;11:493-8. doi: 10.1111/j.1477-2574.2009.00083.x
Machado MA, Makdissi F, Surjan R. Laparoscopic liver resection. Personal experience with 107 cases. Rev. Col. Bras. Cir. 2012; 39(6):483-8. doi: 10.1590/s0100-69912012000600007.
Karamarkovic? A, Doklestic? K. Pre-resectional inflow vascular control: extrafascial dissection of Glissonean pedicle in liver resections. Hepatobiliary Surg Nutr. 2014;3(5):227-37. doi: 10.3978/j.issn.2304-3881.2014.09.09.
Chouillard E, Gumbs A, Cherqui D. Vascular clamping in liver surgery: physiology, indications and techniques. Annals of Surgical Innovation and Research. 2010;4:2. doi: 10.1186/1750-1164-4-2
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All articles, videos and images published in Revista Cirugía del Uruguay are under the Creative Commons CC licenses, which is a complement to the traditional copyright, in the following terms: first, the authorship of the referred document must always be acknowledged and secondly none of the article or work published in the journal may have commercial purposes of any nature. The authors retain their copyrights and give the magazine the right of first publication of their work, which will be simultaneously subject to the Creative Commons Attribution-NonCommercial 4.0 International License license that allows the work to be shared whenever the initial publication is indicated in this journal.
