A new Simplified Method of Selective Exposure of Hepatic Pedicles for Controlled Hepatectomies

Abstract

Our experience of 90 hepatectomies (HE) and examinations of 64 cadaver livers resulted in the elaboration of a simplified technique for the exposure of hepatic pedicles (HP) and the rapid selective ligation without significant normothermal ischemia of the retained parts of the liver. The method comprises 4 consecutive steps: 1) a superficial T-shaped incision of Glisson's capsule at the site of HP projection on the liver's inferior surface, 2) introduction of the surgeon's forefinger into the liver parenchyma, controlled by clamping the hepatoduodenal ligament, the fingertip finding a tubular structure well distinguished by its smooth elastic surface from the friable parenchyma and bending the finger to hook the pedicle, 3) drawing the hooked pedicle downwards through the slit in the capsule and temporarily clamping it, while releasing the hepatoduodenal ligament so as to restore blood supply to the retained parts of the liver, 4) checking for correct ligature position on the HP before its final ligation by matching the actual ischemic area with the intended line of resection and moving the clamp proximally or distally along the exposed pedicle for the release or clamping of lateral branches as necessary. Whereupon resection can be performed by any of the known methods. This method has been used in 8 major HE, allowing to reduce intraoperative blood loss from 2200±247 ml to 1000±225 ml and reducing general liver ischemia from 10 minutes and more to 2–3 minutes.

Pure laparoscopic hepatectomy in semiprone position for right hepatic major resection

“…In this method, because the full length of the primary branches and the origin of the secondary branches are located extrahepatically, the origin of the three segmental branches can easily be taped outside the liver without having to incise the liver parenchyma. In 1990, Galperin and Karagiulian [7] used small incisions on the inferior surface of the liver, tunneling into the liver parenchyma until the sheath was found. In fact, it is not easy to tape each secondary branch without any division of the liver parenchyma because the sense of touch is not utilized in laparoscopic surgery.…”

High hilar dissection: New technique to reduce biliary complication in living donor liver transplantation

“…Galperin and Karagiulian11 introduced the technique of selective exposure of the hepatic pedicles and rapid selective ligation without significant normothermal ischemia of the retained parts of the liver. They reported that this selective ligation technique, using the intrahepatic Glissonian approach, could reduce the blood loss and duration of general liver ischemia during hepatectomy.…”

Systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection based on Laennec's capsule: proposal of a novel comprehensive surgical anatomy of the liver

“…Afterwards, Lin et al [5], Ton-That-Tung and Nguyen-Duong-Quang [6] and Okamoto [7] successfully performed the intrahepatic Glissonean pedicle isolation with major liver transection through the main portal fissure. Meanwhile, Galperin and Karagiulian described the intrahepatic approach with minor transection using digitoclasia in 1989 [8] and Machado et al reported the same type of approach using a clamp or a vascular stapler [9,10]. However, the intrahepatic isolation might be accompanied by a potential risk of unexpected injury to the portal pedicle or the hepatic vein.…”