Application and utility of surgical techniques for cystic plate isolation in liver surgery

One of the most important areas of anatomical knowledge for liver surgery is the plate system in the hilar area. Four plates comprise the hilar area plate system: the hilar plate, cystic plate, umbilical plate, and Arantian plate. Based on the theory that the cystic plate is continuous with the hilar plate, isolation of the cystic plate can be applicable to various scenarios in liver surgery. We describe herein the procedure and usefulness of cystic plate isolation to approach the hilar plate, in both open and laparoscopic surgeries. This isolation can be applied in various manners. First, cystic plate traction can facilitate the Glissonian approach, drawing out the extrahepatic Glissonian pedicles and thus lengthening the pedicle, and facilitate isolation of these pedicles. Second, inflow control can be obtained by applying the cystic plate traction method to the Glissonian approach. This is suitable to control hepatic inflow when there is no need to divide vessels such as lymph node dissection or vascular resection and reconstruction. Third, the Glissonian approach can be used in surgery for hepatocellular carcinoma patients with portal thrombosis. The cystic plate traction method potentially avoids injury to the Glissonian pedicle that would cause unnecessary bleeding, and is thus particularly efficient for advanced cancers such as hepatocellular carcinoma patients with portal thrombosis and collateral vessels around the area of obstruction in the Glissonian sheath. In this article, we focused on our anatomical knowledge and technical tips for making use of cystic plate isolation in liver surgery.