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PRIMARY HILAR TECHNIQUES PRIMARY HILAR TECHNIQUES FOR ISOLATION OF THE FOR ISOLATION OF THE

GLISSONIAN PEDICLES IN MAJOR GLISSONIAN PEDICLES IN MAJOR AND MINOR LIVER RESECTIONSAND MINOR LIVER RESECTIONS

Authors:Authors: I. C I. Cîîmpeanu, M. Bogdan, T. Artenie, mpeanu, M. Bogdan, T. Artenie, R. Petrescu, I. LucescuR. Petrescu, I. Lucescu

Clinical 1-st Department of Surgery– Clinical and Emergency Clinical 1-st Department of Surgery– Clinical and Emergency Central Military Hospital “Dr. Carol Davila” - BucharestCentral Military Hospital “Dr. Carol Davila” - Bucharest

April 2003April 2003

MOTTO:MOTTO:

“Extra-fascial control of the pedicles has been a definite progress and has simplified

considerably sectorectomies and segmentectomies”

Couinaud C., 1989

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

V P

VPD

Artera hepatică proprie

AHD

AHS

AH seg IVA. cistică

VPS

Classic hilar dissection: complicated and dangerous

VI-VII

V-VIII

II

IIIIV

Placa veziculară

Placa hilară (centrală)

Placa ombilicală

Teci glissoniene

Placa glissoniană stangă

GLISSONIAN PLATES AND SHEATHSGLISSONIAN PLATES AND SHEATHS

PGPD

PGAD

Anatomic variants – Anatomic variants – underunder the hilar (and ombilical) plate the hilar (and ombilical) plate(biliary tract)(biliary tract)

Right hilar extensionRight hilar extension

Right hilar extension (detail)Right hilar extension (detail)

Ischaemic limits of segment VI (modal distribution)Ischaemic limits of segment VI (modal distribution)

Isolation of the RPGP (PGPD) in the Raynaud-Coucoravas

point (RC)

Risk of damaging right inferior retro-hepatic vein (VRHID) when

attempting to isolate RPGP (PGPD)

- VI (A)=PG angular segment VI -

(cadaverous dissection)

D

CouinaudLaunois

Takasaki-CouinaudLazorthesLaunois

Placă hilară

V(S)HM

V(S)HD

V(S)HS

COMPLEX EXTRAGLISSONIAN APPROACHHILAR PLATE DESCENDING

1

2

3

4Hilar plate descending - Couinaud

Placa VB

Lob pătrat(IVb)

VB

CUSA

Coborarea PHCoborarea PH

Posterior Posterior approachapproach

(segment IX)(segment IX)

PPD

PPS

Lig rotundPlaca cistică

Linia SPP

IV

PPPS(PGPS)

PPPD(PGPD)

IVb

Couinaud

Takasaki-Couinaud

ISOLATION OF THE GLISSONIAN ISOLATION OF THE GLISSONIAN PEDICLES FOR THE LEFT HEMI-LIVERPEDICLES FOR THE LEFT HEMI-LIVER

Couinaud technique for the isolation of the LPPP (PPPS)

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

IVbIII

Isolation of glissonian Isolation of glissonian pedicles for II and IIIpedicles for II and III

Lig. rotund

Pedicul seg. IV

Pedicul seg. III

Placă ombilicală

PPPS clampat

RESECTION OF SEGMENT III

Resection of segment III 1. 2.

3. 4.

Ombilical plate – epiportal viewOmbilical plate – epiportal view

ISOLATION OF THE GLISSONIAN ISOLATION OF THE GLISSONIAN PEDICLES FOR THE RIGHT PEDICLES FOR THE RIGHT

HEMI-LIVERHEMI-LIVER

TYPE OF PERIHILAR INCISIONS USED FOR TYPE OF PERIHILAR INCISIONS USED FOR EXTRAGLISSONIAN APPROACHEXTRAGLISSONIAN APPROACH

(IX)(IX)

PPD

PPS

Lig rotundPlaca cistică

Linia SPP

IV

PPPS(PGPS)

PPPD(PGPD)

IVb

Couinaud

Takasaki-Couinaud

SUPRAHILAR LAZORTHES APPROACHSUPRAHILAR LAZORTHES APPROACH

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

Dangerous Launois zoneDangerous Launois zone

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

Posterior approach Launois – anatomic portal variant of the right lobePosterior approach Launois – anatomic portal variant of the right lobe

Anterior variants of the RPS (SPD)Anterior variants of the RPS (SPD)

Fosa V.B.

SPP

SPD

Sector paramedian drept

Ischaemic limits of the anterior (paramedian) Ischaemic limits of the anterior (paramedian) sector of the right lobe, with the visualisation sector of the right lobe, with the visualisation of the MPS and RPS (anterior right glissonianof the MPS and RPS (anterior right glissonian

pedicle clamped) – amodal variant of RPS (SPD)pedicle clamped) – amodal variant of RPS (SPD)

Scizura portă principală

Scizura portă dreaptă

V.B.

Pedicul lateral drept ( clampat )

Linie SPD

Modal variant of RPS (SPD)Modal variant of RPS (SPD)

V.B.

VI

SPD

Glissonian pedicle for VI – clamped (amodal distribution)