Glisson’s Pedicle Approach and Liver Round Ligament Approach in Anatomical Hepatectomy

Abstract

The hepatic artery, portal vein, and bile ducts (the portal triad) in the ligamentum hepatoduodenale are encased in a membrane and branch, and they constitute Glisson’s system. This system consists of extrahepatic and intrahepatic portions. The portal triad encased in the connective tissue and peritoneum, up to the porta hepatis, constitutes the extrahepatic portion of Glisson’s system, whereas the portion that extends into the liver is considered intrahepatic. The ligamentum hepatoduodenale is the main stem of Glisson’s system and gives rise to two primary branches at the porta hepatis. The left primary branch of Glisson’s pedicle (including the left branch of the portal vein, the left hepatic artery, and the left hepatic duct) runs in the left hilar plate and turns upward in the fissure toward the ligamentum teres hepatis after giving rise to branches leading to the II segment at the left-most part of the left hilar plate. The left primary branch of Glisson’s pedicle gives off branches to the III segment at the left side of the base of the fissure for the ligamentum teres hepatis and branches to the IV segment at the right side of the base of the fissure for the ligamentum teres hepatis; it then continues with the ligamentum teres hepatis. The main stem of the right primary branch of the Glisson’s pedicle is short and occasionally even absent, and it quickly divides into two secondary branches (Fig. 12.1). Based on this anatomical foundation, Professor Takasaki (Tokyo Women Medical University) divided the liver into three sections: the right segment, middle segment, and left segment, which correspond, respectively, to the right posterior lobe, right anterior lobe, and left lobe in Couinaud’s hepatic segments [1]. By extrahepatic dissection of Glisson’s pedicle, we can address the structure in Glisson’s pedicle without opening Glisson’s sheath, thus avoiding complex operations and potential damage to the hepatic portal. This procedure is called Glisson’s pedicle transection hepatectomy. After development and promotion by Machado and others, this technology has been available for hepatic segmentectomy, hepatic lobectomy, hemihepatectomy, and extensive hepatectomy and shows its unique advantages [2, 3].