Glissonean pedicle approach in liver surgery

Abstract

Glisson's capsule was discovered by Johannis Walaeus in 1640 and described by Francis Glisson in 1654. The capsule wraps the hepatic artery, the portal vein and the bile duct in the liver and forms bundles at the hepatic hilus and in the liver as the Glissonean pedicle tree. Glisson's capsule does not connect to the proper membrane of the liver, which was discovered by Laennec; therefore, the Glissonean pedicles can be detached from the liver parenchyma without liver dissection. Couinaud described three main approaches to control the inflow system at the hepatic hilus in liver surgery; the intrafascial approach, the extrafascial and transfissural approach, and the extrafascial approach. The intrafascial approach is the so-called control method. The extrafascial and transfissural approach, and the extrafascial approach are recognized as the Glissonean pedicle approach. When the Glissonean pedicles are ligated before liver transection, various types of anatomical hepatectomy can be carried out. The Glissonean pedicle approach is, therefore, considered to be one of the most important procedures in liver surgery. We herein describe the historical aspects and procedures of the Glissonean pedicle approach in liver surgery.

Keywords: Laennec's capsule; Walaeus sheath; anatomical hepatectomy; surgical anatomy of the liver; the hilar plate.

Figure 1

The three methods of access to the portal pedicle. A, Intrafascial approach. B, Extrafascial approach. C, Extrafascial and transfissural approach

Figure 2

Anterior sectionectomy with the extrafascial and transfissural approach by Ton That Tung (Reprinted from reference13)

Figure 3

The extrafascial approach by Takasaki (Reprinted from reference17)

Figure 4

Extrafascial approach to the anterior branch of the Glissonean pedicle. The right anterior branch can be approached after strongly pulling the right main portal branch and the right posterior branch

Figure 5

Cone unit resection. The three branches are transected selectively, by the hilar or parenchymal approach. Then the liver parenchyma may be cut on the demarcated line (Reprinted from reference2)