Primary hilar techniques for isolation of the glissonian pedicles in major an minor liver resections

1. PRIMARY HILAR TECHNIQUES
FOR ISOLATION OF THE
GLISSONIAN PEDICLES IN MAJOR
AND MINOR LIVER RESECTIONS
Authors: I. Cîmpeanu, M. Bogdan, T. Artenie,
R. Petrescu, I. Lucescu
Clinical 1-st Department of Surgery– Clinical and Emergency
Central Military Hospital “Dr. Carol Davila” - Bucharest
April 2003

2. MOTTO:
“Extra-fascial control of the pedicles has
been a definite progress and has simplified
considerably sectorectomies and
segmentectomies”
Couinaud C., 1989

3. MOTTO:
Glissonean pedicle transection method prevented
intraoperative metastasis and significantly
improved the postoperative survival in patients
with hepatocellular carcinoma.
Tsuruta K. &col.,
Hepato-Gastroenterology 2002

4. Classic hilar dissection: complicated and dangerous
A. cistică AH seg IV
VPS
AHS
VPD AHD
VP
Artera hepatică proprie

5. Placa hilară (centrală)
V-VIII Placa glissoniană
stangă
Teci
glissoniene
II
VI-VII
IV III
Placa veziculară Placa ombilicală
GLISSONIAN PLATES AND SHEATHS

6. PGAD
PGPD
Anatomic variants – under the hilar (and ombilical) plate
(biliary tract)

7. Right hilar extension

8. Right hilar extension (detail)

9. Ischaemic limits of segment VI (modal distribution)

10. D
Isolation of the RPGP (PGPD) Risk of damaging right inferior
in the Raynaud-Coucoravas retro-hepatic vein (VRHID) when
point (RC) attempting to isolate RPGP (PGPD)
- VI (A)=PG angular segment VI -
(cadaverous dissection)

13. V(S)HM
V(S)HD Placă hilară
V(S)HS
Takasaki-Couinaud Couinaud
Lazorthes Launois
Launois
COMPLEX EXTRAGLISSONIAN APPROACH
HILAR PLATE DESCENDING

14. 1 3
Placa Lob pătrat
VB (IVb)
CUSA
VB
Hilar plate descending - Couinaud
2 4
Coborarea PH
Posterior
approach
(segment IX)

15. Placa cistică
Lig rotund
IVb
IV
Linia
SPP PPPS
PPS
(PGPS)
PPD
PPPD Couinaud
(PGPD)
Takasaki-Couinaud

16. ISOLATION OF THE GLISSONIAN
PEDICLES FOR THE LEFT HEMI-LIVER

17. Couinaud technique for the isolation of the LPPP (PPPS)

18. Launois technique (posterior approach) for the isolation of the LPPP (PPPS).
a)=schematic draw

19. III
IVb
Isolation of glissonian
pedicles for II and III

20. Lig. rotund
Pedicul seg. III
Pedicul seg. IV
Placă ombilicală
PPPS clampat
RESECTION OF SEGMENT III

21. 2.
1.
Resection of segment III
3. 4.

22. Ombilical plate – epiportal view

23. ISOLATION OF THE GLISSONIAN
PEDICLES FOR THE RIGHT
HEMI-LIVER

24. (IX)
TYPE OF PERIHILAR INCISIONS USED FOR
EXTRAGLISSONIAN APPROACH

25. Placa cistică
Lig rotund
IVb
IV
Linia
SPP PPPS
PPS
(PGPS)
PPD Couinaud
PPPD
(PGPD)
Takasaki-Couinaud

26. SUPRAHILAR LAZORTHES APPROACH

27. LAUNOIS technique for the isolation of the RPPP
(PPPD, PGPD)

28. Dangerous Launois zone

29. Ligature level of the glissonian pedicles (right lobe)

30. Posterior approach Launois – anatomic portal variant of the right lobe

31. Anterior variants of the RPS (SPD)

32. SPD
Sector paramedian drept
SPP
Fosa V.B.
Ischaemic limits of the anterior (paramedian)
sector of the right lobe, with the visualisation
of the MPS and RPS (anterior right glissonian
pedicle clamped) – amodal variant of RPS (SPD)

33. Scizura
portă principală
Scizura
portă dreaptă

34. Linie SPD
V.B.
Pedicul lateral drept
( clampat )
Modal variant of RPS (SPD)

35. SPD
V.B.
VI
Glissonian pedicle for VI – clamped (amodal distribution)