The document discusses the evolution and techniques of liver resection, highlighting the glissonian pedicle approach developed over several decades. This method is described as safe and feasible, offering advantages such as shorter operation times, less blood loss, and reduced surgeon stress. Key challenges include handling pedicles carefully and addressing tumors near the hepatic hilum.

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.

4. • 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

5. Branching pattern of Pedicles

6. Takasaki segmentation

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

8. 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)

9. Comparision with other classification systems

10. • 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.

11. Position of Glissonian pedicles inside the segments

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

13. 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

14. Instruments
Boomerang
retractor
Side
retractor
Kent retractor

15. Glisson’s foreceps Sonosurg (CUSA)

18. Selective clamping of segmental pedicles

19. Resection of middle segment

22. Resection of Right segment

24. Isolating whole right segmental branch

25. Resection of left segment

27. Right lobectomy Right trisectionectomy

28. Caudate resection

30. Cone unit resection

31. Counaud’s segmental resection

32. 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

33. Thank you