Laparoscopic Anatomical Right Hemihepatectomy via the In Situ Anterior Approach

This case involved a patient with a giant hepatic cavernous hemangioma, which was successfully removed by laparoscopic anatomical right hemihepatectomy via the in situ anterior approach, and the patient recovered well after surgery. This video demonstrates a technique that offers a safer and more precise anatomical anterior approach to laparoscopic hemihepatectomy. The solitary hemangioma in the right hepatic lobe demonstrated expansive growth, compressing the hepatic pedicles and abutting the inferior vena cava, while partially encircling the middle hepatic vein root, resulting in a high risk of surgical bleeding.

Long-term follow-up serves two primary purposes. To validate the anatomical success of the procedure, including complete resection with patent vasculature, and to ensure normal physiological function of the remnant liver, such as adequate regeneration without complications. Currently, the patient is progressing favorably in all aspects.

Laparoscopic anatomical right hemihepatectomy via the in situ anterior approach demonstrates significant advantages in treating giant hepatic hemangiomas. Precisely defining the hilar structures and transection plane ensures complete resection while avoiding tumor injury caused by manipulation, thereby reducing complications and shortening recovery time. To begin, the gallbladder triangle was dissected.

The cystic artery and cystic duct were ligated and dissected. The gallbladder was then dissected from the fundus downward, and the right hepatic hilar plate was lowered through the gallbladder bed approach to expose the right anterior hepatic pedicle. Then, the left and right caudate lobes were split anterior to the inferior vena cava.

A part of the short hepatic veins was transected. The caudate process was then divided longitudinally, and the Glisson pedicle of segment 1C was transected. This exposure revealed the right posterior hepatic pedicle.

Next, the right anterior and posterior hepatic pedicles were bluntly dissected. Using silk sutures, both pedicles were suspended. After confirming the integrity of the structures, a laparoscopic, non-crushing vascular clamp was used to clip the pedicles.

Ischemic demarcation lines were then observed and marked on the liver surface. After that, an intermittent Pringles maneuver was performed using cycles of 15-minute occlusion followed by five-minute reperfusion. The liver parenchyma was then transected along the ischemic demarcation line using an ultrasonic surgical device.

A middle hepatic vein branch was identified at the liver base during intraoperative exploration. This branch was carefully traced to anatomical landmark B.After controlled transection of the right anterior middle hepatic vein tributary, the parenchyma was systematically dissected along the middle hepatic vein axis. The transection plane was maintained in direct alignment with the course of the middle hepatic vein, extending precisely toward its root at the inferior vena cava.

After completing the parenchymal transection, the right hepatic pedicle was meticulously dissected to achieve full circumferential exposure. It was then securely transected using a vascular linear stapler. The liver parenchyma was carefully dissected in a cephalad and dorsal direction along the anterior surface of the inferior vena cava.

The short hepatic veins and Makuuchi's ligament were systematically transected to expose the root of the right hepatic vein. The right hepatic vein was then securely transected using a vascular linear stapling device. Then, the right hepatic lobe was completely mobilized and resected along the predetermined transection plane.

The resected specimen was carefully placed into an endoscopic retrieval bag. The resection surface was meticulously inspected and definitive hemostasis was achieved through systematic coagulation and compression. Follow-up liver-computed tomography showed normal vascularization and venous drainage of the left lobe after resection of the hepatic cavernous hemangioma.