Intrahepatic Glissonean Pedicle Approach to Segment 7 from the Dorsal Side During Laparoscopic Anatomic Hepatectomy of the Cranial Part of the Right Liver  Yukihiro Okuda, MD, PhD, Goro Honda, MD, PhD, FACS, Shin Kobayashi, MD, Katsunori Sakamoto, MD, Yuki Homma, MD, Masahiko Honjo, MD, Manami Doi, MD  Journal of the American College of Surgeons  Volume 226, Issue 2, Pages e1-e6 (February 2018) DOI: 10.1016/j.jamcollsurg.2017.10.018 Copyright © 2017 American College of Surgeons Terms and Conditions

Figure 1 Patient position. The patients were placed in a modified left semidecubitus position, where only the upper body was twisted to the left, while the pelvis and legs were held in the supine position. This position has been standardized for laparoscopic hepatectomy for lesions in the right lobe at our institution. Journal of the American College of Surgeons 2018 226, e1-e6DOI: (10.1016/j.jamcollsurg.2017.10.018) Copyright © 2017 American College of Surgeons Terms and Conditions

Figure 2 (A) Drawing and (B) photo showing location of the trocars. A 12-mm trocar for a laparoscope was placed at the umbilicus. Four working trocars were placed along the line just beneath the right costal arch at regular intervals of 4 to 6 cm. Specifically, 5-mm trocars were placed on the most medial side, next to the xiphoid process, and on the most lateral side. The other two 12-mm trocars were placed between them. The 5-mm intercostal trocar equipped with a balloon stopper was placed through the eighth intercostal space on the right posterior axillary line, and the 12-mm intercostal trocar was placed through the sixth intercostal space on the midclavicular line. The incision for the Pringle maneuver was made on the left mid-upper abdomen. Journal of the American College of Surgeons 2018 226, e1-e6DOI: (10.1016/j.jamcollsurg.2017.10.018) Copyright © 2017 American College of Surgeons Terms and Conditions

Figure 3 Approach to the Glissonean branch of the segment 7 (S7) from the posterior side. (A) The Glissonean branch of S7 (G7) was identified on the posterior side of the right hepatic vein (RHV) by intraoperative ultrasonography from the dorsal side. White arrowheads, the inferior vena cava ligament; black arrow, the short hepatic vein; asterisk, the inferior vena cava. (B) By dividing the liver parenchyma between S7 and the paracaval portion of the caudate lobe (S9) from the dorsal side, G7 was isolated. White arrowheads, the root of the RHV; black arrow, the G7; asterisk, the inferior vena cava. (C) By clamping the G7, S7 was identified as an ischemic area and the demarcation line was marked on the liver surface. S6, segment 6; S7, segment 7. Journal of the American College of Surgeons 2018 226, e1-e6DOI: (10.1016/j.jamcollsurg.2017.10.018) Copyright © 2017 American College of Surgeons Terms and Conditions

Figure 4 Exposure of the right hepatic vein in the cut surface. (A) The posterior aspect of the right hepatic vein (RHV) was exposed at the bottom of the trench between the segment 7 (S7) and the paracaval portion of the caudate lobe (S9) from the root side toward the periphery. White arrow, the stump of the Glissonean pedicle of S7; black arrowheads, the RHV; asterisk, the inferior vena cava. (B) The parenchyma of the border between S7 and the segment 8 (S8), which was a plane located between the RHV and the demarcation line on the liver surface, was dissected from the ventral side. The ventral aspect of the RHV was exposed from the root side to the periphery by using the cavitron ultrasonic surgical aspirator inserted through the trocar placed in the sixth intercostal space. White arrow, peripheral side of the RHV; asterisk, the root of the RHV; S7, segment 7; S8, segment 8. (C) Findings after the completion of parenchymal dissection. White arrow, the stump of the Glissonean branch of S7; black arrowheads, the RHV; asterisk, the inferior vena cava. Journal of the American College of Surgeons 2018 226, e1-e6DOI: (10.1016/j.jamcollsurg.2017.10.018) Copyright © 2017 American College of Surgeons Terms and Conditions

Figure 5 Prevention of split injury of the hepatic vein during exposure of the right hepatic vein on the cut surface by using the intercostal trocar placed at the sixth intercostal space on the midclavicular line. When the cavitron ultrasonic surgical aspirator (CUSA) is inserted through the trocar beneath the costal arch (CUSA on the right side), it is directed cranially and set nearly parallel with the hepatic vein trunk so split injury of the hepatic vein branches can easily occur. When the CUSA is inserted through the intercostal trocar (CUSA on the left side), it has a certain angle to the hepatic vein trunk so that exposure of the hepatic vein trunk can be performed swiftly without split injury. Journal of the American College of Surgeons 2018 226, e1-e6DOI: (10.1016/j.jamcollsurg.2017.10.018) Copyright © 2017 American College of Surgeons Terms and Conditions