Precise Anatomical Resection of the Left Lateral Section Using Extrahepatic Glissonean Approach and Fluorescence...

Anatomical liver resection along the intersegmental plane provides oncological advantages for primary liver malignancies and may reduce complications such as blood loss and postoperative bile leakage. In left lateral sectionectomy (LLS), the falciform ligament and umbilical fissure are conventionally regarded as landmarks; however, tertiary branches from the dorsal and cephalic sides of the portal umbilicus (P4dor) often annulate the left lateral region of the falciform ligament. We propose a novel LLS technique using an extrahepatic Glissonean approach combined with indocyanine green (ICG) fluorescence.

To preliminarily investigate the P4dor territory, protocol-based dynamic computed tomography images of 128 patients scheduled for hepatobiliary and pancreatic surgery were analyzed. The safety and efficacy of the technique were assessed using robotic, laparoscopic, and open LLS. The Glissonean pedicles of segments 2 and 3 were isolated, P4dor boundaries delineated under ICG guidance, and the parenchyma transected along the demarcation line to preserve the P4dor region.

P4dor was identified in 91.4% of cases, with a mean of 1.4 branches, an annular volume of 21.7 ml (2.1%), and a mean distance of 15.9 mm between the left border of the P4dor territory and the portal umbilicus. In all three surgical cases, the P4dor boundaries were clearly delineated and preserved. No postoperative complications occurred.

This LLS technique is simple, feasible for minimally invasive surgery, and enables reproducible anatomical resection by clarifying the P4dor demarcation. It may also facilitate adequate margins in biliary tumors while preserving functional liver parenchyma.