Laparoscopic Anatomical Resection of the Right Anterior Lobe Based on the Laennec Capsule Technique

To begin access the surgical site and fully mobilize the right liver ligaments. Then use intraoperative ultrasound to determine tumor boundaries and visualize the hepatic veins, portal veins, bile ducts, and hepatic arteries. Place the high frequency ultrasound probe at appropriate liver regions to assess tumor size, shape, and its anatomical relationships.

Now mark the resection margins on the liver surface using electrocautery. Use color doppler ultrasound to assess blood flow in hepatic veins, portal veins and hepatic arteries for accurate structure identification and injury prevention. Monitor the tumor's vascularity and proximity to major blood vessels in real time using imaging.

Next, apply the Pringle maneuver using a vascular tape to occlude the hepatoduodenal ligament and maintain the occlusion in 15 minute intervals followed by five minute reperfusion periods. To separate the right anterior Glissonian pedicle using Laennec's membrane and bluntly separate the left edge of the gallbladder plate from the root of the Glissons pedicle at Gate 4. Now, separate the right edge of the gallbladder plate above the Rouviere's groove at Gate 5 and dissect the right anterior lobe which includes segments 5 and 8 along the line connecting Gate 4 and Gate 5.

Expose the gallbladder to dissect it using an ultrasonic scalpel. Then set the ultrasonic scalpel to an appropriate frequency and power level. Use it to separate the gallbladder from the liver bed, simultaneously cutting tissue and sealing small blood vessels to reduce bleeding.

Now carefully isolate the cystic duct and cystic artery. Divide both using the ultrasonic scalpel and secure any bleeding vessels with clips. Once the gallbladder is completely detached, remove it from the abdominal cavity through the incision.

After removing the gallbladder, perform another intraoperative ultrasound to identify and mark the tumor boundaries and the surface projections of the middle hepatic vein, right hepatic vein, and right anterior liver pedicle. Then use ICG mediated near-infrared imaging to confirm the tumor margins. Occlude the right anterior liver pedicle using a 7-0 suture to stop blood flow to segments 5 and 8.

Then inject 0.5 to one milligram per kilogram of ICG intravenously about 15 to 30 minutes before the resection begins. During surgery, visualize ICG uptake using a near-infrared fluorescence camera. Observe that the right anterior lobe shows no fluorescence, clearly defining the resection boundary.

Now incise the liver capsule along the middle hepatic veins course and identify small hepatic vein branches. Use non-energy instruments like forceps and suction to separate tissue along the plane between Laennec's capsule and the vein, then clamp and cut the veins on the resection side. Transect the liver parenchyma with an ultrasonic scalpel.

Continue separating the tumor using laparoscopic dissecting forceps. Dissect along the cephalic side of the middle hepatic vein until both the right and middle hepatic vein roots are fully exposed. Dissect tissue around the right anterior hepatic pedicle and transect it with a stapler before transecting the liver parenchyma between the right anterior and posterior lobes.

Confirm that the tumor remains closely adherent to the right hepatic vein but does not invade it. Then using blunt dissection and suction, separate the tumor from the right hepatic vein along Laennec's capsule. Clamp tributary veins on the resection side and use an energy device to complete liver transection.

Finish the right anterior lobe resection, preserving both hepatic veins and place the resected liver specimen in a sterile bag. Now irrigate the abdominal cavity with sterile distilled water and inspect the surgical site for bleeding, bile leaks, or gastrointestinal injury before placing drains at the liver cut surface and gallbladder fossa. The surgery was completed in 240 minutes with 200 milliliters of intraoperative blood loss, and the patient showed recovery signs within 24 hours by passing gas and starting a liquid diet after one day.

The patient had no postoperative complications such as bleeding, bile leakage, abdominal infection, or incision infection, and was discharged after seven days. Histopathological examination confirmed moderately to poorly differentiated hepatocellular carcinoma with 76%tumor necrosis and clear resection margins. Six month follow-up using liver function tests and CT scans showed no signs of tumor recurrence.