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Transparenchymal glissonean approach: a novel surgical technique for advanced perihilar bile duct cancer

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Abstract

Purpose

To increase the surgical opportunities for locally advanced perihilar bile duct cancers that require left-sided hepatectomies, we developed the transparenchymal glissonean approach (TGA); it comprises intra-hepatic exposure and dissection of the Glisson’s sheath to gain access to the hepatic artery and portal vein for reconstruction.

Methods

Following skeletonization of the hepatoduodenal ligament, the proximal portions of invaded vessels are exposed. If extra-hepatic attempts to access the distal portions of the invaded vessels fail, TGA can be used. The distal portion of the invaded right or right posterior Glisson’s sheath is exposed following liver transection. The anterior portion of the wall of bile duct is cut and transected circumferentially including the fibrous plate tissue. The non-invaded portal vein and hepatic artery are isolated and dissected towards the hepatic hilum until the invaded distal portion of the vessels, and vascular reconstructions are performed.

Results

TGA was performed in 9 patients; 5 patients underwent left hemihepatectomy and 4 underwent left tri-sectionectomy. Eight patients needed vascular reconstruction. Clavien-Dindo classification (CDC) grades IIIa and IIIb were recorded in 6 and 1 patients, respectively. No patients had CDC grades IV and V disease. Pathologically, all cases were pT4; 3 cases were R0, 5 were R1 with microscopic positive margin, and 2 were R1 with microscopic metastasis. The overall median survival time was 25.0 months.

Conclusions

TGA is feasible with acceptable prognosis and expands the surgical opportunities.

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Authors and Affiliations

  1. Department of Gastroenterological Surgery I, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan

    Hirofumi Kamachi, Toshiya Kamiyama, Yousuke Tsuruga, Tatsuya Orimo, Kenji Wakayama, Shingo Shimada, Tatsuhiko Kakisaka, Hideki Yokoo & Akinobu Taketomi

  2. Department of Transplant Surgery, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan

    Kenichiro Yamashita

Authors
  1. Hirofumi Kamachi
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  2. Toshiya Kamiyama
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  3. Yousuke Tsuruga
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  4. Tatsuya Orimo
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  5. Kenji Wakayama
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  6. Shingo Shimada
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  7. Tatsuhiko Kakisaka
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  8. Hideki Yokoo
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  9. Kenichiro Yamashita
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  10. Akinobu Taketomi
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Contributions

Study conception and design: HK and TK; acquisition of data: HK, YT, TO, KW, SS, TK, HY, and KY; analysis and interpretation of data: HK, YT, and TO; drafting of manuscript: HK; critical revision of manuscript: HK TK, and AT.

Corresponding author

Correspondence to Hirofumi Kamachi.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the Declaration of Helsinki of 1964 and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Cite this article

Kamachi, H., Kamiyama, T., Tsuruga, Y. et al. Transparenchymal glissonean approach: a novel surgical technique for advanced perihilar bile duct cancer. Langenbecks Arch Surg 403, 387–394 (2018). https://doi.org/10.1007/s00423-017-1633-2

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  • DOI: https://doi.org/10.1007/s00423-017-1633-2

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