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Primary hilar techniques for isolation of the glissonian pedicles in major an minor liver resections

PRIMARY HILAR TECHNIQUES
FOR ISOLATION OF THE
GLISSONIAN PEDICLES IN MAJOR
AND MINOR LIVER RESECTIONS

Authors: I. Cîmpeanu, M. Bogdan, T. Artenie,
R. Petrescu, I. Lucescu

Clinical 1-st Department of Surgery– Clinical and Emergency
Central Military Hospital “Dr. Carol Davila” - Bucharest

April 2003

MOTTO:

“Extra-fascial control of the pedicles has
been a definite progress and has simplified
considerably sectorectomies and
segmentectomies”

Couinaud C., 1989

MOTTO:

Glissonean pedicle transection method prevented
intraoperative metastasis and significantly
improved the postoperative survival in patients
with hepatocellular carcinoma.

Tsuruta K. &col.,
Hepato-Gastroenterology 2002

Classic hilar dissection: complicated and dangerous

A. cistică AH seg IV

VPS
AHS

VPD AHD

VP
Artera hepatică proprie

Placa hilară (centrală)

V-VIII Placa glissoniană
stangă
Teci
glissoniene

II
VI-VII

IV III

Placa veziculară Placa ombilicală
GLISSONIAN PLATES AND SHEATHS

PGAD

PGPD

Anatomic variants – under the hilar (and ombilical) plate
(biliary tract)

Ischaemic limits of segment VI (modal distribution)

D

Isolation of the RPGP (PGPD) Risk of damaging right inferior
in the Raynaud-Coucoravas retro-hepatic vein (VRHID) when
point (RC) attempting to isolate RPGP (PGPD)

- VI (A)=PG angular segment VI -
(cadaverous dissection)

V(S)HM

V(S)HD Placă hilară

V(S)HS

Takasaki-Couinaud Couinaud
Lazorthes Launois
Launois
COMPLEX EXTRAGLISSONIAN APPROACH
HILAR PLATE DESCENDING

1 3
Placa Lob pătrat
VB (IVb)

CUSA

VB

Hilar plate descending - Couinaud
2 4

Coborarea PH

Posterior
approach
(segment IX)

Placa cistică
Lig rotund
IVb
IV

Linia
SPP PPPS
PPS
(PGPS)
PPD
PPPD Couinaud
(PGPD)
Takasaki-Couinaud

ISOLATION OF THE GLISSONIAN
PEDICLES FOR THE LEFT HEMI-LIVER

Couinaud technique for the isolation of the LPPP (PPPS)

Launois technique (posterior approach) for the isolation of the LPPP (PPPS).
a)=schematic draw

III
IVb

Isolation of glissonian
pedicles for II and III

Lig. rotund

Pedicul seg. III

Pedicul seg. IV
Placă ombilicală

PPPS clampat

RESECTION OF SEGMENT III

ISOLATION OF THE GLISSONIAN
PEDICLES FOR THE RIGHT
HEMI-LIVER

(IX)
TYPE OF PERIHILAR INCISIONS USED FOR
EXTRAGLISSONIAN APPROACH

Placa cistică
Lig rotund
IVb
IV

Linia
SPP PPPS
PPS
(PGPS)
PPD Couinaud
PPPD
(PGPD)
Takasaki-Couinaud

LAUNOIS technique for the isolation of the RPPP
(PPPD, PGPD)

Ligature level of the glissonian pedicles (right lobe)

Posterior approach Launois – anatomic portal variant of the right lobe

SPD

Sector paramedian drept

SPP

Fosa V.B.
Ischaemic limits of the anterior (paramedian)
sector of the right lobe, with the visualisation
of the MPS and RPS (anterior right glissonian
pedicle clamped) – amodal variant of RPS (SPD)

Scizura
portă principală

Scizura
portă dreaptă

Linie SPD

V.B.

Pedicul lateral drept
( clampat )

Modal variant of RPS (SPD)

SPD

V.B.

VI

Glissonian pedicle for VI – clamped (amodal distribution)

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1. PRIMARY HILAR TECHNIQUES FOR ISOLATION OF THE GLISSONIAN PEDICLES IN MAJOR AND MINOR LIVER RESECTIONS Authors: I. Cîmpeanu, M. Bogdan, T. Artenie, R. Petrescu, I. Lucescu Clinical 1-st Department of Surgery– Clinical and Emergency Central Military Hospital “Dr. Carol Davila” - Bucharest April 2003

2. MOTTO: “Extra-fascial control of the pedicles has been a definite progress and has simplified considerably sectorectomies and segmentectomies” Couinaud C., 1989

3. MOTTO: Glissonean pedicle transection method prevented intraoperative metastasis and significantly improved the postoperative survival in patients with hepatocellular carcinoma. Tsuruta K. &col., Hepato-Gastroenterology 2002

4. Classic hilar dissection: complicated and dangerous A. cistică AH seg IV VPS AHS VPD AHD VP Artera hepatică proprie

5. Placa hilară (centrală) V-VIII Placa glissoniană stangă Teci glissoniene II VI-VII IV III Placa veziculară Placa ombilicală GLISSONIAN PLATES AND SHEATHS

6. PGAD PGPD Anatomic variants – under the hilar (and ombilical) plate (biliary tract)

7. Right hilar extension

8. Right hilar extension (detail)

9. Ischaemic limits of segment VI (modal distribution)

10. D Isolation of the RPGP (PGPD) Risk of damaging right inferior in the Raynaud-Coucoravas retro-hepatic vein (VRHID) when point (RC) attempting to isolate RPGP (PGPD) - VI (A)=PG angular segment VI - (cadaverous dissection)

11.

12.

13. V(S)HM V(S)HD Placă hilară V(S)HS Takasaki-Couinaud Couinaud Lazorthes Launois Launois COMPLEX EXTRAGLISSONIAN APPROACH HILAR PLATE DESCENDING

14. 1 3 Placa Lob pătrat VB (IVb) CUSA VB Hilar plate descending - Couinaud 2 4 Coborarea PH Posterior approach (segment IX)

15. Placa cistică Lig rotund IVb IV Linia SPP PPPS PPS (PGPS) PPD PPPD Couinaud (PGPD) Takasaki-Couinaud

16. ISOLATION OF THE GLISSONIAN PEDICLES FOR THE LEFT HEMI-LIVER

17. Couinaud technique for the isolation of the LPPP (PPPS)

18. Launois technique (posterior approach) for the isolation of the LPPP (PPPS). a)=schematic draw

19. III IVb Isolation of glissonian pedicles for II and III

20. Lig. rotund Pedicul seg. III Pedicul seg. IV Placă ombilicală PPPS clampat RESECTION OF SEGMENT III

21. 2. 1. Resection of segment III 3. 4.

22. Ombilical plate – epiportal view

23. ISOLATION OF THE GLISSONIAN PEDICLES FOR THE RIGHT HEMI-LIVER

24. (IX) TYPE OF PERIHILAR INCISIONS USED FOR EXTRAGLISSONIAN APPROACH

25. Placa cistică Lig rotund IVb IV Linia SPP PPPS PPS (PGPS) PPD Couinaud PPPD (PGPD) Takasaki-Couinaud

26. SUPRAHILAR LAZORTHES APPROACH

27. LAUNOIS technique for the isolation of the RPPP (PPPD, PGPD)

28. Dangerous Launois zone

29. Ligature level of the glissonian pedicles (right lobe)

30. Posterior approach Launois – anatomic portal variant of the right lobe

31. Anterior variants of the RPS (SPD)

32. SPD Sector paramedian drept SPP Fosa V.B. Ischaemic limits of the anterior (paramedian) sector of the right lobe, with the visualisation of the MPS and RPS (anterior right glissonian pedicle clamped) – amodal variant of RPS (SPD)

33. Scizura portă principală Scizura portă dreaptă

34. Linie SPD V.B. Pedicul lateral drept ( clampat ) Modal variant of RPS (SPD)

35. SPD V.B. VI Glissonian pedicle for VI – clamped (amodal distribution)

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