Posterior Extremity of the Cystic Plate Guided Right Anterior Glissonean Approach and Intraoperative Spatial Validation in Minimally Invasive Liver Surgery (With Video).

Abstract

Isolation of the right anterior Glissonean pedicle (RAG) during minimally invasive liver surgery (MILS) remains challenging due to its deep intrahepatic location. Although cystic plate cholecystectomy has been proposed to facilitate RAG identification based on the anatomical importance of the posterior extremity, quantitative clinical evidence remains limited. Therefore, this study evaluated the posterior extremity of the cystic plate as a specific landmark to assess the feasibility of this approach and document its spatial relationship with the RAG. We retrospectively analyzed 57 patients who underwent laparoscopic or robotic anatomical liver resection with successful RAG isolation. Two approaches were utilized: (1) cystic plate cholecystectomy and (2) posterior extremity traction. The intraoperative spatial relationship between the RAG and the posterior extremity of the cystic plate was classified and analyzed using surgical video documentation. Laparoscopic and robotic approaches were performed in 80.7% and 19.3% of cases, respectively. The RAG was located beneath the posterior extremity in 42 patients (73.7%), to the right in 14 patients (24.6%), and to the left in one patient (1.8%). In all cases, successful RAG isolation was intraoperatively confirmed using demarcation lines or indocyanine green (ICG) negative staining. The posterior extremity of the cystic plate serves as a useful anatomical landmark for RAG isolation during MILS. By quantitatively defining its spatial relationship with the RAG, this study offers a practical guide that may facilitate safe and reproducible RAG isolation.