Glissonian pedicle approach presentation.pptx

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1. Glissonian pedicle approach of Liver Resection

2. History Partial liver resection and non-anatomical liver resection were common before 1950 Lortat -Jacob and Robert and Honjo and Araki performed anatomical right hepatectomy with dissection of the hepatic artery, portal vein and bile duct in the hepatoduodenal ligament around 1950 { Infrafascial approach } – Controlled hepatectomy Extrafascial transfissural approach – Ton That Tung in 1960 Glissonian pedicle( Extrafascial )approach at the hepatic hilus was reported by Takasaki et al. in 1986 Launois and Jamieson - described the intrahepatic Glissonian pedicle approach to liver resection in 1992 Makuuchi et al. - to puncture and inject dye to the portal pedicle for confirming the resection area under intraoperative ultrasonography.

3. Glisson’s capsule – Connective tissue wrap around the portal vein, the hepatic artery and the bile duct ( Francis Glisson in 1654 ) Glisson’s capsule forms a thick plate at the inferior part of the liver – ‘ hilar plate’ Hilar plate connects to Cystic plate, Umbilical - plate, Arantius plate Laennec’s capsule – Proper membrane of liver by Counaud

4. Branching pattern of Pedicles

5. Takasaki segmentation

6. RHV, MHV – Intersegmental LHV drains exclusively Left segment Relationship of segments with hepatic veins

7. Caudate area A – Superior part of IVC B – Bifurcation of Rt primary pedicle C – Origin of Lt segmental branch D – Edge of caudate process The border between the left segment and the caudate area is determined by the anterior paracaval triangle ( Traingle ABC ) The border between the right segment and the caudate area is determined by the lateral paracaval triangle ( Triangle ABD )

8. Comparision with other classification systems

9. Each Couinaud’s segment does not necessarily contain only one single tertiary branch. One Couinaud’s segment consists of several cone units. Usually from two to eight tertiary branches ramify from a secondary branch.

10. Position of Glissonian pedicles inside the segments

11. Relation between pedicles and hepatic vein Upper part of liver Lower part of liver

12. Cone unit The area fed by each of the tertiary branches is called a “cone unit” One cone unit is the smallest unit for which a tertiary branch can be transected selectively

13. Instruments Boomerang retractor Side retractor Kent retractor

14. Glisson’s foreceps Sonosurg (CUSA)

15. Selective clamping of segmental pedicles

16. Resection of middle segment

17. Resection of Right segment

18. Isolating whole right segmental branch

19. Resection of left segment

20. Right lobectomy Right trisectionectomy

21. Caudate resection

22. Cone unit resection

23. Counaud’s segmental resection

24. Take home message Glissonian approach – (intrahepatic or extrahepatic ) – safe and feasible method for liver surgery Anatomical hepatectomy has been performed more easily using the Glissonian approach than by using controlled hepatectomy methods This procedure will shorten the operation time, less blood loss, low morbidity and reduce the stress on surgeons Can be used in Minimal access surgery Gentle handling of pedicles – paramount importance Difficulty in encircling the pedicles, parenchymal bleeding during supra hilar dissection – reasons for technical failure Tumors located immediately adjacent to hepatic hilum – better to chose alternate approach

25. Thank you