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, including shorter postoperative recovery, fewer complications, maximal preservation of healthy liver parenchyma, and complete tumor removal, critical for HCC patients. Additionally, it enables complete excision of the tumor-bearing portal venous territory, reducing recurrence risk and improving long-term survival, compared with non-anatomical resection⁴.

Right anterior sectionectomy, involving resection of segments V and VIII, is a central hepatic procedure that engages major branches of the middle hepatic vein (MHV), right hepatic vein (RHV), and the right anterior hepatic pedicle (AP). Laparoscopic anatomical right anterior sectionectomy presents three main challenges: hemorrhage control during parenchymal transection and exposure of the trunks of MHV and RHV, optimal management of the AP, and precise control of the hepatic transection plane to ensure a wide tumor margin^2,5.

Currently, three primary approaches are used in right anterior sectionectomy⁶. First is the parenchymal-first approach: dissecting hepatic parenchyma before identifying vascular and biliary structures, which has a higher bleeding risk⁷. Second is the hepatic vein-first approach: it involves early control of hepatic veins, but requiring advanced anatomical dissection skills⁸. Third is the Glissonean pedicle-first approach: isolating and controlling the target Glissonean pedicle first, then transecting the parenchyma along the ischemic demarcation line^9,10.

This article presents our center's standardized protocol for applying Glissonean pedicle-first approach guided by Laennec's membrane and the "Gate" theory^11,12. Integrated with intraoperative ultrasonography and controlled low central venous pressure (CLCVP), this technique aims to simplify workflow, minimize blood loss, secure safe margins, and reduce the risk of portal vein dissemination in HCC¹³. However, this approach is not recommended when tumors compress the first porta hepatis or invade the bile duct or vascular branches. Under such circumstances, to mitigate the risks of iatrogenic tumor dissemination, such as hematogenous spread due to intraoperative compression or peritoneal seeding from tumor rupture, alternative strategies should be employed. These include liver parenchyma-first dissection or intra-Glissonean sheath dissection, rather than the extra-Glissonean sheath dissection and "Gate" theory-based strategy described in our protocol.

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 duct, and no distant metastasis.
3. Anatomical variants: Portal pedicles of segment 6 or 7 not originating from the AP.

2. Patient introduction

1. Note that the patient has a long-standing history of hepatitis B and received antiviral therapy starting 1 week preoperatively. Confirm Child-Pugh A liver function and a 15 min indocyanine green (ICG) retention rate of < 10%.
2. Perform preoperative three-dimensional (3D) reconstruction. Calculate a standard liver volume (SLV) of 1079 mL. Estimate the future liver remnant (FLR) volume as 724 mL following right anterior sectionectomy with preservation of both the RHV and MHV, yielding an FLR/SLV ratio of 67.1%.

3. Surgical technique

1. Patient positioning: Position the patient supine with legs apart, and elevate the right torso at 45°. Suspend and secure the right upper limb. Ensure the primary surgeon stands on the patient's right, the first assistant on the left, and the second assistant between the legs.
2. Trocar placement: Make a skin incision below the umbilicus to establish pneumoperitoneum, and insert a 10 mm Trocar here as the observation port. Additionally, make skin incisions at the following sites respectively: 5 cm above the umbilicus on the right midaxillary line, below the costal margin on the right anterior axillary line, below the xiphoid process, and slightly left of the midpoint of the line connecting the umbilicus and xiphoid process. Insert 12 mm, 5 mm, 12 mm, and 5 mm Trocars at these incisions as working ports (Figure 1).
3. Abdominal exploration: Perform diagnostic laparoscopy and confirm that the tumors are located at the right anterior section, with no distant metastases in the left hemiliver or the upper/lower abdomen.
4. Cholecystectomy: Begin the retrograde dissection of the gallbladder bed from the base. Clearly expose Calot's triangle, and carefully isolate the cystic artery and duct. Before clipping and dividing these structures with Hemo-lock clips, confirm the anatomical relationships between the cystic duct, common bile duct, and hepatic duct.
5. Liver mobilization: Divide the round and falciform ligaments. Then, expose and lower the second hepatic hilum to access the caval fossa. Next, dissect the hepatorenal, right triangular, and right coronary ligaments to fully mobilize the right liver.
6. Hepatic inflow occlusion: Use a 16-Fr Foley catheter to perform the Pringle maneuver for effective hepatic inflow control.
7. Anterior pedicle dissection: Perform an anatomical right anterior sectionectomy using a pedicle-first approach. Lower the hilar plate along the Laennec's capsule, then dissect the anterior pedicle (AP) extrafascially. Using the "Gate" theory as a guide, connect Gates IV and V, then ligate the pedicle (Figure 2A,B). Establish an ischemic demarcation to define the right anterior section.
8. Resection plane marking and adjustment: Mark the ischemic boundary on the liver surface. Confirm alignment of the left resection plane with the trunk of MHV by intraoperative ultrasound, ensuring an adequate left tumor margin (Figure 3A,B).
   NOTE: As the right ischemic plane does not fully encompass the tumor, ultrasound-guided localization of the trunk of RHV is used to adjust the right resection plane, securing a safe tumor margin.
9. Liver parenchyma transection: Incise the liver parenchyma along the left marked line using an ultrasonic scalpel. Expose the MHV trunk at point B and divide the ventral hepatic vein branches of segment 5 (V5v). Continue the incision cephalad under the guidance of preoperative 3D reconstruction to address the V5v and ventral hepatic vein branches of segment 8 (V8v) (Figure 3C-F). Incise the right resection plane to fully expose the anterior pedicle (AP) (Figure 4A). Divide the AP using a cutting stapler while preserving the RHV trunk within the "APR triangle"¹⁴. Following the trunk of RHV from cephalad and caudad directions, then manage the dorsal venous branches of the right anterior section (Figure 4B-F). Fully expose the vein trunk to ensure a wide right tumor margin (Figure 4G, H). Completely resect the right anterior section, including the tumor.
10. Specimen retrieval and hemostasis: Place the liver specimen and gallbladder into a specimen bag and extract them through an extended sub-umbilical incision. Suture the incision, then re-establish pneumoperitoneum. Use bipolar coagulation to achieve meticulous hemostasis of the liver cut surface. After confirming the absence of bleeding or bile leakage, place drainage tubes at the foramen of Winslow and along the liver transection surface. Close all incisions to complete the procedure.
11. Specimen inspection: Verify that the specimen has negative margins. Inspect the tumor capsule to confirm its integrity. Ensure the distance from the tumor to the resection margin exceeds 1 cm (Figure 5).

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.