Selection of the Occlusion Type of Hepatic Blood Inflow: A Prospective Study

Abstract

Background: The Glissonean pedicle method in liver surgery enhances the technique of liver surgery while introducing fresh information about the surgical anatomy of the liver. The hepatic artery, portal vein, and bile duct are parts of the Glissonean pedicles, which are wrapped in a connective tissue known as the Glisson's capsule. Both intrahepatic and extrahepatic approaches can be used to access the Glissonean pedicles. Couinaud refers to the extrahepatic route at the hepatic hilus as the extra-fascial access. Without requiring the liver to be dissected, the secondary Glissonean pedicles are encircled and tied at the hepatic hilus. The angle of approach should be above the hilar plate to spare the surgeon from having to account for variations in the arteries or bile ducts. The hepatic hilus, which separates the regions nourished by the secondary Glissonean pedicles, can be used to access the tertiary branches either intrahepatically or extrahepatically. This method enables a quick, safe, easily performed liver resection and can be used for any anatomical hepatectomy. Thus, liver surgeons should be aware of the fundamental concept behind the Glissonean pedicle transection technique.

Objectives: In this study, we aim to describe the application of Glissonean pedicle approach in three groups: extrahepatic extrafascial, extrahepatic intrafacial and intrahepatic extrafascial and evaluate the results, focusing on intraoperative and postoperative complications, amount of bleeding, operative times.

Patients and Methods: This prospective clinical study conducted in the Department of Surgery in Gastroenterology and Hepatology Teaching Hospital in Medical City/Baghdad from 14th of December 2020 to 21th of December 2022. Sixteen patients with different type of presentation were included in this prospective study. Liver resection due to trauma was excluded from this study. All patients with liver disease referred from other hospitals in Baghdad and other Iraqi governorates. In all patients, the prospective diagnosis of liver problem was correctly made on history, clinical presentation, blood investigation, ultrasound (US), computed tomography scan (CT), magnetic resonance imaging (MRI).

Results: The age of the participants ranging from 2 to 71 years old (mean age 36.19±23.7 year), 7 (44%) males and 9 (56%) females. We classified the patients in to two groups: extrahepatic extrafascial 4 (25%), extrahepatic intrafascial 5 (31%) and intrahepatic extrafascial 7 (44%). The average operation time was 235.0±51.5 minutes and the mean of blood loss was 287.5±117.6 ml. Total blood transfusion proportion during and after surgery was 37.5%. The number of patients who unreceived blood was more in the selective inflow control group (seven patients). Complications accounted for 50% of the patients in which the bleeding was the most common (25%). There were no pleural effusion and ascites after surgery. One death was recorded postoperatively due to sepsis. Type of resection, resected volume (minor and major), blood loss and operation time were the factors significantly affecting the percentage of complications after surgery in our study. Furthermore, the mean of blood loss and the mean of operation time were more in the group of patients who underwent intrafascial approach.

Conclusion: In Extrafascial approach, there was less blood loss and transfusion, and the duration of surgery was shorter. Extrafascial approach is safe, feasible and effective method to resect precisely liver masses and less complications in the remnant liver. Hilar dissection is preferred in hepatic masses in porta hepatise.