title: Hilar dissection versus the "glissonean" approach and stapling of the pedicle for major hepatectomies: a prospective, randomized trial.
abstract: OBJECTIVE
  A randomized study was conducted of hilar dissection and the "glissonean" approach and stapling of the pedicle for major hepatectomies to contrast their feasibility, safety, amount of hemorrhage, postoperative complications, operative times, and costs.
  
  
  BACKGROUND
  The "glissonean" approach is reported as requiring a shorter portal triad closure time; furthermore, the procedure seems to expedite the transection of the liver.
  
  
  METHODS
  Between 1998 and 2001, 80 patients were enrolled in this study. The major liver resections included 15 extended right, 7 extended left, 42 right, and 16 left hepatectomies. The patients were randomly assigned to the hilar dissection group (G1; n = 40) or to the "glissonean" approach and stapling of the portal triad group (G2; n = 40).
  
  
  RESULTS
  The groups were equally matched for age, sex, diagnosis, mean resected specimen weight, number of tumoral lesions, type of liver resection performed, and percentage of patients with margin invasion (G1: 4; 10% vs G2: 5; 12.5%). The duration of the 2 procedures was similar (G1: 247 +/- 54 min vs G2: 236 +/- 43 min; P = 0.4). However, the duration of the hilar dissection was shorter for G2 (50 +/- 17 min) versus G1 (70 +/- 26 min; P <0.001). By contrast, the duration of pedicular clamping was shorter for G1 (43 +/- 15 min) versus G2 (51 +/- 15 min; P = 0.015). No differences were observed in the amount of hemorrhage (G1: 887 +/- 510 mL vs G2: 937 +/- 636 mL; P = 0.7), and only 6 patients in G1 and 10 in G2 were transfused (P = 0.26). Morbidity rates were similar for both groups (G1: 23% vs G2: 33%; P = 0.3). Surgical injury of the contralateral biliary duct was not observed. However, 3 patients in G1 and 4 patients in G2 presented a biliary fistula that resolved spontaneously. Postoperative hospital stay was similar (G1: 8 [range, 6-24] vs G2: 9 [range, 5-31] days; P = 0.6). The postoperative levels of alanine transaminase (ALT) during the 2 first postoperative days were lower for G1 than G2. Cost of the surgical material was 1235.80 US dollars for G1 and 1301.10 US dollars for G2.
  
  
  CONCLUSIONS
  The 2 techniques are equally effective procedures for treating hilar structures. Although en bloc stapling transection is faster, hilar dissection was associated with a shorter pedicular clamping time, less cytolysis, and the materials required were less expensive.
authors.affiliation: Department of Surgery, Hospital de Bellvitge, Ciutat Sanitaria i Universitaria de Bellvitge, 08907 Barcelona, Spain. jfigueras@csub.scs.es
authors.forename: Joan
authors.initials: J
authors.lastname: Figueras
authors.forename: Santiago
authors.initials: S
authors.lastname: Lopez-Ben
authors.forename: Laura
authors.initials: L
authors.lastname: Lladó
authors.forename: Antoni
authors.initials: A
authors.lastname: Rafecas
authors.forename: Jaume
authors.initials: J
authors.lastname: Torras
authors.forename: Emilio
authors.initials: E
authors.lastname: Ramos
authors.forename: Joan
authors.initials: J
authors.lastname: Fabregat
authors.forename: Eduardo
authors.initials: E
authors.lastname: Jaurrieta
mesh_terms: D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical; D004210:Dissection; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008099:Liver / Q000098:blood supply / Q000601:surgery; D008113:Liver Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011446:Prospective Studies; D017792:Surgical Stapling; D016019:Survival Analysis; D016896:Treatment Outcome