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