Laparoscopic Anatomical Segmentectomy in Tertiary Portal Pedicles with Variations and Deep Location Using the Transfissural Glissonean Approach (Video).

Background: The Glissonean pedicle approach is a widely used technique in anatomical liver resection1. The Glissonean pedicle approach can be divided into the extrafacial approach (conventional Glissonean approach) and the transfissural approach2,3,4. We present pure laparoscopic anatomical segmentectomy in tertiary portal pedicles with anatomical variations and a deep location using the transfissural Glissonean approach.

Methods: According to the branching pattern of the tertiary portal pedicles, selection of the extrafascial or the transfissural approach was determined. The tertiary portal pedicles around the liver hilum can be dissected using the extrafascial approach. The transfissural approach was applied when the tertiary portal pedicles were multiple, variable, and located deep within the liver. These pedicles can be dissected after parenchymal transection along the fissure lines (resection of segment 6: right portal fissure; resection of segment 3: umbilical fissure).

Results: Patients underwent anatomical resection of segments 6 (n = 8; extrafascial: 5; transfissural: 3) and 3 (n = 4; extrafascial: 1; transfissural: 3). The median operative time was 200 min (range 110-250 min), and the median blood loss was 100 mL (range 40-350 mL). The median tumor size was 18.5 mm (range 11-30 mm). All patients were negative resection margin. The median postoperative hospital stay was 5.5 days (range 4-8 days).

Conclusion: The tertiary portal pedicles can be dissected using the extrafascial or the transfissural approach. The transfissural approach in tertiary portal pedicles with anatomical variations and a deep location is a useful and effective method because opening the fissure lines allows direct access to these pedicles.