What are the benefits and recommendations for using the Glissonian approach in liver resection surgeries?

Glissonian Approach in Liver Resection

The Glissonian pedicle approach should be used for major hepatectomies as it significantly reduces operative time, blood loss, and transfusion requirements compared to classical hilar dissection, while maintaining equivalent or superior safety profiles. 1, 2

What is the Glissonian Approach?

The Glissonian approach involves en masse control of the portal structures (hepatic artery, portal vein, and bile duct) wrapped together by Glisson's capsule, without individual dissection of each vessel. 3 This technique can be performed through:

• Extrafascial and transfissural approach: Accessing the pedicles through liver parenchyma 3
• Extrafascial approach: Direct pedicle isolation without entering the liver substance 3
• Intrahepatic approach: Identifying pedicles by tentative clamping within the liver 2

These methods contrast with the traditional intrafascial (hilar dissection) approach where each vessel is individually isolated and ligated. 3

Evidence for Superior Outcomes

Operative Efficiency

The Glissonian approach demonstrates clear advantages in surgical efficiency:

• Shorter operative time: 191 minutes vs. 247 minutes with hilar dissection (p<0.001) 1
• Reduced transection time: 39 minutes vs. 56 minutes (p<0.001) 1
• Decreased ischemic duration: 26 minutes vs. 41 minutes (p<0.001) 1

Blood Loss and Transfusion Requirements

Blood conservation is significantly better with the Glissonian approach:

• Intraoperative blood loss: 246 ml vs. 345 ml with hilar dissection (p=0.018) 1
• Intraoperative transfusion: 323 ml vs. 415 ml (p=0.038) 1
• Postoperative transfusion: 247 ml vs. 337 ml (p=0.026) 1

Safety Profile

A 7-year observational study of 234 laparoscopic liver resections demonstrated that the Glissonian approach had fewer complications despite performing more major hepatectomies, with shorter hospital stays and fewer positive margins compared to standard approaches (p<0.05). 2

Technical Advantages

Avoidance of Anatomical Variations

The Glissonian approach circumvents the risk of encountering anatomical variations in the hepatic hilum that can complicate individual vessel dissection. 4 By controlling structures en masse, surgeons avoid prolonged and potentially hazardous dissection of aberrant vessels or bile ducts. 4

Application in Laparoscopic Surgery

The Glissonian approach is particularly valuable in laparoscopic hepatectomy:

• Facilitates hilar dissection with minimal operative risk 4
• Enables safe control without extensive dissection in limited laparoscopic working space 4
• Allows vascular stapling devices to transect the entire pedicle under direct vision 4
• Reduces blood loss during pedicle control (no bleeding reported during Glissonian dissection in one series) 4

Combination with Half-Pringle Maneuver

For challenging posterosuperior resections (segments 6 and 7), the Glissonian approach can be combined with a half-Pringle maneuver to further minimize blood loss during parenchymal transection. 5 This technique provides selective inflow control while reducing ischemic injury to the remnant liver. 5

Specific Applications

Major Hepatectomies

The Glissonian approach is particularly suited for:

• Right hepatectomy: Safe, simple, and reproducible in both open and laparoscopic approaches 4
• Right posterior sectionectomy: Addresses difficult pedicle access and extensive transection areas 5
• Left hepatectomy: Effective for anatomical resections 5

Integration with ERAS Protocols

When performing liver resection within Enhanced Recovery After Surgery (ERAS) pathways, the Glissonian approach aligns with key principles:

• Low CVP maintenance: The approach facilitates maintaining CVP below 5 cmH₂O during transection 6
• Reduced operative time: Supports early mobilization and recovery 1
• Decreased blood loss: Minimizes transfusion-related complications 1

Technical Execution

Open Surgery Technique

1. Incise liver parenchyma posterior and anterior to the hilum 4
2. Continue dissection outside the portal pedicle bifurcation toward right and left sheaths 4
3. Place vascular stapling device to transect the pedicle en masse 4
4. Proceed with parenchymal transection using standard techniques 1

Laparoscopic Technique

1. Perform lymph node sampling at hepatoduodenal ligament 4
2. Create parenchymal incisions to expose the pedicle 4
3. Use endoscopic vascular stapler under direct vision and cholangiography guidance 4
4. Complete parenchymal transection with harmonic scalpel, CUSA, or other devices 4

Critical Pitfalls to Avoid

Inadequate pedicle identification: Always perform tentative clamping to confirm complete control before definitive ligation. 2 Incomplete pedicle control can lead to intraoperative bleeding or inadvertent injury to adjacent structures.

Excessive traction on pedicles: Gentle handling prevents avulsion injuries to vessels or bile ducts within the Glissonian sheath. 3

Failure to verify anatomy: Despite the en masse approach, intraoperative cholangiography or ultrasound should confirm appropriate pedicle selection, particularly in patients with variant anatomy. 4

Neglecting remnant liver perfusion: When combining with Pringle maneuvers, limit ischemic time to prevent postoperative liver dysfunction, especially in diseased livers (steatosis, cirrhosis, post-chemotherapy). 5

Comparison with Standard Hilar Dissection

The traditional hilar dissection approach requires individual identification and ligation of the hepatic artery, portal vein, and bile duct. 4 While this provides precise anatomical control, it:

• Requires longer operative time 1
• Increases risk of injury with anatomical variations 4
• Results in greater blood loss 1
• Demands more extensive dissection in the hepatoduodenal ligament 4

The Glissonian approach should be the preferred technique for surgeons performing major hepatectomies, with the caveat that liver surgeons must develop familiarity with the anatomy of Glissonian pedicles and their variations. 1