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Clinical Study

Laparoscopic extrahepatic Glissonian versus hilar dissection approach for major hepatectomy in patients with HCC: a randomized controlled trial

British Journal of Cancer (2026) Cite this article

Subjects

Abstract

Background

During laparoscopic major hepatectomy (LMH) for patients with hepatocellular carcinoma (HCC), an appropriate approach for hepatic hilum treatment is crucial. However, to date, there is still controversy about whether the Glissonian approach or hilar dissection approach is more advantageous for hepatic hilum treatment. Thus, we performed this randomized controlled trial to compare the short- and long-term outcomes between the Glissonian and hilar dissection approaches for LMH.

Methods

Between November 2017 and July 2021, 256 HCC patients who initially met the criteria via preoperative evaluation were randomly assigned to this trial. After surgical exploration, 119 patients in the Glissonian group and 121 patients in the hilar dissection group were eventually enrolled in the modified intention-to treat (ITT) principled analysis. Perioperative data and survival outcomes between both groups were recorded and compared, and subgroup analysis was further performed.

Results

The 5-year OS rates and 5-year DFS rates were comparable between the two groups. In addition, postoperative overall complications, including bile duct injury, leakage, and stricture, did not differ between the groups. However, the operative time (P = 0.044) and the hilar dissection time (P < 0.001) were significantly shorter in the Glissonian group than the hilar dissection group. Additionally, for patients with liver cirrhosis, the Glissonian group had shorter operative time (P = 0.002) and less intraoperative blood loss (P = 0.004) than the hilar dissection group.

Conclusions

The Glissonian approach for LMH in selected HCC patients is superior to the hilar dissection approach in short-term outcomes, but the survival outcomes were comparable between both groups. Registration number: ChiCTR-IOR-17013077.

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Fig. 1: Some surgical techniques of the Glissonian approach for LMH (taking right/left hemihepatectomy as an example).
The alternative text for this image may have been generated using AI.
Fig. 2: Some surgical techniques of the hilar dissection approach for LMH (taking right/left hemihepatectomy as an example).
The alternative text for this image may have been generated using AI.
Fig. 3: The trial flow chart. * These patients were enrolled in the modified intention-to-treat analysis.
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Fig. 4: The survival curves of the two groups.
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Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

References

  1. Buell JF, Cherqui D, Geller DA, O’Rourke N, Iannitti D, Dagher I, et al. The international position on laparoscopic liver surgery: the Louisville Statement, 2008. Ann Surg. 2009;250:825–30.

    Article  PubMed  Google Scholar 

  2. Wakabayashi G, Cherqui D, Geller DA, Buell JF, Kaneko H, Han HS, et al. Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg. 2015;261:619–29.

    PubMed  Google Scholar 

  3. Abu Hilal M, Aldrighetti L, Dagher I, Edwin B, Troisi RI, Alikhanov R, et al. The Southampton consensus guidelines for laparoscopic liver surgery: from indication to implementation. Ann Surg. 2018;268:11–8.

    Article  PubMed  Google Scholar 

  4. Lortat-Jacob JL, Robert HG, Henry C. [Case of right segmental hepatectomy]. Mem Acad Chir. 1952;78:244–51.

    CAS  PubMed  Google Scholar 

  5. Takasaki K, Kobayashi S, Tanaka S, Saito A, Yamamoto M, Hanyu F. Highly anatomically systematized hepatic resection with Glissonean sheath code transection at the hepatic hilus. Int Surg. 1990;75:73–7.

    CAS  PubMed  Google Scholar 

  6. Ramacciato G, Aurello P, D’Angelo F, Caramitti A, Barillari P, Fornasari V. Effective vascular endostapler techniques in hepatic resection. Int Surg. 1998;83:317–23.

    CAS  PubMed  Google Scholar 

  7. Takasaki K. Glissonean pedicle transection method for hepatic resection: a new concept of liver segmentation. J Hepatobiliary Pancreat Surg. 1998;5:286–91.

    Article  CAS  PubMed  Google Scholar 

  8. Figueras J, Lopez-Ben S, Lladó L, Rafecas A, Torras J, Ramos E, et al. Hilar dissection versus the “glissonean” approach and stapling of the pedicle for major hepatectomies: a prospective, randomized trial. Ann Surg. 2003;238:111–9.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Cho A, Yamamoto H, Kainuma O, Souda H, Ikeda A, Takiguchi N, et al. Safe and feasible extrahepatic Glissonean access in laparoscopic anatomical liver resection. Surg Endosc. 2011;25:1333–6.

    Article  PubMed  Google Scholar 

  10. Machado MA, Makdissi FF, Galvão FH, Machado MC. Intrahepatic Glissonian approach for laparoscopic right segmental liver resections. Am J Surg. 2008;196:e38–42.

    Article  PubMed  Google Scholar 

  11. Machado MA, Surjan RC, Basseres T, Schadde E, Costa FP, Makdissi FF. The laparoscopic Glissonian approach is safe and efficient when compared with standard laparoscopic liver resection: results of an observational study over 7 years. Surgery. 2016;160:643–51.

    Article  PubMed  Google Scholar 

  12. Liu F, Wei Y, Chen K, Li H, Wang W, Wu H, et al. The extrahepatic glissonian versus hilar dissection approach for laparoscopic formal right and left hepatectomies in patients with hepatocellular carcinoma. J Gastrointest Surg. 2019;23:2401–10.

    Article  PubMed  Google Scholar 

  13. Fong Y, Blumgart LH. Useful stapling techniques in liver surgery. J Am Coll Surg. 1997;185:93–100.

    Article  CAS  PubMed  Google Scholar 

  14. Tsuruta K, Okamoto A, Toi M, Saji H, Takahashi T. Impact of selective Glisson transection on survival of hepatocellular carcinoma. Hepatogastroenterology. 2002;49:1607–10.

    PubMed  Google Scholar 

  15. Yamamoto M, Takasaki K, Ohtsubo T, Katsuragawa H, Fukuda C, Katagiri S. Effectiveness of systematized hepatectomy with Glisson’s pedicle transection at the hepatic hilus for small nodular hepatocellular carcinoma: retrospective analysis. Surgery. 2001;130:443–8.

    Article  CAS  PubMed  Google Scholar 

  16. Chinburen J, Gillet M, Yamamoto M, Enkh-Amgalan T, Taivanbaatar E, Enkhbold C, et al. Impact of Glissonean pedicle approach for centrally located hepatocellular carcinoma in Mongolia. Int Surg. 2015;100:268–74.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Ji B, Wang Y, Wang G, Liu Y. Curative resection of hepatocellular carcinoma using modified Glissonean pedicle transection versus the Pringle maneuver: a case control study. Int J Med Sci. 2012;9:843–52.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Abraha I, Montedori A. Modified intention to treat reporting in randomised controlled trials: systematic review. BMJ. 2010;340:c2697.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Liu F, Xu H, Li Q, Wei Y, Li H, Wang W, et al. Outcomes of pure laparoscopic Glissonian pedicle approach hepatectomy for hepatocellular carcinoma: a propensity score matching analysis. Surg Endosc. 2019;33:1155–66.

    Article  PubMed  Google Scholar 

  20. Yamamoto M, Katagiri S, Ariizumi S, Kotera Y, Takahashi Y, Egawa H. Tips for anatomical hepatectomy for hepatocellular carcinoma by the Glissonean pedicle approach (with videos). J Hepatobiliary Pancreat Sci. 2014;21:E53–56.

    Article  PubMed  Google Scholar 

  21. Sugioka A, Kato Y, Tanahashi Y. Systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection based on Laennec’s capsule: proposal of a novel comprehensive surgical anatomy of the liver. J Hepatobiliary Pancreat Sci. 2017;24:17–23.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D, et al. The “50-50 criteria” on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Ann Surg. 2005;242:824–8.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Ishizawa T, Hasegawa K, Kokudo N, Sano K, Imamura H, Beck Y, et al. Risk factors and management of ascites after liver resection to treat hepatocellular carcinoma. Arch Surg. 2009;144:46–51.

    Article  PubMed  Google Scholar 

  25. Koch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L, et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery. 2011;149:680–8.

    Article  PubMed  Google Scholar 

  26. Rahbari NN, Garden OJ, Padbury R, Maddern G, Koch M, Hugh TJ, et al. Post-hepatectomy haemorrhage: a definition and grading by the International Study Group of Liver Surgery (ISGLS). HPB. 2011;13:528–35.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Galperin EI, Karagiulian SR. A new simplified method of selective exposure of hepatic pedicles for controlled hepatectomies. HPB Surg. 1989;1:119–30.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Yang P, Si A, Yang J, Cheng Z, Wang K, Li J, et al. A wide-margin liver resection improves long-term outcomes for patients with HBV-related hepatocellular carcinoma with microvascular invasion. Surgery. 2019;165:721–30.

    Article  PubMed  Google Scholar 

  29. Shi M, Guo RP, Lin XJ, Zhang YQ, Chen MS, Zhang CQ, et al. Partial hepatectomy with wide versus narrow resection margin for solitary hepatocellular carcinoma: a prospective randomized trial. Ann Surg. 2007;245:36–43.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Aoki T, Kubota K, Hasegawa K, Kubo S, Izumi N, Kokudo N, et al. Significance of the surgical hepatic resection margin in patients with a single hepatocellular carcinoma. Br J Surg. 2020;107:113–20.

    Article  CAS  PubMed  Google Scholar 

  31. Lee N, Cho CW, Kim JM, Choi GS, Kwon CHD, Joh JW. Application of temporary inflow control of the Glissonean pedicle method provides a safe and easy technique for totally laparoscopic hemihepatectomy by Glissonean approach. Ann Surg Treat Res. 2017;92:383–6.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Liao KX, Yu F, Cao L, Wang BL, Li XS, Wang XJ, et al. Laparoscopic Glissonian pedicle versus hilar dissection approach hemihepatectomy: a prospective, randomized controlled trial. J Hepatobiliary Pancreat Sci. 2022;29:629–40.

  33. Karamarković A, Doklestić K, Milić N, Djukić V, Bumbasirević V, Sijački A, et al. Glissonean pedicle approach in major liver resections. Hepatogastroenterology. 2012;59:1896–901.

    PubMed  Google Scholar 

  34. Karanicolas PJ, Farrokhyar F, Bhandari M. Practical tips for surgical research: blinding: who, what, when, why, how? Can J Surg. 2010;53:345–8.

    PubMed  PubMed Central  Google Scholar 

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Funding

This work was supported by grants from the National Natural Science Foundation of China (No. 82403592), the China Postdoctoral Science Foundation (Nos. GZB20240486 and 2024M762234), the Sichuan Science and Technology Program (No. 2024NSFSC1899), and 1.3.5 project for disciplines of excellence, West China Hospital, Sichuan University (25HXJS028).

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Authors and Affiliations

  1. Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China

    Yufu Peng, Yubo Yang, Kefei Chen, Bo Li, Hongwei Xu, Suqi Guo, Yonggang Wei & Fei Liu

Authors
  1. Yufu Peng
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  2. Yubo Yang
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  3. Kefei Chen
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  4. Bo Li
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  7. Yonggang Wei
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  8. Fei Liu
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Contributions

Conceptualization: FL and YW. Data curation: YP, YY and SG. Formal analysis: YP, YY, KC, and HX. Methodology: YP, HX, SG, and FL. Supervision: BL, FL and YW. Resources: BL, KC, FL and YW. Writing-original draft: YP and FL. Writing-review and editing: all authors.

Corresponding authors

Correspondence to Yonggang Wei or Fei Liu.

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The authors declare no competing interests.

Ethical approval

This study was approved by the clinical trial ethics committee of West China Hospital (Approval Number: 2017-236).

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Peng, Y., Yang, Y., Chen, K. et al. Laparoscopic extrahepatic Glissonian versus hilar dissection approach for major hepatectomy in patients with HCC: a randomized controlled trial. Br J Cancer (2026). https://doi.org/10.1038/s41416-026-03458-2

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