Contribution of the Glissonian approach for laparoscopic anatomical liver resection (Editorial)

Machado MA,

Laparosc Surg 2018;2:31. doi: 10.21037/ls.2018.05.05



PDF (112 Kb)


The current approach to a segmental LLR is the dissection of the elements of the hepatic hilum within the hilar plate. This technique may be technically challenging and may result in excessive bleeding, that is directly related to postoperative morbidity and mortality (19). Besides, anatomical variations and portal hypertension may impair vascular and biliary control.
To overcome these difficulties, the Glissonian approach for laparoscopic anatomical liver resection allowed straightforward control of the Glissonian pedicle . With small incisions around the hilar plate on specific anatomical landmarks, the Glissonian pedicle correspondent to the area to be resected can be clamped. This technique minimizes
bleeding, allows precise ischemic delineation of the area to be resected, allows inflow control, minimizes ischemia to the remnant liver and simplifies the procedure. In addition,
this technique can also be used to major hepatic resections and anatomical segmentectomies, by achieving more selective distal control of segmental or sectional pedicles, allowing parenchymal sparing resections.

The use of the Glissonian approach can be hazardous in special cases, especially in the presence of anatomic variations. These variations should be recognized before or even during the operation. More rare, aberrant bile duct anatomy also needs to be perceived by detailed preoperative imaging. Whenever biliary anatomy anomaly is suspected, cholangiography should be considered to identify and avoid any possible bile duct injury. Feasibility may depend on previous experience with the technique, specific knowledge
of anatomy, selected instruments, and gentle handling of anatomic structures. Moreover, tumors located immediately adjacent to the hepatic hilum is a known contraindication
for this technique once adequate margins may not be obtained. The non-anatomical wedge resection is an alternative approach for parenchymal sparing. Nevertheless, it can
present high rates of margin positivity between 16% and 35% . In our more recent study on LLR using the Glissonian approach, we noted several advantages over standard LLR including shorter operative time, lower transfusion rates, fewer patients with a postoperative positive margin, as well as less morbidity and a shorter duration of hospital stay .