UPDATED TOPICS IN MINIMALLY INVASIVE ABDOMINAL SURGERY

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84 Updated Topics in Minimally Invasive Abdominal Surgery Fig. 9. The medial Glissonean pedicle is encircled with an Endo Mini Retract. Fig. 10. The medial Glissonean pedicle is divided using an endocopic stapler.
Hilar Glissonean Access in Laparoscopic Liver Resection 2.2 Encircling left-sided Glissonean pedicles, including the left, medial, and lateral pedicles Dividing the ligamentum venosum (Fig. 7) and retracting the round ligament upward extends the umbilical portion, facilitating isolation of its root. A parenchymal bridge is divided if present. Dissection between the hepatic parenchyma and umbilical plate is performed. The metallic arch of an Endo Retract Maxi or Endo Mini-Retract is meticulously extended behind the umbilical plate, so the left Glisonean pedicle is encircled extrahepatically (Fig. 8). Hepatic parenchyma is divided along the main portal fissure, which facilitates dividing the left Glissonean pedicle using an endoscopic stapler. A little dissection of the hepatic parenchyma along the umbilical fissure facilitates isolation of the root of the medial Glissonean pedicle (G4) or lateral Glissonean pedicles (G2, G3). Dissection between the hepatic parenchyma and umbilical plate is performed, and G2, G3, or G4 is extrahepatically encircled using Endo Mini-Retract (Fig. 9) and divided using an endoscopic stapler based on resection type (Fig. 10). 3. Comments Laparoscopic anatomical segmental resection has not been widely accepted due to technical difficulties in controlling each Glissonean pedicle laparoscopically. Previous reports relating to laparoscopic hemihepatectomy have described separate dissection and division of each of the hepatic artery, duct and portal vein [3-6], or an intrahepatic Glissonean approach [12, 13]. The entire length of primary branches of the Glissonean pedicle and the origin of secondary branches are located outside the liver and the trunks of the secondary and more peripheral branches run inside the liver [8]. Therefore, the right, left, anterior, posterior, medial, or lateral Glissonean pedicle can be encircled and divided en bloc extrahepatically. Using an Endo Retract Maxi or Endo Mini-Retract, an extrahepatic Glissonean approach can be safe and feasible. However, each Glissonean pedicles should be divided as distally as possible to avoid biliary injury. The right Glissonean pedicle should not be transacted en bloc but the right anterior and posterior Glissonean branches should be divided respectively. The left Glissonean pedicle should be divided at the root of the umbilical portion to avoid injury of the right hepatic duct. Therefore, the pedicle should be encircled left to the Spiegel branch. In addition, each pedicles show shorter extrahepatic courses, and thus are better divided after some amount of parenchymal dissection. 4. References [1] Buell JF, Cherqui D, Geller DA, O'Rourke N, Iannitti D, Dagher I, Koffron AJ, Thomas M, Gayet B, Han HS, Wakabayashi G, Belli G, Kaneko H, Ker CG, Scatton O, Laurent A, Abdalla EK, Chaudhury P, Dutson E, Gamblin C, D'Angelica M, Nagorney D, Testa G, Labow D, Manas D, Poon RT, Nelson H, Martin R, Clary B, Pinson WC, Martinie J, Vauthey JN, Goldstein R, Roayaie S, Barlet D, Espat J, Abecassis M, Rees M, Fong Y, McMasters KM, Broelsch C, Busuttil R, Belghiti J, Strasberg S, Chari RS; World Consensus Conference on Laparoscopic Surgery: The international position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg 2009; 250: 825-380. [2] Azagra JS, Goergen M, Gilbart E, Jacobs D: Laparoscopic anatomical (hepatic) left lateral segmentectomy-technical aspects. Surg Endosc.1996; 10: 758-761. 85
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VI Contents Chapter 9 Appendicitis
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Part 1 Laparoscopic Biliary-Pancrea
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UPDATED TOPICS IN MINIMALLY INVASIVE ABDOMINAL SURGERY

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