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262
Fig. 32.11 Right hepatectomy + SI or Left hepatectomy. Tape upper
end: Between MHV & LHV, Tape lower end: Between Right & Left
portal pedicle
J. Belghiti and S. Dokmak
Fig. 32.13 Right anterior sectionectomy. Tape 1 Upper end: Between
RHV & MHV—Tape 2 upper end: Between RHV & MHV, Tape 1
lower end: Between right anterior & right posterior portal pedicle—
Tape 2 lower end: between Right & Left portal pedicle
Fig. 32.12 Central bisectionectomy. Tape 1 Upper end: Between RHV
& MHV—Tape 2upper end: Between MHV & LHV, Tape 1 Lower end
1: Between Right anterior & Right posterior portal pedicle—Tape 2
Between Right & Left portal pedicle
this traction should be released from time to time allowing
identication of venous tears. In patients with intrahepatic
venous collateral circulation, bleeding of the transection
parenchyma is exacerbated when the liver remains in ana-
Fig. 32.14 Left medial sectionectomy. Tape 1 upper end: Between
RHV & MHV—Tape 2 upper end: Between MHV & LHV, Tape 1
lower end: Between Right & Left portal pedicle—tape 2 lowed end
Between Right & Left portal pedicle
tomic position and therefore, a vertical mobilization of the
liver is required in order to reduce the outow. The presence
of this venous collateral circulation is clearly a limitation of
LHM with the anterior approach.
32 Open andLaparoscopic Liver Hanging Maneuver
Fig. 32.15 Caudate lobectomy. Upper end: Tape passed between RHV
& MHV and then behind MHV and LHV. Lower end: Tape passed
behind the Gilson pedicle
References
1. Sutherland F, Harris J.Claude Couinaud: a passion for the liver.
Arch Surg. 2002;137:1305–10.
2. Belghiti J, Guevara OA, Noun R, etal. Liver hanging maneuver:
a safe approach to right hepatectomy without liver mobilization. J
Am Coll Surg. 2001;193(1):109–11.
3. Ogata S, Belghiti J, Varma D, et al. Two hundred liver hanging
maneuvers for major hepatectomy: a single-center experience. Ann
Surg. 2007;245(1):31–5.
4. Beppu T, Imai K, Okuda K, etal. Anterior approach for right hepatectomy with hanging maneuver for hepatocellular carcinoma: a
multi-institutional propensity score-matching study. J Hepatobiliary
Pancreat Sci. 2017;24(3):127–36.
5. Llado L, Muñoz A, Ramos E, etal. The anterior hanging-approach
improves postoperative course after right hepatectomy in patients
with colorectal liver metastases. Results of a prospective study
263
with propensity-score matching comparison. Eur J Surg Oncol.
2016;42(2):176–83.
6. Kim SH, Kim YK.Living donor right hepatectomy using the hanging maneuver by Glisson’s approach under the upper midline incision. World J Surg. 2012;36(2):401–6.
7. Liu CL, Fan ST, Cheung ST, et al. Anterior approach versus conventional approach right hepatic resection for large hepatocellular
carcinoma: a prospective randomized controlled study. Ann Surg.
2006;244(2):194–203.
8. Shindoh J, Aoki T, Hasegawa K, etal. Donor hepatectomy using
hanging maneuvers: Tokyo University experiences in 300 donors.
Hepato-Gastroenterology. 2012;59(118):1939–43.
9. Vennarecci G, Levi Sandri GB, Ettorre GM. Performing the
ALPPS procedure by anterior approach and liver hanging
maneuver. Ann Surg. 2016;263(1):e11. https://doi.org/10.1097/
SLA.0000000000001007.
10. Liddo G, Buc E, Nagarajan G, etal. The liver hanging manoeuvre.
HPB (Oxford). 2009;11(4):296–305.
11. Kim SH, Park SJ, Lee SA, etal. Various liver resections using hanging maneuver by three Glisson’s pedicles and three hepatic veins.
Ann Surg. 2007;245(2):201–5.
12. Troisi RI, Montalti R. Modied hanging maneuver using the
Goldnger dissector in laparoscopic right and left hepatectomy.
Dig Surg. 2012;29(6):463–7.
13. Dokmak S, Aussilhou B, Rebai W, Cauchy F, Belghiti J, Soubrane
O.Up-to-down open and laparoscopic liver hanging maneuver: an
overview. Langenbeck's Arch Surg. 2020; https://doi.org/10.1007/
s00423- 020- 01945- 5. Epub ahead of print
14. Nitta H, Sasaki A, Fujita T, etal. Laparoscopy-assisted major liver
resections employing a hanging technique: the original procedure.
Ann Surg. 2010;251(3):450–3.
15. Rhaiem R, Piardi T, Kellil T, et al. The liver hanging maneuver
in laparoscopic liver resection: a systematic review. Surg Today.
2018;48(1):18–24.
16. Kim JH, Kim H.Modied liver hanging maneuver in laparoscopic
major hepatectomy: the learning curve and evolution of indications.
Surg Endosc. 2020;34(6):2742–8.
17. Kim JH. Three-dimensional ventral approach with the modied
liver-hanging maneuver during laparoscopic right hemihepatectomy. Ann Surg Oncol. 2019;26(7):2253.
18. Nanashima A, Tobinaga S, Araki M, etal. Double liver hanging manoeuvre for central hepatectomy. HPB (Oxford). 2009;11(6):529–31.
The Glissonean Pedicle Approach:
TheTakasaki Technique
Shun-ichiAriizumi andMasakazuYamamoto
33
Abstract
Couinaud described three main approaches to control the
inow system at the hepatic hilus in liver surgery: the
intrafascial, the extrafascial, and the transssural with
extrafascial approach. The intrafascial approach is the socalled control method. The extrafascial approach and the
transssural with extrafascial approach are considered to
be the Glissonean pedicle approach. The Glissonean pedicle approach by extrafascial approach is considered to be
the Takasaki technique. The key steps of the Takasaki
technique are the following: (1) clamping the Glissonean
pedicle, (2) conrming the portal territory which includes
the tumor, (3) dissecting the liver parenchyma. When the
Glissonean pedicles are ligated at the hepatic hilus prior
to liver dissection, various types of anatomical hepatectomy, such as right or left hemihepatectomy and various
types of sectionectomy can be carried out. When the tertiary branches of the Glissonean pedicles are ligated
extra- or intrahepatically, various types of segmentectomy
and cone unit resection can be carried out. This procedure
is suitable for patients with hepatocellular carcinoma
(HCC), because patients with HCC usually have liver
dysfunction and HCC often invades the portal vein. The
procedure is also available in laparoscopic hepatectomy,
because of its simplicity and safety. The Glissonean pedicle approach is, therefore, considered to be one of the
most important procedures in liver surgery which can be
achieved safely and has oncological benet.
33.1 Introduction
Couinaud described three main approaches to the inow
system at the hepatic hilus; the intrafascial, the extrafascial, and the transssural with extrafascial approach
(Fig.33.1) [1]. The extrafascial approach and the transssural with extrafascial approach are considered to be the
Glissonean pedicle approach. Takasaki etal. successfully
performed anatomical anterior sectionectomy with the
Glissonean pedicle approach at the hepatic hilus in a
patient with hepatocellular carcinoma (HCC) in 1984 and
reported the newly developed systematized hepatectomy
by Glissonean pedicle transection method in 35 patients
with HCC in 1986 (Japanese article) [2]. Therefore, anatomical hepatectomy at the Glissonean pedicle approach is
considered to be the Takasaki technique [3–6]. The key
steps of the Takasaki technique are the following: (1)
clamping the Glissonean pedicle, (2) conrming the portal
territory, (3) dissecting the liver parenchyma. Currently,
the Glissonean pedicle approach is performed worldwide
and is preferred in laparoscopic hepatectomy because of
its simplicity and safety.
33.2 Fundamental Concept ofLiver
Segmentation Based
ontheGlissonean Pedicle (Takasaki’s
Liver Anatomy)
The Glissonean pedicle consisting of the portal vein, hepatic
artery and bile duct is wrapped in a connective tissue sheath
known as Glisson’s capsule (Fig.33.1a). The extrahepatic or
Glissonean pedicle branches to form right and left primary
Glissonean pedicles (Fig. 33.1a) [3–6]. The left primary
S.-i. Ariizumi · M. Yamamoto (*)
Department of Surgery, Institute of Gastroenterology, Tokyo
Women’s Medical University, Tokyo, Japan
e-mail: yamamoto.masakazu@twmu.ac.jp
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_33
Glissonean pedicle continues to form a single secondary
pedicle, whilst the right primary Glissonean pedicle branches
into two secondary pedicles, namely the middle (right anterior) and right (right posterior) pedicles (Fig. 33.1a). The
265
266
ab
Fig. 33.1 Components of the Glissonean pedicle and Takasaki’s liver segmentation. The three secondary Glissonean pedicles divide the liver into
3 segments
S.-i. Ariizumi and M. Yamamoto
three secondary Glissonean pedicles divide the liver into
three segments (left, middle and right) according to the ramication of the secondary pedicles (Fig.33.1b) [3–6].
33.3 Glissonean Pedicle Approach at
theHepatic Hilus (Extrafascial
Approach)
The Glissonean pedicles can be detached from the liver
parenchyma without liver dissection. The extrafascial
approach is to tape the Glissonean pedicles at the hepatic
hilus prior to liver dissection. After cholecystectomy, the
connective tissue behind Calot’s triangle is identied. This
connective tissue is referred to as the cystic plate. After
dividing the cystic plate, the middle (right anterior)
Glissonean pedicle behind the cystic plate can be readily
identied (Fig. 33.2a). First, this middle (right anterior)
Glissonean pedicle is detached from the liver parenchyma
(Fig.33.2b). The Glissonean pedicle can be detached easily
from the liver parenchyma by blunt dissection. After clamping this pedicle, the middle segment (right anterior section)
can be recognized by its change of color (Fig.33.2c). After
conrming the demarcation lines between the middle
segment (anterior section) and the other segments (sections),
the liver parenchyma is dissected along the demarcation
lines (Fig.33.2d). This fundamental technique is useful not
only for middle segmentectomy (anterior sectionectomy) but
also for right segmentectomy (posterior sectionectomy) or
right hemihepatectomy.
For right hepatectomy or right segmentectomy (right posterior sectionectomy), the right (right posterior) Glissonean
pedicle can be detached directly from the liver parenchyma.
However, the following subtraction method is recommended
for taping of the right (right posterior) Glissonean pedicle. At
rst, the middle (right anterior) Glissonean pedicle is taped
(Fig 33.3a). Next, the right primary Glissonean pedicle is
taped (Fig33.3b). The right (right posterior) Glissonean pedicle can then be taped after securing the middle (right anterior) Glissonean pedicle (Fig33.3c). This technique is useful
for right segmentectomy (posterior sectionectomy) and right
hemihepatectomy. The left Glissonean pedicle (secondary
Glissonean pedicle) can be accessed at the left side of the
hilar plate, and the left pedicle can easily be taped prior to
liver dissection (Fig33.3d). Therefore, all three secondary
Glissonean pedicles can be taped at the hepatic hilus
(Fig33.3d).
33.4 Ligation oftheGlissonean Pedicle
Ligation of the pedicles should be done as close to the liver
parenchyma as possible to avoid injury to the remaining bile
duct. The pedicle should be doubly ligated with transxion
suture to avoid slipping out (Fig33.3c). After ligation, the
pedicle is divided.
33 The Glissonean Pedicle Approach: TheTakasaki Technique
ab
cd
267
Fig. 33.2 Middle segmentectomy (right anterior sectionectomy) with the Glissonean pedicle approach at the hepatic hilus
33.5 Dissection oftheLiver Parenchyma
The territory of a single tertiary branch does not correspond
to a Couinaud’s segment. We therefore refer to the area fed by
Dissection should be performed on the demarcated margin
line with the crush-clamp method, ultrasonic dissector
(CUSA), and energy device. Some branches from the hepatic
vein are ligated and cut, but the trunk of the hepatic vein
should be maintained intact on the cut surface of the remaining segments. (Fig.33.4).
one tertiary branch as a cone unit of the liver. For cone unit
resection in the middle segment (S5 section), the middle
(right anterior) Glissonean pedicle is taped and hepatic dissection is performed along the Rex-Cantlie line. Two tertiary
branches from the middle (right anterior) Glissonean pedicle
are ligated and divided. For cone unit resection in the middle
segment (S8 section), the middle (right anterior) Glissonean
pedicle is taped and a test clamp is performed. After conrm-
33.6 Segmentectomy, Cone Unit Resection
ing the Rex-Cantlie line, liver dissection is performed, and
tertiary branches from the middle (right anterior) Glissonean
When the tertiary branches of the Glissonean pedicles are
ligated extra- or intrahepatically, various types of segmentectomy and cone unit resection can be carried out. A single secondary Glissonean pedicle has six to eight tertiary branches.
pedicle are taped intrahepatically. The area of S8 can then be
identied by demarcation. The tertiary branches are ligated
and divided. The middle hepatic vein is identied in the cut
surface of the remnant liver.
268
ab
cd
ab
S.-i. Ariizumi and M. Yamamoto
Fig. 33.3 Basic technique to tape the Glissonean pedicle at the hepatic hilus
Fig. 33.4 Cone unit resection (segmentectomy No 8) with the Glissonean pedicle approach
33 The Glissonean Pedicle Approach: TheTakasaki Technique
269
33.7 Surgical Outcomes
During a 30-year period, 1953 patients with HCC underwent
anatomical hepatectomy with the Glissonean pedicle
approach at our institute [7]. The 30-day and 90-day mortality rates decreased gradually in the recent eras (between
2010 and 2014) down to 0.5% and 1.4%, respectively, and
the 5-year survival rate increased gradually up to 75% in the
recent eras (between 2010 and 2014) [7]. Reducing blood
loss and bile leakage are re-recognized as the most important
factors in anatomical hepatectomy for patients with HCC.
In conclusion, the Glissonean pedicle approach is suitable for patients with HCC, because patients with HCC
usually have liver dysfunction and HCC often invades the
portal vein. The procedure is also available in laparoscopic
hepatectomy, because of its simplicity and safety. The
Glissonean pedicle approach is, therefore, considered to be
one of the most important procedures in liver surgery
which can be achieved safely and has oncological benet.
Acknowledgments The authors are indebted to Associate Professor
Raoul Breugelmans of the Department of English of Tokyo Medical
University for his review of this manuscript.
References
1. Couinaud C. Surgical anatomy of the liver revisited. Paris:
Selfprinted; 1989.
2. Takasaki K, Kobayashi S, Tanaka S, et al. New developed systematized hepatectomy by Glissonean pedicle transection method.
Syujutsu. 1986;40:7–14. (in Japanese)
3. Takasaki K, Kobayashi S, Tanaka S, Saito A, Yamamoto M,
Hanyu F.Highly anatomically systematized hepatic resection with
Glissonean sheath cord transection at the hepatic hilus. Int Surg.
1990;75:73–7.
4. Takasaki K. Glissonean pedicle transection method for hepatic
resection: a new concept of liver segmentation. J Hepato-BiliaryPancreat Surg. 1998;5:286–91.
5. Takasaki K. Glissonean pedicle transection method for hepatic
resection. Tokyo: Springer; 2007.
6. Yamamoto M, Ariizumi S.Glissonean pedicle approach in liver surgery. Ann Gastroenterol Surg. 2018;13:124–8.
7. Ariizumi S, Katagiri S, Kotera Y, etal. Improved mortality, morbidity and long-term outcome after anatomical hepatectomy with the
Glissonean pedicle approach in patients with hepatocellular carcinoma: 30 years’ experience at a single institute. Ann Surg. 2020;
(in press)
Laparoscopic Major Hepatectomy
andParenchymal-Sparing Anatomical
Hepatectomy
KoheiMishima, GoWakabayashi, KazuharuIgarashi,
andTakahiroOzaki
34
Abstract
Although laparoscopic liver resection (LLR) has become
recognized as the standard treatment worldwide, laparoscopic major hepatectomy (LMH) has yet to become
widespread. LMH was rst dened as resection of 3 or
more segments or the difcult posterosuperior segments
(4a, 7, 8) in 2008. Although the denition is still under
debate and is not clearly dened, several studies reported
that LMH was associated with less blood loss, shorter
hospital stays and fewer complications compared with
open surgery. According to a nationwide survey of
Japanese National Clinical Database, advanced LLR
increased from 3.3% of all resections in 2011 to 10.8% in
2017, with its mortality 3.6% in 2011, and 1.0% in 2017.
The IWATE criteria can be used to predict the difculty of
LLR from preoperative variables and to appropriately
select patients according to the surgeons’ skill level. The
learning curve for LMH has been discussed, but conclusive number of cases for the mastery of LMH cannot be
decided with variety of studies. Since laparoscopic
parenchymal- sparing anatomical liver hepatectomy (LapPSAH = segmentectomies and sub-segmentectomies)
shares some surgical techniques with LMH, it may help
shorten the learning curve of LMH.In conclusion, LMH
still remains technically demanding, but it has been gradually developed with the improvement of surgical techniques and the careful expansion of indications.
34.1 Introduction
Although laparoscopic liver resection (LLR) has become
recognized as the standard treatment worldwide, laparoscopic major hepatectomy (LMH) has yet to become wide-
spread [1]. This can be attributed to the complexity of the
procedures and fear of uncontrolled hemorrhage, combined
with high-level technical demands and lack of training
opportunities for most surgeons [2]. In this chapter, we
reviewed the current status of LMH, referring to the history
of LLR and the current surgical techniques that has been
standardized in high volume centers.
34.2 Developments ofLLR
LLR was rst reported in 1991 as laparoscopic excision of
benign liver lesions [3]. Since then, LLR has gradually
developed with the improvements of surgical techniques
and equipment. In 2008, the rst international consensus
conferences on LLR (ICCLLR) was held in Louisville,
USA.Standardized terminologies on LLR were dened and
variable technical approaches were introduced by 45 experts
[4]. In 2014, the second ICCLLR was held in Morioka,
Japan. The summary of expert recommendations covered a
novel difculty scoring system [5, 6], techniques for bleeding control and parenchymal transection, and suitability of
energy devices [7]. The conference concluded that LLR had
become a standard practice, but LMH was still an innovative
procedure in its exploratory phase [1]. After these two
ICCLLRs, LLR spread globally with rapidity and the proportion of major LLRs has gradually increased. According
to a nationwide survey of the national clinical database of
Japan [8], the number of LLRs increased from 1868 (9.9%
of all liver resections) in 2011 to 5648 (24.8%) in 2017. The
rates of morbidity and 30-day mortality of LLR were 10.8%
and 0.5%, respectively, which were better than those of
open liver resection (OLR) (19.9% and 0.9%, respectively)
in 2017.
K. Mishima · G. Wakabayashi (*) · K. Igarashi · T. Ozaki
Center for Advanced Treatment of HBP Diseases, Ageo Central
General Hospital, Saitama, Japan
e-mail: gowaka@ach.or.jp
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_34
271
272
K. Mishima et al.
34.3 Denitions ofLMH
Liver resection has been categorized according to the
Brisbane 2000 classication as follows: hemihepatectomies, sectionectomies, and segmentectomies [9].
LMH was rst dened as resection of 3 or more segments
or the difcult posterosuperior segments (4a, 7, 8) in the
1st ICCLLR [4]. Behind this denition is the fact that
resections of posterosuperior segments by laparoscopic
approach shares some technically difculties with hemihepatectomies [10]. On the other hand, a standard denition of major hepatectomy is resection of four or more
segments based on the theory that the extent of resection is
most involved in postoperative mortality [11]. Di Fabio
etal. divided a total of 156 patients who had undergone
LMH according to the Louisville Statement into two subcategories: laparoscopic “traditional” major hepatectomy
(LTMH), including hemi-hepatectomies and tri-sectionectomies, and laparoscopic “posterosuperior” major hepatectomy (LPMH), including resection of posterosuperior
segments 4a, 7, and 8 [10]. The creation of two subcategories of LMH seemed appropriate to reect differences in
intraoperative and postoperative outcomes between LTMH
and LPMH [10]. With improvements in surgical techniques
and the innovation of laparoscopic devices over the last
decade, the classication of LMH has reached the time of
reconsideration based on the technical difculty and the
risk of postoperative mortality [12].
34.4 Diculty Scoring System (IWATE
Criteria) andLearning Curve ofLMH
In an effort to estimate the difculty of LLR appropriately
before surgery, a novel difculty scoring system [5] was created for discussion at the 2nd ICCLLR.After the discussion
at the conference, the scoring system was modied and the
updated version of the difculty scoring system (IWATE criteria) has a scale ranging from 0 to 12 [6]. The IWATE criteria can be used to predict the difculty from preoperative
variables and to appropriately select patients according to the
surgeons’ skill level, ranked as low, intermediate, advanced,
or expert. LMH requires a high level of technical skill and
has a steep learning curve. A CUSUM analysis of learning
curve concluded that 45 standard LMHs are required to over-
come the initial learning curve, and expertise in more complex or technically demanding LMHs can be achieved over
the next 30 cases [13]. LMH remains challenging as the
effective performance of the procedure requires experience;
however, it has low mortality rate relative to open major hepatectomy (OMH) (Fig.34.1).
34.5 Feasibility andSafety ofLMH
Since the 2nd ICCLLR Morioka 2014 [1], several studies
have described the feasibility of LMH [14–16]. In 2016,
Takahara etal. compared LMH and OMH using a propensity
score analysis with the national clinical database of Japan,
reporting that LMH was associated with less blood loss,
shorter hospital stays, and fewer complications [14]. Similar
results were obtained from meta-analyses of cases where
major LLR was performed for HCC patients [15, 16]. In
Japan, the mortality rate of advanced LLRs (trisectionenctomy, hemi-hepatectomy, and sectionectomy)
improved from 3.6% in 2011 to 1.0% in 2017 [8]. However,
it should be noted that these short-term outcomes were from
some specialized high volume centers in Japan. Although
gradually increasing, the proportion of advanced LLRs is
still low (10.8% in 2017) and the dissemination of LMH has
yet to be achieved.
34.6 Laparoscopic Parenchymal Sparing Anatomical Hepatectomy (Lap-PSAH)
Anatomical hepatectomy (AH) involves systemic removal
of the liver parenchyma conned by tumor-bearing portal
tributaries [17, 18], and it has been shown to improve the
oncological outcomes in HCC patients [19, 20]. Recently,
remnant liver ischemia was noted to be associated with
early recurrence and poor survival after hepatectomy in
HCC patients [21]. In 2019, we reported a novel technique
of laparoscopic parenchymal-sparing AH (Lap-PSAH)
(sub- segmentectomies and segmentectomies) [22] with
extrahepatic Glissonian approach. The liver segmentation
of Lap-PSAH is based on Takasaki’s cone unit concept
[23]. Our principle of Lap-PSAH is to resect all of the
malignant tissue (tumor and possible satellite nodules)
while preserving enough liver parenchyma. The extent of
11
34 Laparoscopic Major Hepatectomy andParenchymal-Sparing Anatomical Hepatectomy
IWATE Criteria
273
Difficulty index
Difficulty level
Index surgery
VIII
5
VII
V
6
2
VI
Partial resection
Left lateral sectionectomy
Segementectomy
Segementectomy and more
012
Simple and small partial hepatoctomy in segment III
IVa
4
3
IVb
3
Extend liver resection
34 56789101
Low
Left lateral sectionectomy
Scoring system
Tumor location (Couinaud segment)
II
2
1
III
4
I
Segement
Score
0
2
3
4
Intermediate Advanced Expert
Right or left hepatectomy
Poeterior sectionectomy for segment VII tumor
Tumor size
Score
0
1
Score
0
1
Liver function
Child Pugh A
S2
S3
S4a
S4b
S5
S6
S7
S8
Score
4S1
2
1
4
3
3
2
5
5
HALS/Hybrid
No
Ye s
<3 cm
>3 cm
Proximity to major vessel
No
Ye s
*Main or second branch of Gisson’s tree.
major hepatic vein, or inferior vena cava
Score
0
–1
2
3 cm
Score
0
1Child Pugh B
Fig. 34.1 IWATE Criteria [6]
resection is planned prior to surgery by means of CT liver
volume calculation. Concordance between preoperative
three-dimensional (3D) simulation and intraoperative
resection was 98.7% and favorable short-term outcomes
were achieved [22]. Precise preoperative planning and a
standardized surgical technique enable performing this procedure (Fig.34.2). Since Lap-PSAH shares some surgical
techniques with LMH, it may help shorten the learning
curve of LMH.Long-term outcomes should be evaluated in
the future.
34.7 Surgical Procedures at Ageo Central General Hospital (ACGH)
Although the rst case series of LMHs were reported in
1998 [24], the procedure has been very slow to progress
worldwide [12]. At our hospital, LLR is indicated for all
liver malignancies except for cases of vascular or biliary
reconstruction. Our standard procedure for LLR is extrahepatic Glisonnian approach [23] with ICG negative staining.
Glissonian pedicles can be safely isolated based on