The Glissonian Approach of the Hilum

The detailed knowledge of the segmental anatomy of the liver has led to a rapid evolution in resectional surgery based on the intrahepatic distribution of the portal trinity (the hepatic artery, hepatic duct and portal vein). The classical intrafascial or extrahepatic approach is to isolate the appropriate branch of the portal vein, hepatic artery and the hepatic duct, outside the liver substance. Another method, the extrafascial approach, is to dissect the whole sheath of the pedicle directly after division of a substantial amount of the hepatic tissue to reach the pedicle, which is surrounded by a sheath, derived from Glisson's capsule. This Glissonian sheath encloses the portal trinity. In the transfissural or intrahepatic approach, these sheaths can be approached either anteriorly (after division of the main, right or umbilical fissure) or posteriorly from behind the porta hepatis. We describe the technique for approaching the Glissonian sheath and hence the hepatic pedicle structures and their branches by the intrahepatic posterior approach that allows early delineation of the liver segment without the need for ancillary techniques. In addition, the indications for the use of this technique in the technical and oncologic settings are also discussed.

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The anatomy and physiology of the liver

Abstracts of the Papers Printed in the Philosophical Transactions of the Royal Society of London ◽

10.1098/rspl.1830.0129 ◽

1837 ◽

Vol 3 ◽

pp. 211-212

Keyword(s):

Portal Vein ◽

Hepatic Artery ◽

External Surface ◽

Hepatic Duct ◽

Hepatic Veins ◽

Short Account ◽

Anatomy And Physiology ◽

Mixed Blood ◽

Portal Veins ◽

Vena Portae

After giving a short account of the descriptions of Malpighi and other writers respecting the minute structure of the liver, the author proceeds to state the results of his own investigations on this subject. The hepatic veins, together with the lobules which surround them, resemble in their arrangement the branches and leaves of a tree; the substance of the lobules being disposed around the minute branches of the v ins like the parenchyma of a leaf around its fibres. The hepatic veins may be divided into two classes: namely, those contained in the lobules, and those contained in canals formed by the lobules. The first class, is composed of interlobular branches, one of which occupies the centre of each lobule, and receives the blood from aplexus formed in the lobule by the portal vein; and the second class of hepatic veins is composed of all those vessels contained in canals formed by the lobules, and including numerous small branches, as well as the large trunks terminating in the inferior cava. The external surface of every lobule is covered by an expansion of Glisson’s capsule, by which it is connected to, as well as separated from, the contiguous lobules, and in which branches of the hepatic duct, portal veins and hepatic artery ramify. The ultimate branches of the hepatic artery terminate in the branches of the portal vein, where the blood they respectively contain is mixed together, and from which mixed blood the bile is secreted by the lobules, and conveyed away by the hepatic ducts which accompany the portal veins in their principal ramifications. The remaining blood is returned to the heart by the hepatic veins, the beginnings of which occupy the centre of each lobule, and when collected into trunks pour their contents into the inferior cava. Hence the blood which has circulated through the liver, and has thereby lost its arterial character, is, in common with that which is returning from the other abdominal viscera, poured into the vena portae, and contributes its share in furnishing materials for the biliary secretion. The paper is accompanied by numerous drawings of preparations made by the author, of the minute structure of the liver, in which the different sets of vessels and ducts were injected in various ways. The Society then adjourned over the Long Vacation to the 21st of November next.

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Hepatic Preservation with Histidine—Tryptophan—Ketoglutarate Solution in Living-Related and Cadaveric Liver Transplantation

Clinical Science ◽

10.1042/cs0930081 ◽

1997 ◽

Vol 93 (1) ◽

pp. 81-88 ◽

Cited By ~ 30

Author(s):

Etsuro Hatano ◽

Tetsuya Kiuchi ◽

Akira Tanaka ◽

Hisashi Shinohara ◽

Toshiyuki Kitai ◽

...

Keyword(s):

Liver Transplantation ◽

Portal Vein ◽

Hepatic Artery ◽

Near Infrared ◽

Tissue Oxygenation ◽

Graft Function ◽

Hepatic Tissue ◽

Uw Solution ◽

Living Related Liver Transplantation ◽

Living Related

1. Living-related liver transplantation has some advantages in the evaluation of novel clinical protocols, since many complicated factors affecting initial graft function are almost uniform in grafts obtained from healthy donors. 2. To compare histidine—tryptophan—ketoglutarate (HTK) and University of Wisconsin (UW) solution in terms of tissue oxygenation in living-related liver transplantation, oxygen saturation of haemoglobin (SO2) in hepatic tissue and its heterogeneity (CV, coefficient of variation) were measured by near-infrared spectroscopy. The HTK and UW groups consisted of 15 and 49 successful transplants respectively, in which no statistical differences in background were observed. 3. In the HTK group, hepatic SO2 after portal vein reflow was higher (P<0.01) than that in the UW group, as was that after hepatic artery reflow (P<0.05). In the UW group, hepatic SO2 remained at the lower level at the end of the operation. 4. Furthermore, the increase in CV after portal vein reflow was normalized after hepatic artery reflow in the HTK group. However, the CV remained at a high level at the end of the operation in the UW group. 5. Postoperative peak aspartate aminotransferase level in the HTK group was lower than that in the UW group (P<0.05). 6. In cadaveric liver transplantation, higher hepatic SO2 and lower CV of hepatic SO2 in the early phase after reperfusion compared with the UW group (n = 18) were also observed in the HTK group (n = 30) (P<0.05). 7. In conclusion, recovery of tissue oxygenation and its heterogeneity after reperfusion in HTK-preserved livers were more rapid and homogeneous than in UW-preserved livers in living-related liver transplantation. Accordingly, HTK solution may be a potential alternative to UW solution.

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Robotic anatomical resection of liver segment 4 with glissonian approach and selective hepatic artery clamping

Arquivos de Gastroenterologia ◽

10.1590/s0004-2803.202100000-21 ◽

2021 ◽

Vol 58 (1) ◽

pp. 127-128

Author(s):

Marcel Autran C MACHADO ◽

André O ARDENGH ◽

Murillo M LOBO FILHO ◽

Bruno H MATTOS ◽

Fábio F MAKDISSI

Keyword(s):

Hepatic Artery ◽

Anatomical Resection ◽

Liver Segment ◽

Glissonian Approach

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The Occurrence of a Pseudoaneurysm of the Hepatic Artery within the Thrombosed Portal Vein of a Patient with Chronic Pancreatitis: A Case Report

Journal of the Korean Radiological Society ◽

10.3348/jkrs.2008.58.4.399 ◽

2008 ◽

Vol 58 (4) ◽

pp. 399

Author(s):

Eun Soo Kim ◽

Kyung Mi Jang ◽

Min Jeong Kim ◽

Hoi Soo Yoon ◽

Hyun Lee ◽

...

Keyword(s):

Case Report ◽

Chronic Pancreatitis ◽

Portal Vein ◽

Hepatic Artery

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Portal vein arterialization for iatrogenic embolization of the hepatic artery. An old but still useful technique?

International Journal of Surgery Case Reports ◽

10.1016/j.ijscr.2020.04.022 ◽

2020 ◽

Vol 71 ◽

pp. 91-94

Author(s):

Tim Reese ◽

York von Rittberg ◽

Karl J. Oldhafer

Keyword(s):

Portal Vein ◽

Hepatic Artery ◽

Portal Vein Arterialization

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Hemodynamic profile and tissular oxygenation in orthotopic liver transplantation: Influence of hepatic artery or portal vein revascularization of the graft

Liver Transplantation ◽

10.1002/lt.20794 ◽

2006 ◽

Vol 12 (11) ◽

pp. 1607-1614 ◽

Cited By ~ 40

Author(s):

Carlos Moreno ◽

Antoni Sabaté ◽

Joan Figueras ◽

Imma Camprubí ◽

Antonia Dalmau ◽

...

Keyword(s):

Liver Transplantation ◽

Portal Vein ◽

Hepatic Artery ◽

Orthotopic Liver Transplantation ◽

Hemodynamic Profile

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Vascular Involvements in Cholangiocarcinoma: Tips and Tricks

Cancers ◽

10.3390/cancers13153735 ◽

2021 ◽

Vol 13 (15) ◽

pp. 3735

Author(s):

Roberta Angelico ◽

Bruno Sensi ◽

Alessandro Parente ◽

Leandro Siragusa ◽

Carlo Gazia ◽

...

Keyword(s):

Portal Vein ◽

Hepatic Artery ◽

Vena Cava ◽

High Volume ◽

Vascular Reconstruction ◽

Ex Situ ◽

Vascular Involvement ◽

Hepatic Veins ◽

Hepatic Artery Resection ◽

Artery Resection

Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract. To date, surgical treatment remains the only hope for definitive cure of CCA patients. Involvement of major vascular structures was traditionally considered a contraindication for resection. Nowadays, selected cases of CCA with vascular involvement can be successfully approached. Intrahepatic CCA often involves the major hepatic veins or the inferior vena cava and might necessitate complete vascular exclusion, in situ hypothermic perfusion, ex situ surgery and reconstruction with autologous, heterologous or synthetic grafts. Hilar CCA more frequently involves the portal vein and hepatic artery. Resection and reconstruction of the portal vein is now considered a relatively safe and beneficial technique, and it is accepted as a standard option either with direct anastomosis or jump grafts. However, hepatic artery resection remains controversial; despite accumulating positive reports, the procedure remains technically challenging with increased rates of morbidity. When arterial reconstruction is not possible, arterio-portal shunting may offer salvage, while sometimes an efficient collateral system could bypass the need for arterial reconstructions. Keys to achieve success are represented by accurate selection of patients in high-volume referral centres, adequate technical skills and eclectic knowledge of the various possibilities for vascular reconstruction.

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Doppler ultrasound in liver cirrhosis: correlation of hepatic artery and portal vein measurements with model for end-stage liver disease score in Egypt

Egyptian Journal of Radiology and Nuclear Medicine ◽

10.1186/s43055-020-00344-6 ◽

2020 ◽

Vol 51 (1) ◽

Author(s):

Ahmed Abdelrahman Mohamed Baz ◽

Rana Magdy Mohamed ◽

Khaled Helmy El-kaffas

Keyword(s):

Liver Cirrhosis ◽

Liver Disease ◽

Portal Vein ◽

Hepatic Artery ◽

Meld Score ◽

Hepatic Decompensation ◽

End Stage Liver Disease ◽

Cirrhotic Patients ◽

Us Findings ◽

End Stage

Abstract Background Liver cirrhosis is a multi-etiological entity that alters the hepatic functions and vascularity by varying grades. Hereby, a cross-sectional study enrolling 100 cirrhotic patients (51 males and 49 females), who were diagnosed clinically and assessed by model for end-stage liver disease (MELD) score, then correlated to the hepatic Doppler parameters and ultrasound (US) findings of hepatic decompensation like ascites and splenomegaly. Results By Doppler and US, splenomegaly was evident in 49% of patients, while ascites was present in 44% of them. Increased hepatic artery velocity (HAV) was found in70% of cases, while 59% showed reduced portal vein velocity (PVV). There was a statistically significant correlation between HAV and MELD score (ρ = 0.000), but no significant correlation with either hepatic artery resistivity index (HARI) (ρ = 0.675) or PVV (ρ =0.266). Moreover, HAV had been correlated to splenomegaly (ρ = 0.000), whereas HARI (ρ = 0.137) and PVV (ρ = 0.241) did not significantly correlate. Also, ascites had correlated significantly to MELD score and HAV (ρ = 0.000), but neither HARI (ρ = 0.607) nor PVV (ρ = 0.143) was significantly correlated. Our results showed that HAV > 145 cm/s could confidently predict a high MELD score with 62.50% and 97.62 % sensitivity and specificity. Conclusion Doppler parameters of hepatic vessels (specifically HAV) in addition to the US findings of hepatic decompensation proved to be a non-invasive and cost-effective imaging tool for severity assessment in cirrhotic patients (scored by MELD); they could be used as additional prognostic parameters for improving the available treatment options and outcomes.

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Multidisciplinary treatment of left hepatic artery pseudoaneurysm after hepatobiliary resection for gallbladder cancer: a case report

Surgical Case Reports ◽

10.1186/s40792-019-0757-8 ◽

2019 ◽

Vol 5 (1) ◽

Author(s):

Ryusei Yamamoto ◽

Teiichi Sugiura ◽

Yukiyasu Okamura ◽

Takaaki Ito ◽

Yusuke Yamamoto ◽

...

Keyword(s):

Portal Hypertension ◽

Portal Vein ◽

Liver Failure ◽

Hepatic Artery ◽

Remnant Liver ◽

Left Hepatic Artery ◽

Artery Pseudoaneurysm ◽

Hepatobiliary Resection ◽

Portal Vein Arterialization ◽

Arterial Inflow

Abstract Background When a postoperative hepatic artery pseudoaneurysm develops after massive hepatectomy, both an intervention for the pseudoaneurysm and patency of hepatic artery should be considered because occlusion of the residual hepatic artery results in critical liver failure. However, the treatment strategy for a pseudoaneurysm of the hepatic artery after hepatobiliary resection is not well established. Case presentation A 65-year-old woman underwent right hepatectomy, extrahepatic duct resection, and portal vein resection, for gallbladder cancer. Although the patient had an uneventful postoperative course, computed tomography on postoperative day 6 showed a 6-mm pseudoaneurysm of the hepatic artery. Angiography revealed the pseudoaneurysm located on the bifurcation of the left hepatic artery to the segment 2 artery plus the segment 3 artery and 4 artery. Stent placement in the left hepatic artery was not feasible because the artery was too narrow, and coiling of the pseudoaneurysm was associated with a risk of occluding the left hepatic artery and inducing critical liver failure. Therefore, portal vein arterialization constructed by anastomosing the ileocecal artery and vein was performed prior to embolization of the pseudoaneurysm to maintain the oxygen level of the remnant liver, even if the left hepatic artery was accidentally occluded. The pseudoaneurysm was selectively embolized without occlusion of the left hepatic artery, and the postoperative laboratory data were within normal limits. Although uncontrollable ascites due to portal hypertension occurred, embolization of the ileocolic shunt rapidly resolved it. The patient was discharged on postoperative day 45. Conclusion Portal vein arterialization prior to embolization of the aneurysm may be a feasible therapeutic strategy for a pseudoaneurysm that develops after hepatectomy for hepatobiliary malignancy to guarantee arterial inflow to the remnant liver. Early embolization of arterioportal shunting after confirmation of arterial inflow to the liver should be performed to prevent morbidity induced by portal hypertension.

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