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

Abstract

Anatomical liver resection with the Glissonean pedicle isolation is widely approved as an essential procedure for safety and curability. Especially, the extrahepatic Glissonean pedicle isolation without parenchymal destruction should be an ideal procedure. However, the surgical technique has not been standardized due to a lack of anatomical understanding. Herein, we proposed a novel comprehensive surgical anatomy of the liver based on Laennec's capsule that would give a theoretical background to the extrahepatic Glissonean pedicle isolation. Laennec's capsule is the proper membrane that covers not only the entire surface of the liver including the bare area but also the intrahepatic parenchyma surrounding the Glissonean pedicles. Consequently, there exists a gap between the Glissonean pedicle and Laennec's capsule that could be reached extrahepatically and allows us to isolate the extrahepatic Glissonean pedicle without parenchymal destruction systematically. For standardization, it is essential to approach the “six gates” indicated by the “four anatomical landmarks”: the Arantius plate, the umbilical plate, the cystic plate and the Glissonean pedicle of the caudate process (G1c). This novel anatomy would contribute to standardize the surgical techniques of the systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection including laparoscopic or robotic liver resection and to bring innovative changes in hepatobiliary surgery for spreading safe and curable liver resection.

Glissonean pedicle approach in liver surgery

“…Furthermore, Sugioka recently reported that Glisson's capsule and Laennec's capsule can be divided outside and inside the liver. Therefore, the Glissonean pedicles can be separated from Laennec's capsule and not only the main portal pedicles but also the sectional and segmental pedicles can be approached at the hepatic hilus without liver dissection . This concept supports Takasaki's procedure.…”

Structure and surgical dissection layers of the bare area of the liver

“…There is a relatively dense connective tissue on the liver side and sparse connective tissue on the diaphragm side of the fused peritoneal peritoneum. The structure composed of dense connective tissue on the liver side and liver serosa is the Laennec's capsule [12,13]. Because the liver surface of the bare area is covered with the Laennec's capsule, as shown in our study, the phrase "bare area" may not be appropriate.…”

Recipient Hepatic Vein as an Autologous Vascular Graft for Hepatic Vein Reconstruction in Living Donor Liver Transplantation

“…In our method, however, the RHV trunk can be isolated with a thick wall by attaching the fibrous tissue around it. This tissue ("Laennec's capsule") essentially covers the liver parenchyma (5) Brief report | 5 can be intentionally preserved on the RHV wall by exposing it from the root side (Fig. 1).…”