Laparoscopic Left Lateral Sectionectomy: Guided by the Ligamentum Teres Hepatis and the Umbilical Fissure Vein

Summary

Laparoscopic left lateral sectionectomy guided by the ligamentum teres hepatis and umbilical fissure vein effectively controls intraoperative bleeding even without controlled low central venous pressure and prevents loss of direction during parenchymal dissection.

Abstract

Laparoscopic left lateral sectionectomy (LLLS), a mainstream procedure in liver surgery, often utilizes controlled low central venous pressure (CLCVP) to reduce bleeding in the hepatic venous system. However, anesthesiologists may avoid the use of CLCVP in patients with concurrent cardiovascular and cerebrovascular diseases to prioritize the maintenance of vital organ perfusion. In this report, we present an LLLS guided by the ligamentum teres hepatis (LTH) for dissection of the Glissonian pedicles for segments 2/3 outside the liver, followed by hepatic parenchymal dissection along the falciform ligament and umbilical fissure vein (UFV) while approaching the left hepatic vein root. Guided by LTH and UFV, this LLLS procedure effectively controlled intraoperative bleeding, even in the absence of CLCVP. Additionally, hepatectomy guided by extrahepatic and intrahepatic anatomical landmarks prevents loss of direction during liver dissection and ensures precise hepatic resection. These attributes suggest that the potential benefits extend beyond patients with cardiovascular or cerebrovascular conditions, making it applicable in a wide range of LLLS cases.

Introduction

Laparoscopic techniques are extensively used in liver surgery and are considered safe and effective. Compared with open surgery, laparoscopic left lateral sectionectomy (LLLS) offers several advantages, including a reduced overall complication rate, shorter postoperative hospitalization, and decreased blood loss¹. In the traditional LLLS procedure, the parenchyma is dissected using a harmonic scalpel, starting on the upper liver surface, proceeding from front to back, taking layers 2-3 mm deep ventral and dorsal to the level of the LHV, followed by direct dissection of the left outer lobe hepatic hilum with a staple². This method may lead to injury of the hepatic parenchyma and veins, thereby increasing the risk of bleeding. The controlled low central venous pressure (CLCVP) technique is often employed in traditional LLLS procedures to mitigate intraoperative bleeding³. However, in patients with concurrent cardiovascular and cerebrovascular diseases, anesthesiologists may opt to avoid using the CLCVP technique to prioritize the perfusion of vital organs⁴. Herein, we present a standardized procedure for LLLS that does not rely on the CLCVP technique but effectively manages intraoperative bleeding. The key components of the procedure are as follows: (1) utilizing the ligamentum teres hepatis (LTH) approach to control the Glissonian pedicles for segments 2/3; (2) determining the transection plane of the liver based on anatomical landmarks such as the falciform ligament, umbilical fissure vein (UFV), and the canal of Arantius; and (3) using the UFV as a guide for hepatic parenchymal transection to enhance accessibility to the root of the left hepatic vein. The rationale for this technique, which is guided by anatomical landmarks such as the Glissonian pedicle and intrahepatic veins (e.g., UFV), enables more precise lobular and segmental resections while reducing the risk of hemorrhage⁵. This procedure is straightforward and easy to disseminate and learn. Xie et al.⁶ and Prof. Sugioka et al.⁷ have highlighted the safety, effectiveness, simplicity, and anatomical correctness of the LTH approach in hepatectomy procedures. We introduced the LLLS procedure guided by LTH and UFV to further improve the surgical technique.

In this study, we present a representative case to elucidate the procedural steps involved. A 74-year-old male patient presented with chronic upper abdominal pain that had persisted for 3 months. Pre-operative magnetic resonance imaging (MRI) revealed left intrahepatic bile duct stones and localized cystic dilatation of the bile ducts (Figure 1A,B). Additionally, the patient had a history of two cerebral infarctions. Head MRI indicated multiple ischemic and infarct lesions in various brain regions, including the bilateral periventricular regions, basal ganglia, corona radiata, brainstem, and frontal lobes. Notably, lesions in the left basal ganglia and adjacent parts of the right lateral ventricle softened with gliosis. The patient's Child-Pugh score was 5 (Grade A), and indocyanine green (ICG) retention at 15 min was 6.5%. Based on the radiological features, the patient was diagnosed with left intrahepatic bile duct stones. Subsequently, the patient underwent LLLS.

Protocol

The protocol follows the guidelines of the Human Research Ethics Committee of Nanchong Central Hospital.

1. Pre-operative workup

1. Perform MRI scanning to confirm the diagnosis and assess the extent of the lesion, bile duct, and vascular anatomy. Perform a magnetic resonance cholangiopancreatography imaging scan on a 3.0 T MRI unit using T2 weighted image thick single-shot fast spin echo/turbo spin echo and fast acquisition relaxation enhancement sequences (Table of Materials).
2. Perform the ICG retention test to effectively assess liver function.
   1. Utilize the liver function reserve analyzer for experimental analysis. Input the patient's height, body weight, and hemoglobin concentration on the analyzer's touch screen. The software will automatically compute the required amount of ICG to be injected.
   2. Subsequently, rapidly inject the ICG through the left median cubital vein, while the nasal probe automatically measures the wavelength of the spectrophotometric spectra. Employ spectroscopic analysis to determine the concentration of ICG, followed by calculating the retention rate after a 10-min injection period⁸ (Table of Materials).
3. Extend invitations to surgical, anesthesiology, neurology, and cardiology experts for multidisciplinary consultation to develop surgical strategies, anesthesia management plans, and perioperative medication guidelines.

2. Anesthesia

1. Administer pre-operative antibiotics, typically 1.0 g of ceftazidime (Table of Materials), intravenously on induction of anesthesia.
2. Place an arterial line in the patient's left radial artery and insert a central venous line into the right internal jugular vein.
3. Control the intraoperative central venous pressure (CVP) at 5-10 mmHg to ensure cerebral blood perfusion and avoid intraoperative hypotension.

3. Patient positioning

1. Position the patient supine on the operating table in a split-leg position, with the camera assistant standing between the patient's legs, the first assistant on the patient's left side, and the surgeon on the patient's right side.
2. Elevate the patient to 30° right lateral position.

4. Port site insertion and laparoscope (Figure 2)

1. Make a longitudinal incision 1 cm below the umbilicus and establish pneumoperitoneum using the Veress needle technique.
2. Place 5 mm and 12 mm ports below the costal margin along the left and right anterior axillary lines.
3. Place a 12 mm port below the rib cage along the midclavicular line on both the left and right sides.
4. Maintain pneumoperitoneum pressure at 10-14 mmHg.
5. Perform the procedure using a 30° high-definition laparoscopic device (Table of Materials).

5. Operative steps

1. Mobilization of the left lobe of the liver
   1. Dissect the hepatic round ligament and falciform ligament using an ultrasonic scalpel (Table of Materials).
   2. Expose the root of the left hepatic vein. Completely divide the triangular ligament and coronary ligament to expose the root of the left hepatic vein.
2. Pringle's maneuver
   1. Utilize laparoscopic Pringle's maneuver to apply an extracorporeal tourniquet, and initiate a first porta hepatis block with Pringle's maneuver if necessary⁹.
   2. Employ a grasper posterior to the hepatic pedicle via the foramen of Winslow to facilitate the placement of a cotton tape. Subsequently, extract the ends of the cotton tape through a 5 mm port trocar under the guidance of the grasper.
   3. Upon removal of the 5 mm trocar, thread one end of the cotton tape through a suction tube and advance into the abdominal cavity up to the level of the hepatic pedicle. Concurrently, maintain the external end of the cotton tape outside the patient's body.
3. Left lateral pedicle control via Glissonian approach
   1. Dissect the superficial peritoneum with an ultrasonic scalpel along the left side of the LTH.
   2. Dissect the Glissonian pedicles for segments 2/3 from the ventral to the dorsal side.
   3. Excise the Glissonian pedicles for segments 2/3 with clips (Table of Materials) or a stapler (Table of Materials).
4. Parenchymal transection
   1. Dissect the hepatic parenchyma ventrally along the left side of the falciform ligament with an ultrasonic scalpel.
   2. Use fine-tip forceps and induce energy stimulation to dissect liver parenchyma with an ultrasonic scalpel.
   3. Dissect the hepatic parenchyma along the UFV within the hepatic parenchyma, facilitating the identification of the root of the left hepatic vein.
   4. Divide small vessels with the ultrasonic scalpel.
   5. Divide large vessels or pedicle structures between clips.
5. Left hepatic vein transection
   1. Transect the left hepatic vein with a stapler.
6. Bleeding control
   1. Perform the first porta hepatis block with Pringle's maneuver if needed.
   2. Perform meticulous dissection and identification of intrahepatic vessels.
   3. Divide hilum and hepatic venules with clips or stapler.
   4. Use a vascular suture to secure bleeding from vessels.
   5. Utilize bipolar electrocoagulation forceps to coagulate hemorrhagic points.

6. Specimen retrieval

1. Place the specimen into a plastic bag and retrieve it through the subumbilical incision.

Results

In the representative case, the operative time was 120 min with an estimated blood loss of 50 mL, and there were no postoperative complications. The postoperative hospital stay was 7 days. Table 1 summarizes the intra- and postoperative data. A computed tomography(CT) performed on postoperative day 5 revealed no evidence of blood or fluid accumulation in the liver section (Figure 3). The patient was successfully discharged from hospital after surgery. Histological examination of the specimen revealed intrahepatic bile duct stones, accompanied by inflammatory cell infiltration and proliferation of small bile ducts in the porta hepatis region (Figure 4). The patient showed satisfactory postoperative incision healing without infection (Figure 5).

Figure 1: Pre-operative magnetic resonance images. (A,B) The white circles in panels A and B indicate the presence of left intrahepatic bile duct stones along with localized cystic dilatation of the bile ducts. Please click here to view a larger version of this figure.

Figure 2: Port placement. The blue solid dots represent ports as follows: A 10 mm sub-umbilical port (camera port), and 5 mm and 12 mm ports at the costal margin along the left and right anterior axillary lines, respectively. Additionally, 12 mm ports were placed in the rib cage along the midclavicular line on both the left and right sides. Please click here to view a larger version of this figure.

Figure 3: CT scan on postoperative day 5. The white circle indicated the surgical area, and no fluid collection was observed in the surgical liver section. Please click here to view a larger version of this figure.

Figure 4: Histological examination. Histological examination of the specimen revealed intrahepatic bile duct stones accompanied by inflammatory cell infiltration and proliferation of small bile ducts in the porta hepatis region (100x). Scale bar: 100 µm. Please click here to view a larger version of this figure.

Figure 5: Postoperative incision healing. Postoperative incision healing without infection. Black arrows indicate the locations of incisions. Please click here to view a larger version of this figure.

Variables	Values
Operating time (min)	120
Estimated blood loss (ml)	50
Postoperative hospital stay (days)	7
Time to first passage of flatus(days)	3
First post-operative CT	Figure 2
Histopathological examination	intrahepatic bile duct stones
	inflammatory cell infiltration and proliferation of small bile ducts in the porta hepatis region
Postoperative incision healing	Uninfected

Table 1: Surgical outcomes.

Discussion

Management of intraoperative bleeding remains a crucial challenge in laparoscopic hepatectomy. To address this issue, Pringle's maneuver and the CLCVP technique are commonly employed to control hepatic blood flow¹⁰. However, not all patients are suitable candidates for CLCVP, particularly those with concurrent cardiovascular and cerebrovascular diseases.

In this study, we present our experience with laparoscopic hepatectomy in patients with comorbid cerebrovascular disease for whom the CLCVP technique was deemed unfeasible. In summary, the approach involved the dissection of the hepatic parenchyma along the left side of the LTH using an ultrasonic scalpel. The Glissonian pedicles were dissected for segments 2/3 from ventral to dorsal. The hepatic parenchyma was dissected along the left side of the falciform ligament and along the UFV within the hepatic parenchyma to identify the root of the left hepatic vein. Finally, the left hepatic vein was transected using a stapler. Specifically, in the LLLS, we leveraged the enhanced visualization of laparoscopy to meticulously dissect the Glissonian pedicle for segments 2/3 using the LTH approach. Additionally, we utilized UFV as a guide for dissecting branch hepatic veins to control the hemorrhage. The case patient had no perioperative complications despite not undergoing the CLCVP technique.

The surgical approach demonstrated improved precision and better control of intraoperative bleeding than conventional LLLS². The operation time was 120 min with 50 ml blood loss, which was better than that in previously reported cases^11,12,13. Van der Poel et al.¹¹, Darnis B et al.¹², and Chong Y et al.¹³ reported 200, 84, and 672 cases of laparoscopic liver resection, respectively. The average operation times were 144, 189, and 155 min, with 100, 100, and 80 ml blood loss, respectively. The advantages of our technique are as follows: First, it avoids hepatic hilum dissection. Second, during liver parenchymal dissection, utilizing the intrahepatic anatomical landmark of the UFV as a guide prevented the loss of direction.

The initial critical step of this procedure was to isolate the Glissonian pedicle for segments 2/3 via LTH. Xie et al. reported the clinical efficacy of the LTH approach in various hepatectomies, including left lateral sectionectomy, left hemihepatectomy, middle hepatic lobe resection, and right triple hepatectomy, affirming its safety, efficacy, simplicity, and favorable short-term outcomes⁶. Similarly, Zheng et al. demonstrated the feasibility and effectiveness of the LTH approach in laparoscopic anatomic segmentectomy IV¹⁴. The key to this approach is to first utilize the LTH as an anatomical landmark to dissect and ligate the Glissionian pedicle of segments 2/3 outside the liver. This approach offers the advantage of preventing dissection of the first hepatic hilum, thereby reducing the risk of bile duct injury and bleeding, particularly in patients with a history of hepatobiliary surgery or intraoperative hepatic hilum adhesions. Meanwhile, the hepatic hilum may not be blocked, thereby reducing ischemia-reperfusion injury to the liver¹⁵.

During hepatectomy within the liver parenchyma, the surgical approach presented here was guided by the UFV. The UFV is a hepatic vein that travels within the umbilical fissure (or its vicinity) and provides venous drainage for liver segments 3 and 4. It is a crucial surgical landmark that should be preserved during left external lobectomy and right triple hepatectomy to avoid residual hepatic parenchyma congestion^16,17. Utilizing Glisson prioritization and navigating with intrahepatic anatomical landmarks, including the UFV, in combined laparoscopic segmental hepatectomy (S3 and S4b) has been proposed to be feasible and effective^18,19. This approach offers the advantage of achieving the benefits of anatomical hepatectomy while optimizing the postoperative hepatic functional reserve. In our protocol, early identification of the UFV and anatomical resection along the UFV plane minimized the risk of injury to the returning hepatic veins, even without CLCVP. Furthermore, dissection along the UFV prevented the loss of direction during parenchymal dissection and facilitated localization of the root of the left hepatic vein, which ultimately requires dissection.

Nevertheless, these surgical procedures have some inherent limitations. First, in cases involving variations in the UFV, the hepatic parenchyma cannot be separated along the UFV during intrahepatic dissection. Second, this was a complex case of left extrahepatic lobe choledocholithiasis in which the bile duct could not be separated from the UFV owing to severe adhesion of the duct to the UFV.

In summary, we presented an LLLS guided by LTH for the dissection of the Glissonian pedicle for segments 2/3, followed by hepatic parenchymal dissection along the UFV while approaching the left hepatic vein root. LTH- and UFV-guided LLLS effectively control intraoperative bleeding even without CLCVP, suggesting its potential benefit beyond patients with cardiovascular/cerebrovascular conditions, and is widely applicable to all LLLS cases.

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
30° high-definition laparoscopic device	KARL STORZ,Germany	26606BCA/ACA	New 3D Electronic Laparoscope
Bipolar electrocoagulation	KANGJI, China	KJ-XRH05Q	Electrocoagulation for hemostasis
Ceftazidime	Zhejiang Jutai Pharmaceutical Co.,China	(China) Drug Administration Code (DAC)H20033369	usage: 1.0 g, intravenous drip
Computed Tomography (CT)	Siemens, Germany	SOMATOM Force	Force is a 96-row dual-source CT scanner that revolutionizes a series of imaging chains including the tube, high-voltage generator, detector, data acquisition system, and reconstruction system, opening up a new era of CT imaging and achieving faster, wider, thinner, more capable, and lower radiation dose.
Echelon Flex Endopath Stapler	Ethicon	EC60A	Manual stapler that compresses tissue while it simultaneously lays down a staple line and transects the tissue, 60 mm Stapler (Standard), Size 60 mm, Length 34 cm
Harmonic ACE+7 Shears	Ethicon	HARH36	Curved tip, energy sealing and dissecting, diameter 5 mm, length 36 cm
Hem-o-lok Clips L	Weck Surgical Instruments, Teleflex Medical, Durham, NC	544240	Vascular clip 5–13 mm Size Range
Hem-o-lok Clips ML	Weck Surgical Instruments, Teleflex Medical, Durham, NC	544230	Vascular clip 3–10 mm Size Range
Indocyanine Green(ICG)	Dandong Medical Creation Pharmaceutical Co., Ltd.	H20055881	25 mg/vial, Detecting liver reserve function
Liver function reserve analyzer	Shanghai Optoelectronic Medical Electronic Instruments Co., Ltd	DDG3300K	A medical instrument that detects and analyzes indocyanine green (ICG) injected into the body based on spectroscopic analysis techniques.
Magnetic resonance imaging (MRI)	GE company,American	Signa Hoxt 3.0T MRI,JB00988XC	provides 360-degrees of coil coverage, RF technology, and a direct digital interface with more channels. Patient-friendly design maximizes comfort and system utility, accommodating all types of patients and sizes with feet-first imaging.