Laparoscopic Donor Left Lateral Sectionectomy Using the Glissonean Pedicle Approach: Technical Details With Video
Description 1.1 Introduction Pure laparoscopy for living donor hepatectomy (PLDH) is gaining popularity due to its advantages  However, despite the introduction of left lateral PLDH, the dissection of the Glisson branch, portal vein, and biliary ducts, particularly those of the caudate lobe, remains insufficiently described. Although the Glissonean approach offers easy standardization for hilar dissection, clear landmarks for parenchymal transection, and reduces postoperative bile leakage, it has not been widely adopted in PLDH . Here, we introduce a modified Glissonean pedicle approach to address the movement restrictions in laparoscopic surgery. 1.2 Surgical Technique After the mobilization of the left lateral section of the liver, the Glissonean pedicle of the Spiegel lobe (G1L) was divided, and the left Glissonean pedicle was encircled (Figure ). To extend the bile duct and portal vein for anastomosis, the G1L was divided. A tape for the liver hanging maneuver was placed from the right edge of the left Glissonean pedicle, along the Arantius plate, to the left edge of the left hepatic vein (LHV) (Figure , Video ). This tape provided counter‐traction and a landmark during parenchymal transection. The Glissonean branches of the paracaval portion (G1r)  were divided intra‐hepatically during the parenchymal transection process. When the parenchymal transection was completed, the LHV was automatically taped. Then, the hilar dissection started. The left hepatic artery (LHA) and left portal vein (LPV) were exposed, and some branches of P1 were cut to lengthen for anastomosis. The left hepatic duct (LHD) was taped by removing the LHA and LHV from the left Glissonean pedicle (Figure ). In this process, the B1 branches were not cut individually; instead, they had been cut in Glisson units intra‐hepatically. This approach minimized the exposure of the LHD. The LHD was divided under intraoperative cholangiography. Next, the LHA, LPV, and LHV were divided. Finally, the graft liver was retrieved via a suprapubic incision (Video ). 

Introduction Pure laparoscopy for living donor hepatectomy (PLDH) is gaining popularity due to its advantages  However, despite the introduction of left lateral PLDH, the dissection of the Glisson branch, portal vein, and biliary ducts, particularly those of the caudate lobe, remains insufficiently described. Although the Glissonean approach offers easy standardization for hilar dissection, clear landmarks for parenchymal transection, and reduces postoperative bile leakage, it has not been widely adopted in PLDH . Here, we introduce a modified Glissonean pedicle approach to address the movement restrictions in laparoscopic surgery. 

Surgical Technique After the mobilization of the left lateral section of the liver, the Glissonean pedicle of the Spiegel lobe (G1L) was divided, and the left Glissonean pedicle was encircled (Figure ). To extend the bile duct and portal vein for anastomosis, the G1L was divided. A tape for the liver hanging maneuver was placed from the right edge of the left Glissonean pedicle, along the Arantius plate, to the left edge of the left hepatic vein (LHV) (Figure , Video ). This tape provided counter‐traction and a landmark during parenchymal transection. The Glissonean branches of the paracaval portion (G1r)  were divided intra‐hepatically during the parenchymal transection process. When the parenchymal transection was completed, the LHV was automatically taped. Then, the hilar dissection started. The left hepatic artery (LHA) and left portal vein (LPV) were exposed, and some branches of P1 were cut to lengthen for anastomosis. The left hepatic duct (LHD) was taped by removing the LHA and LHV from the left Glissonean pedicle (Figure ). In this process, the B1 branches were not cut individually; instead, they had been cut in Glisson units intra‐hepatically. This approach minimized the exposure of the LHD. The LHD was divided under intraoperative cholangiography. Next, the LHA, LPV, and LHV were divided. Finally, the graft liver was retrieved via a suprapubic incision (Video ). 

Results This technique was applied in four cases and successfully completed in all of them. The median operative time, including great saphenous vein harvest, was 381 min (range: 312–571 min), with an estimated intraoperative blood loss of 75 mL (range: 5–100 mL). The median postoperative hospital stay was 9 days (range: 9–13). No major bile leakage or vascular complications were observed, and all grafts exhibited good postoperative function. 

Discussion This study evaluated the application of the modified Glissonean pedicle approach in pure laparoscopic donor left lateral sectionectomy. Our findings underscore the significant benefits of this technique in simplifying and standardizing hilar dissection for donor hepatectomy. The Glissonean pedicle approach is characterized by its use of clear anatomical landmarks and its ability to minimize tissue damage, as documented in prior studies . These features contribute to its effectiveness in standardizing hilar dissection for donor hepatectomy. However, conventional Glissonean approaches face limitations in the laparoscopic setting, particularly in the dissection and transection of the Glissonean branches of the caudate lobe. This challenge arises due to the restricted maneuverability inherent in laparoscopic surgery, which complicates the precise handling of these branches. In contrast, a key advancement of the modified Glissonean pedicle approach is the systematic dissection of the caudate lobe's Glissonean branches, which addresses these limitations. Additionally, individual hilar dissection methods, often employed as an alternative, face their own set of challenges, including difficulty in identifying the optimal starting point for detaching the left bile duct. The modified Glissonean approach overcomes these issues by clearly defining the insertion point for encircling the left Glissonean pedicle, thereby offering a reliable reference to standardize hilar dissection in donor hepatectomy (Table ). In alignment with earlier reports , our findings confirm that the Glissonean pedicle approach reduces the risk of postoperative complications, including bile leakage. A critical feature of this technique is its ability to predefine the transection point of the bile ducts, thereby minimizing the risk of bile duct injury and enhancing overall surgical safety. Furthermore, incorporating the liver hanging maneuver, facilitated by encircling the left Glissonean pedicle, provides stable counter‐traction and creates a clear surgical plane during parenchymal transection. This maneuver improves the precision of parenchymal transection and mitigates some of the inherent challenges of laparoscopic surgery, such as restricted visibility and limited maneuverability. As this is an initial report on our modified approach, we have applied this technique in four cases. All procedures were successfully completed without major complications, indicating its feasibility. However, further validation with a larger cohort is necessary to confirm its broader applicability. In cases where this approach is not feasible, two alternative strategies can be considered. The first involves the conventional Glissonean pedicle approach, in which the Glissonean encircling maneuver is performed twice (G1234 and G234). The second option is individual hilar dissection of the left hepatic artery, left portal vein, and left hepatic duct. While we generally follow these steps in the order mentioned above, surgeons may select an approach based on their familiarity and experience. Although the Spiegel lobe Glissonean pedicle (G1L) could be divided after parenchymal transection, our experience suggests that it can be successfully managed during the procedure without additional technical difficulty. Consistent with previous reports , the Glissonean pedicle approach improves procedural reproducibility and safety while potentially shortening the learning curve for surgeons. However, successful implementation of this technique across institutions will require structured training programs and further evaluation of its applicability in diverse clinical settings. Furthermore, although our findings suggest that the modified Glissonean pedicle approach is both safe and feasible for all donors in our cohort, further validation with a larger patient population is needed to confirm its broader applicability. In conclusion, the modified Glissonean pedicle approach offers a standardized and reliable technique for left lateral pure laparoscopic donor hepatectomy. It minimizes left hepatic duct exposure, facilitates B1 branch dissection, and reduces the risk of complications. Future efforts should focus on promoting the widespread adoption of this technique through targeted training and continued research aimed at refining its application. 

Approval of the research protocol by an institutional review board: The study was approved by the Ethics Review Committee of Keio University School of Medicine (Approval no. 20120443). 

The patient was provided with the option to opt out of the study, and the requirement for informed consent was waived because of the retrospective and observational nature of this study. 

Dr. Yuko Kitagawa is the chairman of the Japan Society for Endoscopic Surgery and a co‐author of this article. The other authors declare no conflicts of interest. 

Video S1. Glissonean pedicle encircle and parenchymal transection. The Glissonean pedicle of Spiegel lobe (G1L) was divided, and the left Glissonean pedicle was encircled. A tape for the liver hanging maneuver was placed, and the liver parenchymal transection was performed. Video S2. Hilar vessel dissection and graft retrieval. The left hepatic artery (LHA) and left portal vein (LPV) were exposed, and the left hepatic duct (LHD) was taped by removing LHA and LPV from the left Glissonean pedicle. This approach minimized the exposure of LHD. 

