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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
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MOTTO:MOTTO:
“Extra-fascial control of the pedicles has been a definite progress and has simplified
considerably sectorectomies and segmentectomies”
Couinaud C., 1989
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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
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V P
VPD
Artera hepatică proprie
AHD
AHS
AH seg IVA. cistică
VPS
Classic hilar dissection: complicated and dangerous
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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
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PGPD
PGAD
Anatomic variants – Anatomic variants – underunder the hilar (and ombilical) plate the hilar (and ombilical) plate(biliary tract)(biliary tract)
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Right hilar extensionRight hilar extension
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Right hilar extension (detail)Right hilar extension (detail)
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Ischaemic limits of segment VI (modal distribution)Ischaemic limits of segment VI (modal distribution)
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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
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CouinaudLaunois
Takasaki-CouinaudLazorthesLaunois
Placă hilară
V(S)HM
V(S)HD
V(S)HS
COMPLEX EXTRAGLISSONIAN APPROACHHILAR PLATE DESCENDING
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1
2
3
4Hilar plate descending - Couinaud
Placa VB
Lob pătrat(IVb)
VB
CUSA
Coborarea PHCoborarea PH
Posterior Posterior approachapproach
(segment IX)(segment IX)
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PPD
PPS
Lig rotundPlaca cistică
Linia SPP
IV
PPPS(PGPS)
PPPD(PGPD)
IVb
Couinaud
Takasaki-Couinaud
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ISOLATION OF THE GLISSONIAN ISOLATION OF THE GLISSONIAN PEDICLES FOR THE LEFT HEMI-LIVERPEDICLES FOR THE LEFT HEMI-LIVER
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Couinaud technique for the isolation of the LPPP (PPPS)
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Launois technique (posterior approach) for the isolation of the LPPP (PPPS). a)=schematic draw
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IVbIII
Isolation of glissonian Isolation of glissonian pedicles for II and IIIpedicles for II and III
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Lig. rotund
Pedicul seg. IV
Pedicul seg. III
Placă ombilicală
PPPS clampat
RESECTION OF SEGMENT III
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Resection of segment III 1. 2.
3. 4.
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Ombilical plate – epiportal viewOmbilical plate – epiportal view
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ISOLATION OF THE GLISSONIAN ISOLATION OF THE GLISSONIAN PEDICLES FOR THE RIGHT PEDICLES FOR THE RIGHT
HEMI-LIVERHEMI-LIVER
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TYPE OF PERIHILAR INCISIONS USED FOR TYPE OF PERIHILAR INCISIONS USED FOR EXTRAGLISSONIAN APPROACHEXTRAGLISSONIAN APPROACH
(IX)(IX)
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PPD
PPS
Lig rotundPlaca cistică
Linia SPP
IV
PPPS(PGPS)
PPPD(PGPD)
IVb
Couinaud
Takasaki-Couinaud
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SUPRAHILAR LAZORTHES APPROACHSUPRAHILAR LAZORTHES APPROACH
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LAUNOIS technique for the isolation of the RPPP(PPPD, PGPD)
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Dangerous Launois zoneDangerous Launois zone
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Ligature level of the glissonian pedicles (right lobe)Ligature level of the glissonian pedicles (right lobe)
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Posterior approach Launois – anatomic portal variant of the right lobePosterior approach Launois – anatomic portal variant of the right lobe
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Anterior variants of the RPS (SPD)Anterior variants of the RPS (SPD)
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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)
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Scizura portă principală
Scizura portă dreaptă
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V.B.
Pedicul lateral drept ( clampat )
Linie SPD
Modal variant of RPS (SPD)Modal variant of RPS (SPD)
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V.B.
VI
SPD
Glissonian pedicle for VI – clamped (amodal distribution)