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Asian J Endosc Surg ISSN 1758-5902

S U RG I C A L TE C H N I Q U E

Arantius ligament approach for the left extrahepatic

Glissonean pedicle in pure laparoscopic left hemihepatectomy
Akihiro Cho, Hiroshi Yamamoto, Osamu Kainuma, Takumi Ota, SeongJin Park, Hiroo Yanagibashi,
Hidehito Arimitsu, Atsushi Ikeda, Hiroaki Souda, Yoshihiro Nabeya, Nobuhiro Takiguchi & Matsuo Nagata
Division of Gastroenterological Surgery, Chiba Cancer Center Hospital, Chiba, Japan

Keywords
Arantius ligament; Glissonean pedicle;
laparoscopic liver resection
Correspondence
Akihiro Cho, Division of Gastroenterological
Surgery, Chiba Cancer Center Hospital,
666-2 Nitonachou, Chuouku, Chiba
260-8717, Japan.
Tel: +81 43 264 5431
Fax: +81 43 262 8680
Email: acho@chiba-cc.jp
Received: 2 March 2012; revised: 12 April
2012; accepted: 17 April 2012
DOI:10.1111/j.1758-5910.2012.00139.x

Abstract
Introduction: Laparoscopic hemihepatectomy has not yet become widely
accepted because of the technical difficulties in controlling each Glissonean
pedicle laparoscopically.
Materials and Surgical Technique: The subjects in the present study included 12
patients who underwent laparoscopic left hemihepatectomy between August
2007 and June 2011. Arantius ligament was divided. Retracting the caudal
stump of the ligament revealed a space between the left Glissonean pedicle
and the liver parenchyma. The left Glissonean pedicle could be easily encircled
by using an Endo Retract Maxi. No Glissonean injuries, including bleeding or
biliary leakage, occurred in any of the 12 patients.
Discussion: Therefore, the Arantius ligament approach for the left extrahepatic Glissonean pedicle appears to be feasible and safe for successfully performing pure laparoscopic left hemihepatectomy.

Introduction
Recent technological innovations and improvements in
surgical skills as well as the extensive experience of surgeons have greatly increased the number of applications
for laparoscopic liver resection (15). A comparative
study found that laparoscopic hemihepatectomy is associated with less bleeding, fewer complications and better
quality of life compared to the conventional open procedure (6). During open hemihepatectomy, each Glissonean pedicle is often transected selectively through either
a hilar or a parenchymal approach (7,8). We previously
proposed a technique for extrahepatic Glissonean access
during laparoscopic anatomical liver resection (9,10).
Herein, we describe a novel technique that uses the
Arantius ligament approach, by which the left Glissonean pedicle can be easily and safely encircled and
divided en bloc extrahepatically during pure laparoscopic
left hemihepatectomy.

Materials and Surgical Technique

There were 12 subjects (5 women, 7 men) who underwent laparoscopic left hemihepatectomy using the

Arantius ligament approach for the left extrahepatic Glissonean pedicle between August 2007 and June 2011. The
mean patient age at the time of resection was 67.5 years
(range, 5178 years). The postoperative outcomes were
retrospectively analyzed. All patients were informed of
the possible advantages and complications of the new
experimental method and the possibility of conversion to
open surgery. They provided informed consent for the
new method instead of conventional surgery. The procedure was approved by the local ethical review board.
A 12-mm trocar was placed via the umbilicus, through
which CO2 gas was delivered. The pneumoperitoneum
was controlled electronically to a pressure of 10 mmHg.
Additional working ports were placed to optimize the
manipulation and mobilization of the liver, as described
previously (9). Laparoscopic encircling of the hepatoduodenal ligament was performed with an Endo Retract
Maxi (Covidien Japan, Tokyo, Japan) as a tourniquet for
complete interruption of blood inflow to the liver only if
necessary (11). The left lateral section was lifted by dividing the lesser omentum and the falciform, left triangular
and coronary ligaments. Arantius ligament was then
identified, encircled and divided (Figure 1). The caudal

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A Cho et al.

Figure 1 The left lateral section is lifted up. Arantius ligament (arrow)
is identied and encircled. LHV, left hepatic vein; LS, left lateral section;
Sp, Spiegel lobe.

Figure 3 The left Glissonean pedicle is encircled extrahepatically with

an Endo Retract Maxi. GB, gallbladder; LG, left Glissonean pedicle; MS,
medial section; RL, round ligament.

Figure 2 Retracting the ligament caudal and to the right revealed a

space (arrow) between the left Glissonean pedicle and the liver parenchyma. LHV, left hepatic vein; LS, left lateral section; Sp, Spiegel lobe.

Figure 4 The left Glissonean pedicle is divided using an endoscopic

stapling system during retraction of the round ligament upward. LG, left
Glissonean pedicle.

stump of the ligament was grasped and dissected downward toward the left Glissonean pedicle. Retracting the
ligament caudal and to the right revealed a space
between the left Glissonean pedicle and the liver parenchyma (Figure 2). The metallic arch of the Endo Retract
Maxi was then meticulously extended into this space, so
that the tip of the metallic arch could be visualized at the
right side of the left Glissonean pedicle (Figure 3). The
left Glissonean pedicle was encircled extrahepatically.
Clamping the left Glissonean pedicle allowed ischemic
delineation of the left hemiliver. Before parenchymal
dissection, introduction of an endoscopic stapler into the

left Glissonean pedicle may potentially injure small

vessels, but hepatic parenchymal dissection along the
Cantile line facilitates the introduction. Parenchymal dissection proceeded from an ischemic delineation line on
the liver surface to the left Glissonean pedicle, which was
then divided by using an endoscopic stapling system
while retracting the round ligament upward (Figure 4).
The parenchymal dissection then proceeded to the left
hepatic vein, which was finally divided. The specimen
was placed in a plastic endobag, and extracted through a
suprapubic incision measuring approximately 6 cm in
size. A drainage tube was left near the hepatic stump.

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Asian J Endosc Surg 5 (2012) 187190

2012 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd

Laparoscopic left hepatectomy

A Cho et al.

We successfully performed laparoscopic left hemihepatectomy in 12 patients as planned. The underlying

pathology was hepatocellular carcinoma in five patients,
liver metastasis in four patients, and intrahepatic lithiasis
in three patients. No postoperative mortality was
encountered and no Glissonean injuries, including bleeding or biliary leakage, occurred. The mean length of
surgery was 255 113 min, and the mean blood loss
was 305 187 g. The mean duration of hospital stay was
10.7 2.5 days. Two patients developed pleural effusion,
which resolved spontaneously.

Discussion
Laparoscopic hemihepatectomy has not yet become
widely accepted because of the technical difficulties in
controlling each Glissonean pedicle laparoscopically.
Previous reports related to laparoscopic hemihepatectomy have described an intrahepatic Glissonean
approach (1214). During an intrahepatic Glissonean
approach, small parenchymal incisions are made on the
liver surface, through which a large laparoscopic vascular clamp is used to split the hepatic parenchyma. Small
Glissonean or hepatic venous branches may potentially
be injured during such procedures. The entire length of
the primary branches of the Glissonean pedicle and the
origin of the secondary branches are located outside the
liver, and the trunks of the secondary and more peripheral branches run inside the liver (8). Each Glissonean
pedicle can thus be accessed extrahepatically without
any parenchymal incision (10). Arantius ligament,
which originates from the ductus venosus during fetal
development, connects the left portal vein to the left
hepatic vein or the junction between the left and middle
hepatic veins. Dividing Arantius ligament and retracting
its cephalad stump can facilitate the isolation and encirclement of the left hepatic vein or the common trunk
between the left and middle hepatic veins (1517).
Similarly, retracting its caudal stump, which is attached
to the left portal vein, can facilitate the isolation and
encircling of the left Glissonean pedicle. The posterior
sectional bile duct is sometimes joined to the left hepatic
duct (18). Therefore, the left Glissonean pedicle should
be encircled left to the Spiegel branch in order to avoid
right bile duct injury during en bloc transection of the
left Glissonean pedicle. In addition, the Arantius ligament approach is very useful in encircling the left extrahepatic Glissonean pedicle, even in cirrhotic cases.
Although our experience remains limited, prospective
studies will be necessary to confirm the benefits and
results of this approach. We believe that the Arantius
ligament approach for the left extrahepatic Glissonean

pedicle offers a feasible and safe method for performing

pure laparoscopic left hemihepatectomy.

Acknowledgment
The authors have no conflicts of interest and received no
financial support for this study.

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Asian J Endosc Surg 5 (2012) 187190

2012 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd