Laparoscopic Anatomical Right Anterior Sectionectomy with a Hepatic Pedicle-first Approach: Technical Details and Representative Case Illustration

Summary

This article aims to present a novel Laennec's capsule-guided laparoscopic approach for right anterior sectionectomy, highlighting its potential to improve safety, precision, and reproducibility in complex liver resections.

Abstract

Laparoscopic anatomical right anterior sectionectomy remains technically demanding due to intricate hepatic anatomy and the need to preserve segmental portal inflow and outflow during resection. Key challenges include intraoperative hemostasis, prevention of bile leakage, and lack of standardized approaches across segments. The hepatic pedicle-first technique offers a promising solution to simplify the procedure and reduce risks. This article presents a clinical case to illustrate our institutional approach, which involves lowering the hepatic portal plate along Laennec's capsule, then extra-capsularly dissecting and ligating the right anterior pedicle (AP) to create an ischemic demarcation in its drainage territory. The left transection plane follows preoperative planning with precise ligation of the middle hepatic vein (MHV) branches. For tumors near the dorsal of the right anterior section, intraoperative ultrasonography refines the right transection along the right hepatic vein (RHV) plane, exposing the entire RHV to ensure a wide margin. The innovations for this approach include: (1) Laennec's capsule and "portal" theory-guided resection, simplifying steps and reducing cancer spread via excision of the tumor-bearing portal territory; (2) intraoperative ultrasonography for dynamic transection plane adjustment, ensuring precision and margin adequacy. This case presentation demonstrates the potential of the approach to enhance safety and efficacy in laparoscopic right anterior sectionectomy and highlights its feasibility as a reproducible framework for complex hepatic surgeries.

Introduction

Anatomical liver resection (ALR) is widely regarded as a safe and effective procedure for hepatocellular carcinoma (HCC)¹. Central hepatectomy remains highly challenging in minimally invasive surgery, due to the complex hepatic anatomy and the requirement for preserving segmental portal inflow and outflow during resection². Despite advancements in surgical techniques and instruments expanding their application, intraoperative hemostasis and prevention of complications like bile leakage remain key hurdles³.

Laparoscopic anatomical resection offers distinct advantages, in....

Protocol

This protocol adhered to the ethical guidelines of Zhuzhou Hospital Affiliated with Xiang Ya Medical College, and written informed consent was obtained from patients for the publication of this article and associated video materials.

NOTE: The list of materials and instruments, including their specifications, is presented in the Table of Materials.

1. Patient selection

1. Select patients with hepatocellular carcinoma (HCC) located in the right anterior section of the liver.
2. Ensure that these patients have no invasion of the portal vein, hepatic vein, or bile du....

Results

Intraoperative details
The procedure lasted 150 min, with four intermittent Pringle maneuver occlusions totaling 70 min. Intraoperative blood loss was 50 mL (Table 1).

Postoperative Management and Follow-Up
Postoperatively, the patient received hepatoprotective therapy, antibiotics, intravenous fluid resuscitation, and albumin supplementation. A computed tomography (CT) scan on postoperative day 5 revealed no significant peritoneal eff.......

Discussion

Currently, three primary approaches are employed for right anterior sectionectomy⁶. Firstly, parenchymal-first approach: dissecting hepatic parenchyma before identifying vascular and biliary structures, which carries a higher bleeding risk⁷. Secondly, hepatic vein-first approach: involving early exposure and control of hepatic veins, suitable for tumors adjacent to major veins but demanding advanced anatomical dissection skills

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
3D reconstruction software	United Imaging	uSurgiPlan Abdomen 200	3D reconstruction of liver and surgical planning
Absorbable Hemostat (SURGICEL SNOW)	Ethicon	2082	Oxidized regenerated cellulose hemostatic agent.
Electrosurgical Unit	Covidien	Force FX-8C	High-frequency electrosurgical generator for cutting and coagulation.
Endo-GlA stapler	Golden Stapler Surgical	EC-160	Disposable laparoscopic stapler for tissue transection and stapling
Hem-o-lok	Changzhou Kefeng Medical Technology	ZJS ZJM ZJL	Single-use clip cartridge for vessel/tissue ligation
Insufflator	OLYMPUS	UHI-4	Used to create pneumoperitoneum during laparoscopic surgery
Laparoscopic system / Video system	OLYMPUS	OTV-S300	Video processor and light source system for laparoscopic visualization.
Leparoscopic ultrasound	BK Medica	BK2300	High-resolution ultrasound system for intraoperative imaging.
Non-absorbable Suture (Prolene)	Ethicon	W8556	5-0 polypropylene suture, 17mm RB-1 needle, 90 cm, non-absorbable.
Non-absorbable Suture (Surgipro II)	Covidien	VP-521-X	4-0 monofilament polypropylene suture, 26mm V-20 taper needle, 90 cm.
Ultrasonic Surgical System	Mindray	UP700	Ultrasonic energy system for tissue dissection and hemostasis in surgery.