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 refinement of the Glissonean pedicles approach are fundamental skills in MIALR, ensuring safety, efficiency, and accuracy^3,4,5. Atsushi Sugioka's Gate Theory, based on the anatomical structure of the Laennec capsule, provides a well-established solution that has gained wide recognition^6,7(Figure 1A,B). It also describes the surgical procedure for MIALR, which includes the initial isolation and ligation of the Glissonean pedicle corresponding to the hepatic lobe, followed by the resection of the lobe.

In clinical practice, conventional hepatectomy of the right posterior liver lobe is typically performed by dissecting and ligating the right posterior Glissonean pedicle in the Rouviere's groove or by directly accessing Gate V and Gate VI through the porta^7,8. However, surgery limitations, diminished tactile sensitivity, reduced global visual control ability, and anatomical variations may cause intraoperative confusion in anatomical orientation for tumors located near the bifurcation of the Glissonean pedicle in the liver (excluding hilar cholangiocarcinoma). These challenges may lead to inadvertent damage to variant blood vessels of the posterior portal vein, subsequent bleeding, and rupture of the tumor capsule^5,9,10,11. Furthermore, conventional hepatectomy of the right posterior liver lobe, or occlusion of the hepatoduodenal ligament or right Glissonean pedicle, is often necessary to minimize intraoperative bleeding^2,3. However, this occlusion not only induces ischemia on the tumor-bearing side of the liver but also affects the normal side, exacerbating hepatic ischemia-reperfusion injury (IRI)^1,12.

Takasaki et al. previously described the extrahepatic isolation of the posterior sectional pedicle using the subtraction method^7,8, while Sugioka and Kato described subtraction techniques for the extrahepatic isolation of peripheral segmental pedicles¹³. These applications align with liver resection in the context of peripheral subtractive dissection of the Glissonean pedicle (PSDGP), with the primary objective of mitigating pedicle injury or tumor rupture during direct pedicle isolation. Therefore, this study proposes the use of PSDGP technology for specific tumor types located near the bifurcation of the Glissonean pedicle in the liver (excluding hilar cholangiocarcinoma). The primary objective is to mitigate bleeding risk during the separation of the right posterior hepatic pedicle and prevent rupture of the tumor capsule, while concurrently reducing IRI in the residual liver.

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 hepatoduodenal ligament and perform the intermittent Pringle maneuver in an intracorporeal manner.
   1. Insert a 10 mm trocar above the umbilicus for the observation port.
   2. Insert a 12 mm trocar below the xiphoid process for the assistant's port.
   3. Insert a 5 mm trocar at the upper one-third of the line connecting the xiphoid process to the umbilicus.
   4. Insert a 12 mm trocar at the intersection of the midclavicular line and the costal margin for the surgeon's port.
   5. Insert a 5 mm trocar at the intersection of the anterior axillary line and the costal margin for the second surgeon's port.
2. Carefully expose the Laennec's capsule by dissecting along the cystic plate through the surface of the right Glissonean pedicle. Confirm the right Glissonean pedicle in the liver by identifying the continuation of the hepatoduodenal ligament. Continue the dissection until reaching the surfaces of both the right posterior and right anterior Glissonean pedicles (Figure 1C).

3. Pedicle management

1. Retract the base of segment 4 using a laparoscopic long and curved grasper on the upper right side. Pull the hepatoduodenal ligament to the lower left side using the intracorporeal Pringle maneuver.
2. Expose the visceral peritoneum at the base of segment 4 of the liver hilum (Figure 2A). Using non-traumatic forceps and an ultrasonic scalpel, carefully dissect the visceral peritoneum between Laennec's capsule covering segment 4 and the superior surface of the hilar plate.Dissect and ligate small branches from the right Glissonean pedicle to provide sufficient space for isolation. Ensure meticulous dissection of small branches to avoid biliary leakage (Figure 2B).
3. Detach the left side of the hilar plate from the base of segment 4. Continue dissection to the right side of the umbilical plate (Figure 2C).
4. Temporarily occlude the hepatoduodenal ligament during the descent of the hilar plate to minimize hemorrhage and prevent contamination of Laennec's capsules. This ensures optimal visibility and facilitates the subsequent procedural intervention.
5. Prepare a 15 cm long size 0 non-absorbable suture (3.5 metric) or a similar suture, labeled as 'a' and 'b,' with the end 'b' secured in advance.
6. Use non-traumatic forceps to guide end 'a' of the non-absorbable suture (3-0) through gate VI towards gate IV, facilitating access to the right Glissonean pedicle (Figure 3A).
7. Use non-traumatic forceps to direct end 'a' of the non-absorbable suture from gate IV to gate V on the right side, resulting in the acquisition of the right anterior Glissonean pedicle (Figure 3B).
8. Simultaneously pull both ends ('a' and 'b') of the non-absorbable suture to expose the right posterior Glissonean pedicle (Figure 3C).
9. Apply tension to the 'a' and 'b' ends of the non-absorbable suture to occlude the right posterior Glissonean pedicle (Figure 4A). Use the Pringle maneuver to occlude the right Glissonean pedicle, reducing bleeding during liver resection and minimizing ischemia-reperfusion injury (IRI) (Figure 4B).
   NOTE: This approach ensures an optimal outcome, ultimately achieving precise MIALR of the right posterior hepatic lobe (Figure 4C).

4. Post-operative patient care and monitoring

1. Monitor the patient and administer low-flow oxygen on the 1^st day after the operation.
2. Initiate the Enhanced Recovery After Surgery (ERAS) protocol on the first post-operative day, allowing patients to commence liquid diets and engage in bedside activities.
3. Administer hepatoprotective agents, albumin, anti-inflammatory drugs, analgesics, and low-dose spironolactone for diuretic therapy.
4. Monitor liver function (Alanine aminotransferase [ALT], Aspartate aminotransferase [AST], total bilirubin [TBIL], direct bilirubin [DBIL]) and coagulation function (prothrombin time [PT], activated partial thromboplastin time [APTT], thrombin time [TT], fibrinogen [FIB]) on the 1^st, 3^rd, and 5^th days after the operation.

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-operativ...

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

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