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Langenbecks Arch Surg
https://doi.org/10.1007/s00423-017-1633-2
HOW-I-DO-IT ARTICLE
Transparenchymal glissonean approach: a novel surgical
technique for advanced perihilar bile duct cancer
Hirofumi Kamachi 1 & Toshiya Kamiyama 1 & Yousuke Tsuruga 1 & Tatsuya Orimo 1 &
Kenji Wakayama 1 & Shingo Shimada 1 & Tatsuhiko Kakisaka 1 & Hideki Yokoo 1 &
Kenichiro Yamashita 2 & Akinobu Taketomi 1
Received: 13 January 2017 / Accepted: 10 October 2017
# Springer-Verlag GmbH Germany 2017
Abstract
Purpose To increase the surgical opportunities for locally advanced perihilar bile duct cancers that require left-sided hepatectomies, we developed the transparenchymal glissonean
approach (TGA); it comprises intra-hepatic exposure and dissection of the Glisson’s sheath to gain access to the hepatic
artery and portal vein for reconstruction.
Methods Following skeletonization of the hepatoduodenal
ligament, the proximal portions of invaded vessels are exposed. If extra-hepatic attempts to access the distal portions
of the invaded vessels fail, TGA can be used. The distal portion of the invaded right or right posterior Glisson’s sheath is
exposed following liver transection. The anterior portion of
the wall of bile duct is cut and transected circumferentially
including the fibrous plate tissue. The non-invaded portal vein
and hepatic artery are isolated and dissected towards the hepatic hilum until the invaded distal portion of the vessels, and
vascular reconstructions are performed.
Results TGA was performed in 9 patients; 5 patients
underwent left hemihepatectomy and 4 underwent left trisectionectomy. Eight patients needed vascular reconstruction.
Clavien-Dindo classification (CDC) grades IIIa and IIIb were
recorded in 6 and 1 patients, respectively. No patients had
CDC grades IV and V disease. Pathologically, all cases were
* Hirofumi Kamachi
hkamachi@db3.so-net.ne.jp
1
Department of Gastroenterological Surgery I, Graduated School of
Medicine, Hokkaido University, N-15, W-7, Kita-ku,
Sapporo, Hokkaido 060-0838, Japan
2
Department of Transplant Surgery, Graduated School of Medicine,
Hokkaido University, N-15, W-7, Kita-ku,
Sapporo, Hokkaido 060-0838, Japan
pT4; 3 cases were R0, 5 were R1 with microscopic positive
margin, and 2 were R1 with microscopic metastasis. The overall median survival time was 25.0 months.
Conclusions TGA is feasible with acceptable prognosis and
expands the surgical opportunities.
Keywords Perihilar cholangiocarcinoma . Left side
hepatectomy . Glissonean approach . Surgical procedure .
Vascular reconstruction
Introduction
Complete surgical resection remains the most effective
and the only potentially curative therapy for perihilar bile
duct cancer. However, 58.2–79% of patients are deemed
Bunresectable^ at the time of initial evaluation or surgical
exploration, because the patients are either medically unfit
for surgical resection or because of distant metastasis or
locally advanced disease [1–3]. In cases of locally advanced disease, the extent of resection with vascular reconstruction has been discussed well [4–7], and vascular
reconstruction has been found to increase surgical opportunities. To access the distal portions of the hepatic artery
and portal vein for vascular reconstruction, dissection of
the umbilical fissure can expose a long length of the middle and left hepatic arteries, as well as the left portal vein
for right side hepatectomy [8]. In contrast, the right hepatic artery and portal vein flow into the hepatic parenchyma within a shorter length than that on the left side
[9]. Therefore, if the distal portion of the invaded right
hepatic artery and/or portal vein cannot be accessed by
dissecting the right side of hepatic hilum or the
Rouviere’s fissure, then such cases are usually deemed
unresectable. We used a novel surgical technique called
Langenbecks Arch Surg
the transparenchymal glissonean approach (TGA) in such
cases. In this method, we approached the Glisson’s sheath
by transecting the hepatic parenchyma and dissecting the
sheath by cutting the bile duct to access the distal portion
of the invaded right hepatic artery and/or portal vein.
Herein, we describe the surgical procedure and results of
this method.
Methods
Patients
This retrospective study was performed with the approval of
the Internal Review Board on ethical issues at Hokkaido
University Hospital, Sapporo, Japan (016-0026). We examined the medical records of 9 patients with perihilar bile duct
cancer who underwent TGA (Table 1). Five patients
underwent left hemihepatectomy and 4 patients underwent left
tri-sectionectomy with en bloc caudate lobectomy and extrahepatic bile duct resection between November 2006 and
August 2014 at the Department of Gastroenterological
Surgery I, Hokkaido University.
Preoperative assessments and surgical design
Biliary obstruction and invasion were evaluated using direct
cholangiography, magnetic resonance cholangiopancreatography, abdominal ultrasonography, and conventional
three-phase multi-detector computed tomography.
Longitudinal extent of biliary involvement of the intra- and
extra-hepatic ducts was classified according to the BismuthCorlette classification system [10]. We excluded surgical resection in cases with distant metastasis or liver metastasis in
the remnant liver. Regarding the local extension, we abandoned the surgery if the cancer extended over the third right
branch of bile ducts (segmental branch) or invaded beyond the
confluence of P6 and P7 in the right posterior portal vein. With
respect to hepatic artery reconstruction, we abandoned surgical resection in cases with arterial diameter < 2 mm. After
planning surgical resection, parenchymal volume of the
resected liver was calculated. If the proportion of liver parenchyma to be resected was > 60%, preoperative portal vein
embolization (PVE) was performed; the remnant liver was
allowed to undergo hypertrophy until the proportion of liver
parenchyma to be resected was < 60% [11, 12]. Arterial and
portal vein reconstruction was planned preoperatively based
on information obtained from the preoperative imaging studies. All hepatectomies were performed after the serum total
bilirubin concentration decreased to < 2 mg/dl, following biliary drainage.
Surgical procedure of the TGA
The technique of TGA is described with reference to a case of
left tri-sectionectomy (Fig. 1a–c). Following laparotomy
through an upper midline incision with bilateral subcostal extensions (Mercedes incision), the presence of peritoneal dissemination and hepatic metastases in the remnant liver was carefully explored. Intra-operative ultrasonography evaluation and
palpation around the right side of the hepatic hilum were performed to ensure that the tumor had not extended in comparison
with the preoperative evaluation. The Kocher maneuver and
para-aortic lymph node dissection were performed to determine
tumor extension. Systematic lymphadenectomy for the nodes at
the hepatoduodenal ligament, retropancreatic nodes, and celiac
nodes was performed, followed by skeletonization of the
hepatoduodenal ligament. The proximal portions of the invaded
vessels were exposed at this point and the duodenal side of the
bile duct was transected upwards at the level of the duodenum
(Fig. 2a). We decided to perform TGA when extra-hepatic attempt to open the right side of the hepatic hilum or the
Rouviere’s fissure was extremely difficult and might have led
to vascular injury. For hepatic parenchymal transection, the
liver was mobilized and the left caudate lobe was completely
detached from the inferior vena cava, and the common trunk of
the left and middle hepatic veins was looped. Liver transection
was performed using the hook spatula of the ultrasonic harmonic scalpel (Ethicon EndoSurgery Inc., Cincinnati, OH, USA)
and bipolar cautery with saline-irrigation system [13]. The distal portion of the invaded right posterior Glisson’s sheath was
exposed intra-hepatically and the remaining liver parenchyma
was transected along with the right hepatic vein (Fig. 2b).
Transection of the Glisson’s sheath started with cutting the bile
duct. The position of the bile duct in the Glisson’s sheath was
imaged preoperatively and confirmed by puncture and aspiration of bile juice, using a syringe with 25-gauge needle (Fig.
2c). The anterior part of the bile duct wall was cut (Fig. 2d) and
the lumen was visualized (Fig. 3a). Next, the bile duct was
carefully transected circumferentially including the fibrous
plate tissue. After transection of the bile ducts, the noninvaded posterior portal vein was exposed (Fig. 3b). From this
point onwards, dissection was performed towards the exposed
main portal vein (Fig. 3c) and the entire length of the portal vein
and anterior and left portal vein branches was exposed (Fig.
3d). Wedge resection of the right portal vein was performed
using 6–0 Prolene® (Ethicon, Inc.) (Fig. 4a). Posterior branch
of the right hepatic artery was isolated by the transection of B7
(Fig. 4b) and dissection was performed towards the distal portion of the invaded right hepatic artery (Fig. 4c). After the
specimen was excised and removed (Fig. 4d), arterial reconstruction was performed under a surgical microscope using 9-0
nylon interrupted sutures. The blood flow was confirmed using
intra-operative Doppler ultrasonography after reconstruction of
the vessels. Biliary tract reconstruction was conducted via bilio-
Patient characteristics and surgical outcomes
F
F
M
M
F
M
F
F
2
3
4
5
6
7
8
9
70
64
79
63
72
66
69
60
50
II
IV
IIIb
IV
IV
IV
IV
IV
IV
Left
rPV-PV
hemihepatectomy RHA-RHA
Left tri-sectionectomy rPV-PV (wedge)
RHA-RHA
Left tri-sectionectomy rPV-PV (wedge)
p-RHA-MHA
Left tri-sectionectomy None
675
704
902
583
750
880
3380
1610
1115
1300
1850
3080
2040
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Operation Blood
Intratime (min) loss (ml) operative
transfusion
Left hemihepatectomy rPV-PV (interposition) 1095
RHA-GDA
Left hemihepatectomy RHA-GDA
640
Left hemihepatectomy rPV (wedge)
807
Left tri-sectionectomy rPV-PV
679
A6-MHA
Left hemihepatectomy rPV-PV
793
RHA-PHA
Vascular
reconstruction
IIIa
IIIa
IIIa
IIIa
IIIa
I
I
IIIa
IIIb
ClavienDindo
classification
Bile leakage from raw surface of liver
Stenosis of dissecting hepatic artery
Liver abscess
Stenosis of bilio-enteric anastomosis
Delayed gastric emptying
IVR due to bleeding from middle colic artery
Sub-ileus
Pleural effusion
Delayed gastric emptying
Intra-abdominal abscess
Reoperation due to bile leakage
Bile leakage from raw surface of liver
None
None
Bile leakage from raw surface of liver
Detail
Postoperative morbidities
rPV right portal vein, PV portal vein, RHA right hepatic artery, GDA gastroduodenum artery, MHA middle hepatic artery, p-RHA posterior branch of right hepatic artery
F
1
Patient Sex Age
Bismuth Hepatectomy
(years) type
Table 1
64
39
76
70
75
38
46
78
73
Postoperative hospital
stay (days)
Langenbecks Arch Surg
Langenbecks Arch Surg
a
P5
P8
P7
b
c
B8
B5
B7
B6
P7
P6
Fig. 1 The technique of transparenchymal glissonean approach (TGA)
was described in this case of left tri-sectionectomy. a Tumor was located
in the left hilum and involved the right anterior and posterior bile ducts,
RHA (black allow), and PV (black arrowhead). b Coronal view shows B7
and B6 and P7 and P6 were tumor-free. c Tumor was classified as
Bismuth type IV. RHA right hepatic artery, LHA left hepatic artery,
PHA proper hepatic artery, PV portal vein
enterostomy using a Roux-en-Y jejunal limb, and external biliary stents were placed across the bilio-enteric anastomosis.
According to the Bismuth-Corlette classification system, 1
patient (11.1%) was classified as having type II disease, 1
patient (11.1%) as having type IIIb disease, and 7 patients
(77.8%) as having type IV.
The types of hepatectomy (with en bloc caudate lobectomy
and extra-hepatic bile duct resection) were as follows: left
hemihepatectomy (n = 5) and left tri-sectionectomy (n = 4),
and vascular reconstruction was performed in 8 patients
(88.9%). Notably, simultaneous reconstruction of the portal
vein and hepatic artery was required in 6 patients (66.7%).
Definition of mortality and morbidity
The Clavien-Dindo classification (CDC) [14] was used to assess the severity of postoperative morbidity. We classified bile
leakage into two types: (1) bilio-enterostomy leakage that was
diagnosed by injecting contrast medium into the drainage tube
to identify the connection between the abdominal space and
bilio-enterostomy and (2) bile leakage from the raw hepatic
surface. Delayed gastric emptying was defined as requirement
of nasogastric tube beyond postoperative day 3 or reinsertion.
Results
Patient characteristics and surgical procedure
Nine patients, 3 males and 6 females, with a mean age of
66.0 years (range 50–79 years) underwent TGA (Table 1).
Operative performance, morbidity, and mortality
The median operation time was 704 min (range 583–
1095 min) and the median blood loss was 1610 ml (range
750–3380 ml). Six patients (66.7%) needed intra-operative
transfusion. The overall postoperative major morbidity rate
(CDC ≥ grade III) was 77.8%, including 1 case of CDC grade
IIIb that required reoperation due to bile leakage. There were
no patients with CDC grades IV and V disease in this series.
The median postoperative hospital stay was 70 days (range
Langenbecks Arch Surg
Fig. 2 a The hepatoduodenal
ligament was skeletonized and the
bile duct was transected upwards
at the level of duodenum. It was
impossible to access the rightsided hilum and we decided to use
TGA. b Hepatic transection was
done along with the right hepatic
vein, and the right posterior
Glisson’s sheath was exposed. c
The position of the bile duct in the
Glisson’s sheath was confirmed
by aspirating the bile juice. d The
dissection of the right posterior
Glisson’s sheath was started by
cutting the anterior wall of the bile
duct. RHV right hepatic vein
a
b
LHA
RHA
PHA
PV
c
d
39–78 days). In case 5, the patient developed liver abscesses
due to steatosis of the hepatic artery, not at the anastomosis but
at the dissecting distal portion.
Fig. 3 a The lumen of the bile
duct and the drainage tube were
exposed. b The right posterior
portal vein was exposed after
transection of the bile duct. c The
bridge of fibrous tissue between
the main portal vein and the right
posterior portal vein was going to
be dissected. d The entire length
of the portal vein was exposed
and the right portal vein was
looped. Right anterior and left
portal veins are visible. a-PV right
anterior portal vein, l-PV left
portal vein
RHV
a
The American Joint Committee on Cancer (AJCC) 7th edition [15] was used to stage the disease. All 9 cases (100%)
were pT-stage 4 (Table 2). One case of microscopic periaortic
b
p-PV
c
d
a-PV
p-PV
PV
l-PV
Langenbecks Arch Surg
Fig. 4 a After the right anterior
portal vein was ligated, wedge
resection of the right portal vein
was performed. b The right
posterior branch of the hepatic
artery was isolated by transection
of B7. c The distal and the
proximal portions of the invaded
right hepatic artery were exposed.
d Photograph after excision
shows the independent B7 and B6
stumps and the intact confluence
of P7 and P6. RHA right hepatic
artery, p-RHA posterior branch of
right hepatic artery, a-PV right
anterior portal vein, l-PV left
portal vein
a
b
B7
p-RHA
c
d
RHV
B7
p-RHA
RHA
P7
p-RHA
PV-anastomosis
B6
P6
lymph node metastases and 1 case of hepatic metastasis in the
resected liver were of AJCC p-Stage IVB. The percentage of
cases that achieved R0 resection was 33.3%.
Analysis of patient survival
The median survival time (MST) and 3-year and 5-year survival rates were 25.0 months, 20.0%, and 20.0%, respectively.
If the AJCC p-Stage IVB cases were excluded, the MST and
3-year and 5-year survival rates were 55.0 months, 51.4%, and
25.7%, respectively.
Discussion
Surgical resection provides the only chance of cure for
perihilar bile duct cancer and R0 resection is one of the most
important factors that improve patients’ survival [16–18].
Although 20–30% of cases had microscopically positive resection margins, their prognoses were better than those of
unresectable cases [16–19]. To increase the opportunity for
surgical resection, we applied this method in cases with locally advanced perihilar bile duct cancers that required left-sided
hepatectomy, wherein extra-hepatic approach was impossible.
Table 2 Pathological findings
Patient
pT
pN
pM
pStage
R0 or R1
Factor defining R1
1
4
1
0
IVA
R1
Microscopic involvement of proximal bile duct margin
(invasive)
2
4
1
0
IVA
R0
3
4
1
1
IVB
R1
Metastasis in resected liver
Microscopic involvement of proximal bile duct margin
(invasive)
Microscopic involvement of proximal bile duct margin
(invasive)
Microscopic involvement of dissected margin
4
4
0
0
IVA
R1
5
6
7
4
4
4
0
1
1
0
0
0
IVA
IVA
IVA
R1
R0
R1
8
9
4
4
1
1
0
1
IVA
IVB
R0
R1
Microscopic involvement of proximal and distal bile duct
margin (invasive)
Microscopic metastasis in paraaortic LN
Langenbecks Arch Surg
TGA is based on knowledge of anatomy and several surgical
concepts. One of these concepts is the extra- [20] and intrahepatic [21] approach to Glisson’s sheath for liver resection
without dissecting the bile duct, hepatic arteries, and portal
vein. The intra-hepatic approach suggests that the noninvaded peripheral intra-hepatic Glisson’s sheath can be exposed by hepatic parenchymal dissection. The other surgical
concept is that of the Bhigh hilar dissection technique^ for living donor liver transplantation, as described by Lee et al. [22].
In this technique, the Glisson’s pedicles were divided intrahepatically at the third level of pedicles or beyond, such that
the portal vein and hepatic artery could be isolated from the bile
duct along with the surrounding fibrous tissue at that level.
Additionally, anatomical understanding of the hepatic plate system suggests that most of the second-order bile duct branches
and some of the third-order branches are all included in this
system [23]. This suggests that the vascular structures can be
divided from the plate system at this level. As shown in Fig. 4d,
the individual orifices of B6 and B7 branches could be dissected from their corresponding vascular structures using TGA.
Although TGA required complex surgical procedures including vascular reconstructions, it was an acceptable surgical
procedure in our clinical experience. Regarding complications, the postoperative major morbidity rate (CDC ≥ grade
III) was as high as 77.8%. However, the complications for
CDC grades IV and V were not recorded. Although a longer
time was required for recovery from the complications, almost
all of them could be managed by replacement of the drainage
tube. As a direct complication of TGA, dissecting arterial
stenosis occurred in case 5. It seemed that the procedure of
isolating hepatic artery, which was firmly adhered to the surrounding tissues, caused late arterial stenosis. Relative arterial
blood flow reduction resulted in liver abscess and the patient
had to wait for collateral circulation to develop.
As all cases were of AJCC pT-stage 4, TGA was limitedly
performed in locally advanced cases. In such cases, the advantages of TGA included operating in an open wide field and
allowing for access to vascular structures with direct visualization by prior resection of the bile duct. In result, TGA could
avoid the blind manipulation to access blood vessels, as seen
when operating under the deep and narrow fields. As the decision to do TGA was judged during the surgeries, preoperative planning of vascular reconstruction was definitely important, because the technique of vascular reconstruction up to the
segmental branches of the hepatic artery was required in some
cases.
As 2 cases of AJCC p-Stage IVB were included, the overall
R0 resection rate was 33.3%. Regarding the local R0 ratio, R0
resection was achieved in 4 out of 9 cases (44.4%). Left
hemihepatectomy, which resulted in locally R1 resections,
was performed in 4 out of 5 cases. Recently, it has been reported that R0 resection rate can be increased by performing
left tri-sectionectomy for left-side predominant perihilar bile
duct cancers [24]. Apart from using TGA, we should expand
the indication of left tri-sectionectomy in such advanced cases.
In terms of patients’ prognoses, the MST was 25.0 months
for all cases and 55.0 months in cases excluding those with pStage IVB. As the MST of the standard combination therapy
with gemcitabine and cisplatin for unresectable biliary tract
cancer was 11.7 months [25], it was clear that the prognoses
of cases that became resectable by TGA were better than those
of unresectable cases, even if R0 resection was not achieved.
In conclusion, our results showed that TGA safely increased the surgical opportunities with acceptable prognoses
in locally advanced perihilar bile duct cancers requiring leftsided hepatectomies.
Authors’ contributions Study conception and design: HK and TK;
acquisition of data: HK, YT, TO, KW, SS, TK, HY, and KY; analysis
and interpretation of data: HK, YT, and TO; drafting of manuscript: HK;
critical revision of manuscript: HK TK, and AT.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed were in accordance with
the ethical standards of the institutional and/or national research committee and with the Declaration of Helsinki of 1964 and its later amendments
or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
References
1.
2.
3.
4.
5.
6.
7.
Jarnagin WR, Fong Y, DeMatteo RP et al (2001) Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma.
Ann Surg 234(4):507–517
Ito F, Agni R, Rettammel RJ et al (2008) Resection of hilar cholangiocarcinoma: concomitant liver resection decreases hepatic recurrence. Ann Surg 248(2):273–279
Nguyen KT, Steel J, Vanounou T et al (2009) Initial presentation
and management of hilar and peripheral cholangiocarcinoma: is a
node-positive status or potential margin-positive result a contraindication to resection? Ann Surg Oncol 16(12):3308–3315
Ebata T, Nagino M, Kamiya et al (2003) Hepatectomy with portal
vein resection for hilar cholangiocarcinoma: audit of 52 consecutive
cases. Ann Surg 238(5):720–727
Nagino M, Nimura Y, Nishio H et al (2010) Hepatectomy with
simultaneous resection of the portal vein and hepatic artery for
advanced perihilar cholangiocarcinoma: an audit of 50 consecutive
cases. Ann Surg 252(1):115–123
Shimizu H, Kimura F, Yoshidome H et al (2010) Aggressive surgical resection for hilar cholangiocarcinoma of the left-side predominance: radicality and safety of left-sided hepatectomy. Ann Surg
251(2):281–286
Hemming AW, Mekeel K, Khanna A et al (2011) Portal vein resection in management of hilar cholangiocarcinoma. J Am Coll Surg
212(4):604–613
Langenbecks Arch Surg
8.
9.
10.
11.
12.
13.
14.
15.
16.
Neuhaus P, Thelen A, Jonas S et al (2012) Oncological superiority
of hilar en bloc resection for the treatment of hilar cholangiocarcinoma. Ann Surg Oncol 19(5):1602–1608
Bismuth H (1982) Surgical anatomy and anatomical surgery of the
liver. World J Surg 6(1):3–9
Bismuth H, Corlette MB (1975) Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver. Surg Gynecol Obstet
140(2):170–178
Makuuchi M, Thai BL, Takayasu K et al (1990) Preoperative portal
embolization to increase safety of major hepatectomy for hilar bile
duct carcinoma: a preliminary report. Surgery 107(5):521–527
Shimamura T, Nakajima Y, Une Y et al (1997) Efficacy and safety
of preoperative percutaneous transhepatic portal embolization with
absolute ethanol: a clinical study. Surgery 121(2):135–141
Yokoo H, Kamiyama T, Nakanishi K et al (2012) Effectiveness of
using ultrasonically activated scalpel in combination with radiofrequency dissecting sealer or irrigation bipolar for hepatic resection.
Hepato-Gastroenterology 59(115):831–835
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of
6336 patients and results of a survey. Ann Surg 240(2):205–213
Edge S, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A
(eds) (2009) American joint committee on cancer (AJCC) cancer
staging manual, 7th edn. Springer, New York
Miyazaki M, Kimura F, Shimizu H et al (2010) One hundred seven
consecutive surgical resections for hilar cholangiocarcinoma of
Bismuth types II, III, IV between 2001 and 2008. J Hepatobiliary
Pancreat Sci. 17(4):470–475
17.
Rocha FG, Matsuo K, Blumgart LH et al (2010) Hilar cholangiocarcinoma: the Memorial Sloan-Kettering Cancer Center experience. J Hepatobiliary Pancreat Sci 17(4):490–496
18. Nagino M, Ebata T, Yokoyama Y et al (2013) Evolution of surgical
treatment for perihilar cholangiocarcinoma: a single-center 34-year
review of 574 consecutive resections. Ann Surg 258(1):129–140
19. Schiffman SC, Reuter NP, McMasters KM et al (2012) Overall
survival peri-hilar cholangiocarcinoma: R1 resection with curative
intent compared to primary endoscopic therapy. J Surg Oncol
105(1):91–96
20. Takasaki K, Kobayashi S, Tanaka S et al (1990) Highly anatomically systematized hepatic resection with Glissonean sheath code
transection at the hepatic hilus. Int Surg 75(2):73–77
21. Launois B, Jamieson GG (1992) The importance of Glisson’s capsule and its sheaths in the intrahepatic approach to resection of the
liver. Surg Gynecol Obstet 174(1):7–10
22. Lee KW, Joh JW, Kim SJ et al (2004) High hilar dissection: new
technique to reduce biliary complication in living donor liver transplantation. Liver Transpl 10(9):1158–1162
23. Masunari H, Shimada H, Endo I et al (2008) Surgical anatomy of
hepatic hilum with special reference of the plate system and extrahepatic duct. J Gastrointest Surg 12(6):1047–1053
24. Hosokawa I, Shimizu H, Yoshidome H et al (2014) Surgical strategy for hilar cholangiocarcinoma of the left-sided predominance.
Current role of left trisectionectomy. Ann Surg 259(6):1178–1185
25. Valle J, Wasan H, Palmer DH et al (2010) Cisplatin plus
gemcitabine versus gemcitabine for biliary tract cancer. N Engl J
Med 362(14):1273–1281
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