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Updates and Critical Insights on Glissonian Approach in Liver Surgery

Journal of Gastrointestinal Surgery volume 22, pages 154–163 (2018)Cite this article

Abstract

Recent advances in surgical techniques have broadened the indications of surgical management of liver malignancies. Intraoperative bleeding is one of the known predictors of postoperative outcomes following liver surgery, signifying the importance of vascular control during liver resection. Furthermore, preservation of future liver remnant plays a critical role in prevention of post-hepatectomy liver failure as one of the main causes of postoperative morbidity and mortality. Glissonian approach liver resection offers an effective method for vascular inflow control while protecting future liver remnant from ischemia-reperfusion injury. Several studies have demonstrated the feasibility of Glisson’s pedicle resection technique in modern liver surgery with an acceptable safety profile. Moreover, with increasing popularity of minimally invasive surgery, laparoscopic liver resection via Glissonian approach has been shown to be superior to standard laparoscopic hepatectomy. Herein, we systematically review the role of Glissonian approach hepatectomy in current practice of liver surgery, highlighting its advantages and disadvantaged over other methods of vascular control.

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References

  1. Moris D, Vernadakis S, Papalampros A, Petrou A, Dimitroulis D, Spartalis E, et al. The effect of Guidelines in surgical decision making: The paradigm of hepatocellular carcinoma. Journal of BUON : official journal of the Balkan Union of Oncology. 2016;21(6):1332–6.

    Google Scholar 

  2. Moris D, Dimitroulis D, Vernadakis S, Papalampros A, Spartalis E, Petrou A, et al. Parenchymal-sparing Hepatectomy as the New Doctrine in the Treatment of Liver-metastatic Colorectal Disease: Beyond Oncological Outcomes. Anticancer research. 2017;37(1):9–14.

    Article  PubMed  Google Scholar 

  3. Moris D, Felekouras E. Ignore reality but not the consequences of its ignorance: Broaden guidelines in surgery of hepatocellular carcinoma. Hepatology. 2017;65(5):1772–3.

    Article  PubMed  Google Scholar 

  4. Petrou A, Neofytou K, Mihas C, Bagenal J, Kontos M, Griniatsos J, et al. Radiofrequency ablation-assisted liver resection: a step toward bloodless liver resection. Hepatobiliary & Pancreatic Diseases International : HBPD INT. 2015;14(1):69–74.

    Article  Google Scholar 

  5. Moris D, Ronnekleiv-Kelly S, Rahnemai-Azar AA, Felekouras E, Dillhoff M, Schmidt C, et al. Parenchymal-Sparing Versus Anatomic Liver Resection for Colorectal Liver Metastases: a Systematic Review. Journal of Gastrointestinal Surgery : official journal of the Society for Surgery of the Alimentary Tract. 2017.

  6. Bennett S, Baker LK, Martel G, Shorr R, Pawlik TM, Tinmouth A, et al. The impact of perioperative red blood cell transfusions in patients undergoing liver resection: a systematic review. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2017;19(4):321–30.

    Article  Google Scholar 

  7. Margonis GA, Kim Y, Samaha M, Buettner S, Sasaki K, Gani F, et al. Blood loss and outcomes after resection of colorectal liver metastases. The Journal of Surgical Research. 2016;202(2):473–80.

    Article  PubMed  Google Scholar 

  8. Spolverato G, Pawlik TM. Liver-directed therapies: surgical approaches, alone and in combination with other interventions. American Society of Clinical Oncology educational book American Society of Clinical Oncology Meeting. 2014:101–10.

  9. Dimitroulis D, Moris D, Pikoulis E, Spartalis E, Kontadakis G, Vrugt B, et al. Variable Pringle Maneuvers and Effect on Intestinal Epithelium in Rats. A Pilot Experimental Study in Rats. PloS one. 2015;10(10):e0140707.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Lortat-Jacob JL, Robert HG, Henry C. [Case of right segmental hepatectomy]. Memoires Academie de chirurgie. 1952;78(8–9):244–51.

    CAS  Google Scholar 

  11. Ton That T, Nguyen Duong Q. [Segmentary hepatectomy by transparenchymatous vascular ligation]. La Presse medicale. 1965;73(52):3015–7.

    Google Scholar 

  12. Launois B, Sutherland FR, Harissis H. A new technique of Hepp-Couinaud hepaticojejunostomy using the posterior approach to the hepatic hilum. Journal of the American College of Surgeons. 1999;188(1):59–62.

    CAS  PubMed  Google Scholar 

  13. Machado MA, Herman P, Machado MC. A standardized technique for right segmental liver resections. Archives of Surgery. 2003;138(8):918–20.

    Article  PubMed  Google Scholar 

  14. Figueras J, Llado L, Ruiz D, Ramos E, Busquets J, Rafecas A, et al. Complete versus selective portal triad clamping for minor liver resections: a prospective randomized trial. Annals of Surgery. 2005;241(4):582–90.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Figueras J, Lopez-Ben S, Llado 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. Annals of Surgery. 2003;238(1):111–9.

    PubMed  PubMed Central  Google Scholar 

  16. Giordano M, Lopez-Ben S, Codina-Barreras A, Pardina B, Falgueras L, Torres-Bahi S, et al. Extra-Glissonian approach in liver resection. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2010;12(2):94–100.

    Article  Google Scholar 

  17. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Journal of Clinical Epidemiology. 2009;62(10):1006–12.

    Article  PubMed  Google Scholar 

  18. Takasaki K. Glissonean pedicle transection method for hepatic resection: a new concept of liver segmentation. Journal of Hepato-biliary-pancreatic Surgery. 1998;5(3):286–91.

    CAS  Article  PubMed  Google Scholar 

  19. Man K, Fan ST, Ng IO, Lo CM, Liu CL, Wong J. Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study. Annals of Surgery. 1997;226(6):704–11; discussion 11-3.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  20. Gurusamy KS, Kumar Y, Sharma D, Davidson BR. Methods of vascular occlusion for elective liver resections. The Cochrane Database of Systematic Reviews. 2007(4):CD006409.

    Google Scholar 

  21. 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. International Surgery. 1990;75(2):73–7.

    CAS  PubMed  Google Scholar 

  22. Patel NA, Roh MS. Utility of intraoperative liver ultrasound. The Surgical Clinics of North America. 2004;84(2):513–24.

    Article  PubMed  Google Scholar 

  23. Bismuth H, Castaing D, Garden OJ. The use of operative ultrasound in surgery of primary liver tumors. World Journal of Surgery. 1987;11(5):610–4.

    CAS  Article  PubMed  Google Scholar 

  24. Jrearz R, Hart R, Jayaraman S. Intraoperative ultrasonography and surgical strategy in hepatic resection: What difference does it make? Canadian Journal of Surgery Journal canadien de chirurgie. 2015;58(5):318–22.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Donadon M, Costa G, Torzilli G. State of the art of intraoperative ultrasound in liver surgery: current use for staging and resection guidance. Ultraschall in der Medizin. 2014;35(6):500–11; quiz 12-3.

    CAS  Article  PubMed  Google Scholar 

  26. 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. Journal of the American College of Surgeons. 1999;189(3):300–4.

    CAS  Article  PubMed  Google Scholar 

  27. Chinburen J, Gillet M, Yamamoto M, Enkh-Amgalan T, Taivanbaatar E, Enkhbold C, et al. Impact of Glissonean pedicle approach for centrally located hepatocellular carcinoma in mongolia. International Surgery. 2015;100(2):268–74.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Yamamoto M, Takasaki K, Ohtsubo T, Katsuragawa H, Fukuda C, Katagiri S. Effectiveness of systematized hepatectomy with Glisson’s pedicle transection at the hepatic hilus for small nodular hepatocellular carcinoma: retrospective analysis. Surgery. 2001;130(3):443–8.

    CAS  Article  PubMed  Google Scholar 

  29. Karamarkovic A, Doklestic K, Milic N, Djukic V, Bumbasirevic V, Sijacki A, et al. Glissonean pedicle approach in major liver resections. Hepato-gastroenterology. 2012;59(118):1896–901.

    PubMed  Google Scholar 

  30. Capussotti L, Borgonovo G, Bouzari H, Smadja C, Grange D, Franco D. Results of major hepatectomy for large primary liver cancer in patients with cirrhosis. The British Journal of Surgery. 1994;81(3):427–31.

    CAS  Article  PubMed  Google Scholar 

  31. 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. International Journal of Medical Sciences. 2012;9(10):843–52.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Tsuruta K, Okamoto A, Toi M, Saji H, Takahashi T. Impact of selective Glisson transection on survival of hepatocellular carcinoma. Hepato-gastroenterology. 2002;49(48):1607–10.

    PubMed  Google Scholar 

  33. Moris D, Ronnekleiv-Kelly S, Rahnemai-Azar AA, Felekouras E, Dillhoff M, Schmidt C, et al. Parenchymal-Sparing Versus Anatomic Liver Resection for Colorectal Liver Metastases: a Systematic Review. Journal of Gastrointestinal Surgery : official journal of the Society for Surgery of the Alimentary Tract. 2017;21(6):1076–85.

    Article  Google Scholar 

  34. Spolverato G, Bagante F, Aldrighetti L, Poultsides GA, Bauer TW, Fields RC, et al. Management and outcomes of patients with recurrent neuroendocrine liver metastasis after curative surgery: An international multi-institutional analysis. Journal of Surgical Oncology. 2017;116(3):298–306.

    CAS  Article  PubMed  Google Scholar 

  35. Lafaro K, Buettner S, Maqsood H, Wagner D, Bagante F, Spolverato G, et al. Defining Post Hepatectomy Liver Insufficiency: Where do We stand? Journal of Gastrointestinal Surgery : official journal of the Society for Surgery of the Alimentary Tract. 2015;19(11):2079–92.

    Article  Google Scholar 

  36. Chen XP, Qiu FZ. A simple technique ligating the corresponding inflow and outflow vessels during anatomical left hepatectomy. Langenbeck’s Archives of Surgery. 2008;393(2):227–30; discussion 31-4.

    Article  PubMed  Google Scholar 

  37. Xia F, Li G, Lau WY, Ma KS, Bie P. Intrahepatic Glissonian approach and outflow vascular occlusion during partial hepatectomy. Hepatobiliary & Pancreatic Diseases International : HBPD INT. 2014;13(1):101–4.

    Article  Google Scholar 

  38. Doklestic K, Djukic V, Bumbasirevic V, Jovanovic B, Karamarkovic A. Segment-oriented liver resections based on posterior intrahepatic glissonian approach. Acta chirurgica Iugoslavica. 2012;59(3):41–8.

    Article  PubMed  Google Scholar 

  39. Hu JX, Dai WD, Miao XY, Zhong DW, Huang SF, Wen Y, et al. Anatomic resection of segment VIII of liver for hepatocellular carcinoma in cirrhotic patients based on an intrahepatic Glissonian approach. Surgery. 2009;146(5):854–60.

    Article  PubMed  Google Scholar 

  40. Machado MA, Herman P, Machado MC. Intrahepatic Glissonian approach for pedicle control during anatomic mesohepatectomy. Surgery. 2007;141(4):533–7.

    Article  PubMed  Google Scholar 

  41. Figueroa R, Laurenzi A, Laurent A, Cherqui D. Perihilar Glissonian Approach For Anatomical Parenchymal Sparing Liver Resections: Technical Aspects: The Taping Game. Annals of Surgery. 2016.

  42. Okunrintemi V, Gani F, Pawlik TM. National Trends in Postoperative Outcomes and Cost Comparing Minimally Invasive Versus Open Liver and Pancreatic Surgery. Journal of Gastrointestinal Surgery : official journal of the Society for Surgery of the Alimentary Tract. 2016;20(11):1836–43.

    Article  Google Scholar 

  43. Bagante F, Spolverato G, Strasberg SM, Gani F, Thompson V, Hall BL, et al. Minimally Invasive vs. Open Hepatectomy: a Comparative Analysis of the National Surgical Quality Improvement Program Database. Journal of Gastrointestinal Surgery : official journal of the Society for Surgery of the Alimentary Tract. 2016;20(9):1608–17.

    Article  Google Scholar 

  44. Machado MA, Surjan RC, Basseres T, Schadde E, Costa FP, Makdissi FF. 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.

    Article  PubMed  Google Scholar 

  45. Ho KM, Han HS, Yoon YS, Cho JY, Choi YR, Jang JS, et al. Laparoscopic Anatomical Segment 2 Segmentectomy by the Glissonian Approach. Journal of Laparoendoscopic & Advanced Surgical Techniques Part A. 2016.

  46. Ahn KS, Han HS, Yoon YS, Cho JY, Kim JH. Laparoscopic anatomical S5 segmentectomy by the Glissonian approach. Journal of Laparoendoscopic & Advanced Surgical Techniques Part A. 2011;21(4):345–8.

    Article  Google Scholar 

  47. Mizuno T, Sheth R, Yamamoto M, Kang HS, Yamashita S, Aloia TA, et al. Laparoscopic Glissonean Pedicle Transection (Takasaki) for Negative Fluorescent Counterstaining of Segment 6. Annals of Surgical Oncology. 2017;24(4):1046–7.

    Article  PubMed  Google Scholar 

  48. Machado MAC, Surjan R, Basseres T, Makdissi F. Laparoscopic Parenchymal-Sparing Liver Resections Using the Intrahepatic Glissonian Approach. Annals of Surgical Oncology. 2017.

  49. Machado MA, Makdissi FF, Galvao FH, Machado MC. Intrahepatic Glissonian approach for laparoscopic right segmental liver resections. American Journal of Surgery. 2008;196(4):e38–42.

    Article  PubMed  Google Scholar 

  50. Machado MA, Makdissi FF, Herman P, Surjan RC. Intrahepatic Glissonian approach for pure laparoscopic left hemihepatectomy. Journal of Laparoendoscopic & Advanced Surgical Techniques Part A. 2010;20(2):141–2.

    Article  Google Scholar 

  51. Machado MA, Almeida FA, Makdissi FF, Surjan RC, Cunha-Filho GA. Video. One-stage laparoscopic bisegmentectomy 7-8 and bisegmentectomy 2-3 for bilateral colorectal liver metastases. Surgical Endoscopy. 2011;25(6):2011–4.

    Article  PubMed  Google Scholar 

  52. Machado MA, Kalil AN. Glissonian approach for laparoscopic mesohepatectomy. Surgical Endoscopy. 2011;25(6):2020–2.

    CAS  Article  PubMed  Google Scholar 

  53. Machado MA, Surjan RC, Makdissi FF. Video: intrahepatic Glissonian approach for pure laparoscopic right hemihepatectomy. Surgical Endoscopy. 2011;25(12):3930–3.

    CAS  Article  PubMed  Google Scholar 

  54. Jang JY, Han HS, Yoon YS, Cho JY, Choi Y, Lee W, et al. Three-Dimensional Laparoscopic Anatomical Segment 8 Liver Resection with Glissonian Approach. Annals of Surgical Oncology. 2017;24(6):1606–9.

    Article  PubMed  Google Scholar 

  55. Ho CM, Wakabayashi G, Nitta H, Takahashi M, Takahara T, Ito N, et al. Total laparoscopic limited anatomical resection for centrally located hepatocellular carcinoma in cirrhotic liver. Surgical endoscopy. 2013;27(5):1820–5.

    Article  PubMed  Google Scholar 

  56. Machado MA, Surjan RC, Makdissi FF. Intrahepatic glissonian approach for single-port laparoscopic liver resection. Journal of Laparoendoscopic & Advanced Surgical Techniques Part A. 2014;24(8):534–7.

    Article  Google Scholar 

  57. Mouly C, Fuks D, Browet F, Mauvais F, Potier A, Yzet T, et al. Feasibility of the Glissonian approach during right hepatectomy. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2013;15(8):638–45.

    Article  Google Scholar 

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Affiliations

  1. Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA

    Demetrios Moris & Timothy M. Pawlik

  2. Department of Surgery, Division of Surgical Oncology, University of Wisconsin Hospital, Madison, WI, USA

    Amir A. Rahnemai-Azar

  3. 1st Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece

    Diamantis I. Tsilimigras, Ioannis Ntanasis-Stathopoulos & Evangelos Felekouras

  4. Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal

    Hugo P. Marques

  5. Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens, Greece

    Eleftherios Spartalis

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  1. Demetrios Moris
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  2. Amir A. Rahnemai-Azar
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  3. Diamantis I. Tsilimigras
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  6. Eleftherios Spartalis
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  7. Evangelos Felekouras
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  8. Timothy M. Pawlik
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Correspondence to Timothy M. Pawlik.

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Moris, D., Rahnemai-Azar, A.A., Tsilimigras, D.I. et al. Updates and Critical Insights on Glissonian Approach in Liver Surgery. J Gastrointest Surg 22, 154–163 (2018). https://doi.org/10.1007/s11605-017-3613-9

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  • DOI: https://doi.org/10.1007/s11605-017-3613-9

Keywords

  • Glissonian approach
  • Glisson’s pedicle
  • Hepatectomy
  • Liver cancer
  • Liver resection
  • Liver malignancy