Dataset Information

"Liver parenchyma dissecting-first" method facilitates the Glissonean pedicle approach in anatomical laparoscopic hepatolobectomy.

ABSTRACT:

Background

Anatomical laparoscopic hepatolobectomy (ALH) is a difficult and challenging operation, and avoiding massive hemorrhage during parenchyma transection remains one of its major concern. Glissonean pedicle approach (GPA) has achieved great success in open liver surgery due to its simplicity and reproducibility, but it is difficult to apply in ALH for the limited vision and motion. We thus aimed to introduce a modified method to facilitate the GPA in ALH.

Methods

In this retrospective study, in 15 patients who underwent ALH (at least 2 couinaud segments), the liver parenchyma was dissected at first (LPDF) adequately under intermittent total inflow control to reveal the Glissonean pedicle (GP) sufficiently for safe and precise transection. The technical details of LPDF for different types of hepatolobectomy and a modified laparoscopic Pringle maneuver are described, and the surgical outcomes are reviewed.

Results

LPDF was applied in all patients, and intraoperative blood transfusion was not needed. LPDF facilitated GPA in ALH without any severe morbidity or mortality.

Conclusions

LPDF is a safe and effective technique, it reduces the difficulties in inflow occlusion in GPA and can promote the application of ALH. Further clinical control trails are needed to validate the superiority of LPDF compared with GPA in ALH.

SUBMITTER: Xiao L

PROVIDER: S-EPMC7475421 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Publications

"Liver parenchyma dissecting-first" method facilitates the Glissonean pedicle approach in anatomical laparoscopic hepatolobectomy.

Xiao Liang L Wang Zhiming Z Zhou Ledu L

Annals of translational medicine 20200801 15

<h4>Background</h4>Anatomical laparoscopic hepatolobectomy (ALH) is a difficult and challenging operation, and avoiding massive hemorrhage during parenchyma transection remains one of its major concern. Glissonean pedicle approach (GPA) has achieved great success in open liver surgery due to its simplicity and reproducibility, but it is difficult to apply in ALH for the limited vision and motion. We thus aimed to introduce a modified method to facilitate the GPA in ALH.<h4>Methods</h4>In this re ...[more]

PMID: 32953740

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Project description:Background: Inflow control is one of the most important procedures during anatomical liver resection (ALR), and Glissonean pedicle isolation (GPI) is one of the most efficacious methods used in laparoscopic anatomical liver resection (LALR). Recognition of the Laennec's capsule covering the liver parenchyma is essential for safe and precise GPI. The purpose of this study was to verify identification of the Laennec's capsule, to confirm the validity of GPI in minimally invasive surgery, and to demonstrate the value of GPI focusing on the Laennec's capsule using a robotic system that has been developed in recent years. Methods: We used a cadaveric model to simulate the Glissonean pedicle and the surrounding liver parenchyma for pathologic verification of the layers. We performed 60 LALRs and 39 robotic anatomical liver resections (RALRs) using an extrahepatic Glissonean approach, from April 2020 to April 2023, and verified the layers of the specimens removed during LALR and RALR based on pathologic examination. In addition, the surgical outcomes of LALR and RALR were compared. Results: Histologic examination facilitated by Elastica van Gieson staining revealed the presence of Laennec's capsule covering the liver parenchyma in a cadaveric model. Similar findings were obtained following LALR and RALR, thus confirming that the gap between the Glissonean pedicle and the Laennec's capsule can be dissected without injury to the parenchyma. The mean GPI time was 32.9 and 27.2 min in LALR and RALR, respectively. The mean blood loss was 289.7 and 131.6 mL in LALR and RALR, respectively. There was no significant difference in the incidence of Clavien-Dindo grade ≥III complications between the two groups. Conclusions: Laennec's capsule is the most important anatomical landmark in performing a safe and successful extrahepatic GPI. Based on this concept, it is possible for LALR and RALR to develop GPI focusing on the Laennec's capsule. Furthermore, a robotic system has the potential to increase the safety and decrease the difficulty of this challenging procedure.

Project description:BackgroundLimited anatomical liver resection for hepatocellular carcinoma (HCC) is complicated in cirrhotic patients with centrally located HCC and limited liver reserve. We present a case of total laparoscopic left medial and right ventroanterior sectionectomy performed using the intrahepatic Glissonian approach in a cirrhotic liver for curative resection of HCC.MethodsThe patient was a 69-year-old man with a 6.5-cm-diameter HCC located at segments 4, 5, and 8 and which was compressing the middle hepatic vein (MHV). Child-Pugh class A liver cirrhosis was noted, and the 15-min retention rate for indocyanine green was 14 %. Preoperative surgical planning suggested the feasibility of limited anatomical subsegmental resection. The patient was placed in the supine position and 5 trocars were used for the procedure. The operation began with cholecystectomy, division of liver ligaments, and exposure of the right hepatic vein root and the umbilical Glissonian pedicles to the left medial segment. Parenchymal transection was performed using a laparoscopic harmonic scalpel and Cavitron Ultrasonic Surgical Aspirator until the MHV was reached. After exposing the ventral branches of the right anterior Glissonian pedicle and dividing them, resection was continued along the demarcation line. Fissure veins draining to the MHV root were identified and divided. The MHV root was closed using an automatic stapler.ResultsThe operation time was 565 min and estimated blood loss was 665 ml; blood transfusion was not required. Pathological examination confirmed a moderately differentiated HCC with all resected margins free of malignancy. Postoperative recovery was uneventful and the patient was discharged on the postoperative day 7. There was no tumor recurrence 18 months after the operation.ConclusionsTotal laparoscopic left medial and right ventroanterior sectionectomy via the intrahepatic Glissonian approach is feasible for HCC in a cirrhotic liver with limited liver reserve. Preoperative planning is essential in order to compute successful hepatic function. Standardization of surgical techniques may aid in safely performing this procedure.

Project description:BackgroundSurgical process model (SPM) analysis is a great means to predict the surgical steps in a procedure as well as to predict the potential impact of new technologies. Especially in complicated and high-volume treatments, such as parenchyma sparing laparoscopic liver resection (LLR), profound process knowledge is essential for enabling improving surgical quality and efficiency.MethodsVideos of thirteen parenchyma sparing LLR were analyzed to extract the duration and sequence of surgical steps according to the process model. The videos were categorized into three groups, based on the tumor locations. Next, a detailed discrete events simulation model (DESM) of LLR was built, based on the process model and the process data obtained from the endoscopic videos. Furthermore, the impact of using a navigation platform on the total duration of the LLR was studied with the simulation model by assessing three different scenarios: (i) no navigation platform, (ii) conservative positive effect, and (iii) optimistic positive effect.ResultsThe possible variations of sequences of surgical steps in performing parenchyma sparing depending on the tumor locations were established. The statistically most probable chain of surgical steps was predicted, which could be used to improve parenchyma sparing surgeries. In all three categories (i-iii) the treatment phase covered the major part (~ 40%) of the total procedure duration (bottleneck). The simulation results predict that a navigation platform could decrease the total surgery duration by up to 30%.ConclusionThis study showed a DESM based on the analysis of steps during surgical procedures can be used to predict the impact of new technology. SPMs can be used to detect, e.g., the most probable workflow paths which enables predicting next surgical steps, improving surgical training systems, and analyzing surgical performance. Moreover, it provides insight into the points for improvement and bottlenecks in the surgical process.

Dataset Information

"Liver parenchyma dissecting-first" method facilitates the Glissonean pedicle approach in anatomical laparoscopic hepatolobectomy.

Background

Methods

Results

Conclusions

Publications

"Liver parenchyma dissecting-first" method facilitates the Glissonean pedicle approach in anatomical laparoscopic hepatolobectomy.

Similar Datasets

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