Evaluation of intrahepatic, extra-Glissonian stapling of the right porta hepatis vs. classical extrahepatic dissection during right hepatectomy.

Background: Control of hepatic inflow is a key manoeuvre during right hepatectomy and has traditionally been achieved by extrahepatic dissection of the component right portal inflow structures at the hepatic hilum. An alternative technique is the anterior intrahepatic approach (AIA), in which the Glissonian sheath is isolated within the substance of the liver during parenchymal transection and secured using an endovascular stapling device. This study evaluates the intrahepatic, extra-Glissonian technique in comparison with classical extrahepatic dissection (EHD) in right hepatectomy.

Methods: A retrospective case-controlled study referring to a 20-year period identified 342 consecutive patients who underwent right hepatectomy for colorectal liver metastases from a prospectively compiled database. The AIA to right hepatectomy was used in 182 of these patients and the extrahepatic approach in 160. The two groups were matched for age, gender, stage of primary tumour and number and size of metastases. Outcome measures included safety factors (bleeding, bile duct injury and gun failure), operative duration, oncological margin, morbidity and mortality.

Results: There were no significant differences between the two groups in terms of operative duration (240 min vs. 260 min) or postoperative change in haemoglobin (1.3 g/dl vs. 1.4 g/dl). The AIA was associated with lower operative blood loss (355 ml vs. 425 ml; P < or = 0.001), a reduced rate of significant morbidity (14.6% vs. 23.1%; P = 0.005), better R0 resection rates (93% vs. 89%; P = 0.014) and a lower 90-day mortality rate (3% vs. 7%; P = 0.046). There was one minor bile leak in each group, two clinically significant bile leaks requiring endoscopic retrograde cholangiopancreatography and stenting in the extrahepatic group, and a further persistent bile leak requiring biliary reconstruction in each group. In two instances the endovascular stapler misfired. Both cases were dealt with at the time of surgery with no further sequelae. The length of hospital stay was equivalent in the two groups (8 days vs. 9 days).

Conclusions: In selected patients, intrahepatic, extra-Glissonian stapled right hepatectomy is feasible, safe and avoids the need for EHD. The anterior approach to right hepatectomy may achieve outcomes at least as good as those associated with the classical extrahepatic approach.