Combination of a Glissonean Approach and Indocyanine Green Fluorescence Imaging to Perform a Laparoscopic Right Anterior Sectionectomy

Laparoscopic right anterior sectionectomy (LRAS) remains a technically demanding procedure as it requires two transection planes where the middle and right hepatic veins run; however, the main difficulty is locating these two planes^1–3. The aim of this video was to show the technique of an LRAS performed with a transparenchymal glissonean pedicle approach and guided by indocyanine green (ICG) staining.

This was the case of an 80-year-old man with a history of hemochromatosis and normal liver function. He was diagnosed with a 6 cm hepatocellular carcinoma (HCC) located at segment 8, close to the right anterior pedicle.

The technique consisted of parenchymal transection along the main portal fissure along the right border of the middle hepatic vein. Opening the liver facilitated access to the right anterior glissonean pedicle and selective transparenchymal clamping. A negative-stain ICG test permitted to demarcate the transection line along the right lateral portal fissure. The parenchymal transection was carried out in a caudal approach, along two perfectly marked planes, preserving the middle and right hepatic veins.

The duration of the procedure was 200 min and blood loss was 300 mL. Postoperative course was uneventful and the patient was discharged on the third postoperative day.

Guidance during resection, and protection of the right posterior pedicle and right hepatic vein are the key points of the LRAS. The glissonean approach and the ICG imaging technology are of great help in resolving these difficulties.