Safe and efficient surgical dissection using anatomical ‘gateways’ around the liver and pancreas

Abstract

Objective: Safe and efficient tissue dissection requires division of certain critical structures which act as ‘gateways’ to progressing the dissection. The aim of this educational video is to demonstrate important gateways in liver and pancreas surgery, with a primary target audience of surgical residents and general surgeons who are occasionally involved in liver and pancreas surgery. Methods: Using video from common liver and pancreas procedures, combined with computer generated animation, six key anatomical gateways are demonstrated. Explanations are provided on why each structure must be divided in order to progress the dissection along a plane or to expose a structure at a deeper level. Results: The video demonstrates that division of the gastroepiploic vein and gastroduodenal artery exposes the superior mesenteric vein and portal vein, respectively, during pancreaticoduodenectomy. Division of the left gastric vein exposes the origin of the splenic artery during distal pancreatectomy and mulivisceral organ procurement. During portal dissection for right hepatectomy the cystic duct and artery are divided in order to expose the right hepatic artery and right portal vein. The right hepatic vein, during right hepatectomy, may only be fully encircled by first dividing the hepatocaval ligament. Finally, the ligamentum venosum must be divided to allow the left hepatic vein to be fully encircled during left hepatectomy. Conclusion: Knowledge of six key anatomical gateways in liver and pancreas surgery allows tissue dissection to proceed appropriately. By opening up these gateways, surgeons are more likely to develop safe and efficient tissue dissection.