Name: Laparoscopic Anatomical Right Hemihepatectomy via the In Situ Anterior Approach (Video) | JoVE Journal
Uploaded: 2025-08-08T14:45:00.000+00:00
Duration: 5 min 30 s
Description: Learn laparoscopic anatomical right hemihepatectomy via the in situ anterior approach for giant hepatic cavernous hemangiomas. This technique minimizes bleeding risks and ensures precise anatomical resection with favorable recovery outcomes.

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5 minutes

This study protocol complied with the ethical requirements of the Medical Ethics Committee of the People&#39;s Hospital of Ningxia Hui Autonomous Region, and written informed consent was obtained from the participant.
1. Pre-surgical steps
<ol>
	<li>Induce general anesthesia following institutional protocols, then perform endotracheal intubation.</li>
	<li>Position the patient supine with legs abducted. Elevate the right hepatic region approximately 30&#176; using a bolster.</li>
	<li>Employ a five-trocar technique.
	<ol>
		<li>Make a 2-cm incision slightly superior and to the right of the umbilicus to establish pneumoperitoneum, then place a 12-mm trocar and insert a 30&#176; laparoscope.</li>
		<li>Place additional trocars as follows: a 12-mm trocar 2 cm below the xiphoid process, a 5-mm trocar 5 cm above the umbilicus on the anterior midline, and a 5-mm trocar 6 cm below the right costal margin along the midclavicular line.</li>
		<li>Finally, insert a 5-mm trocar at the 9th intercostal space along the right anterior axillary line.</li>
	</ol>
	</li>
	<li>Position the surgical team.
	<ol>
		<li>Position the monitor at the head of the patient; have the surgeon stand on the patient&#39;s right side holding a suction device in the left hand for aspiration and exposure assistance while using an ultrasonic scalpel in the dominant hand to transect the liver parenchyma.</li>
		<li>Position the first assistant on the patient&#39;s left side to operate instruments such as dissecting forceps, bipolar electrocautery, or a suction device, and place the laparoscope operator between the patient&#39;s lower limbs.</li>
	</ol>
	</li>
</ol>
2. Main steps of surgery
<ol>
	<li>Dissect the gallbladder triangle and ligate and dissect the cystic artery and cystic duct. Then dissect the gallbladder from the fundus downward, and lower the right hepatic hilar plate through the gallbladder bed approach to expose the right anterior hepatic pedicle.</li>
	<li>Split the left and right caudate lobes anterior to the inferior vena cava; transect part of the short hepatic veins; divide the caudate process longitudinally; transect the Glisson pedicle of segment 1c (G1c); then expose the right posterior hepatic pedicle.</li>
	<li>Bluntly dissect the right anterior and posterior hepatic pedicles; suspend them with silk sutures; after confirming structural integrity, clip the pedicles using a laparoscopic non-crushing vascular clamp (Figure 2A); then observe and mark ischemic demarcation lines on the liver surface (Figure 2B).</li>
	<li>Perform intermittent Pringle&#39;s maneuver with 15 min occlusion and 5 min reperfusion cycles. Transect the parenchyma along the ischemic demarcation line using an ultrasonic surgical device (Figure 2C).</li>
	<li>Identify a middle hepatic vein (MHV) branch at the liver base during intraoperative exploration; carefully trace it to anatomical landmark B (Figure 2D). After controlled transection of the right anterior MHV tributary, systematically dissect the parenchyma along the MHV axis. Maintain the transection plane in direct alignment with the MHV course, extending precisely toward its root at the inferior vena cava (Figure 2E).</li>
	<li>After completing parenchymal transection, meticulously dissect the right hepatic pedicle to achieve full circumferential exposure; then, securely transect it using a vascular linear stapler. (Figure 2F).</li>
	<li>Carefully dissect the liver parenchyma cephalad and dorsally along the anterior surface of the inferior vena cava (IVC) (Figure 2G). Systematically transect the short hepatic veins and Makuuchi&#39;s ligament to fully expose the right hepatic vein (RHV) root (Figure 2H). Then, securely transect the RHV using a vascular linear stapling device (Figure 2I).</li>
	<li>Completely mobilize and resect the right hepatic lobe along the predetermined transection plane. Carefully place the surgical specimen in an endoscopic retrieval bag. Meticulously inspect the resection surface and achieve definitive hemostasis through systematic coagulation and compression.</li>
</ol>
3. Postoperative management
<ol>
	<li>Stain specimens of liver-occupying lesions with Hematoxylin and Eosin (HE) for pathological diagnosis confirmation.</li>
	<li>Provide liver protection, infection prevention, and stress ulcer prevention.</li>
	<li>Review complete blood count, hepatic and renal function panels, and coagulation profiles on postoperative days 1, 3, 5, 7, and 10.</li>
	<li>Remove the urinary catheter on postoperative day 1; initiate ambulation; advance diet to clear liquids.</li>
	<li>Perform non-contrast CT of the thorax and abdomen on postoperative day 5.</li>
	<li>Perform contrast-enhanced CT of the liver and remove the abdominal drain on postoperative day 10.</li>
</ol>

<ol><li>Chen, X., Zhang, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Review+and+prospect+of+laparoscopic+liver+cancer+surgery+in+China+in+the+past+20+years%5BTitle%5D)+AND+%22Chin+J+Gen+Oper+Surg%22%5BJournal%5D)">Review and prospect of laparoscopic liver cancer surgery in China in the past 20 years.</a> Chin J Gen Oper Surg. 15 (4), 355-358 (2021).</li>
<li>Yoshida, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Current+status+of+laparoscopic+hepatectomy%5BTitle%5D)+AND+%22J+Nippon+Med+Sch%22%5BJournal%5D)">Current status of laparoscopic hepatectomy.</a> J Nippon Med Sch. 86 (4), 201-206 (2019).</li>
<li>Zhu, J., Hu, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+research+status+of+laparoscopic+hepatectomy%5BTitle%5D)+AND+%22J+Lap+Surg%22%5BJournal%5D)">Clinical research status of laparoscopic hepatectomy.</a> J Lap Surg. 26 (12), 881-884 (2021).</li>
<li>Ban, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+difficulty+of+laparoscopic+liver+resection%5BTitle%5D)+AND+%22Updates+Surg%22%5BJournal%5D)">The difficulty of laparoscopic liver resection.</a> Updates Surg. 67 (2), 123-128 (2015).</li>
<li>Ban, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+novel+difficulty+scoring+system+for+laparoscopic+liver+resection%5BTitle%5D)+AND+%22J+Hepatobiliary+Pancreat+Sci%22%5BJournal%5D)">A novel difficulty scoring system for laparoscopic liver resection.</a> J Hepatobiliary Pancreat Sci. 21 (10), 745-753 (2014).</li>
<li>Yu, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Safety+and+feasibility+of+laparoscopy+technology+in+right+hemihepatectomy%5BTitle%5D)+AND+%22Sci+Rep%22%5BJournal%5D)">Safety and feasibility of laparoscopy technology in right hemihepatectomy.</a> Sci Rep. 9 (1), 18809(2019).</li>
<li>Hu, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laennec%27s+approach+for+laparoscopic+anatomical+hemihepatectomy%5BTitle%5D)+AND+%22World+J+Surg+Oncol%22%5BJournal%5D)">Laennec's approach for laparoscopic anatomical hemihepatectomy.</a> World J Surg Oncol. 19 (1), 295(2021).</li>
<li>Chen, Y., Chen, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Technical+essentials+of+laparoscopic+right+hemihepatectomy%3A+standardization+of+surgical+procedures%5BTitle%5D)+AND+%22Chin+J+Pract+Surg%22%5BJournal%5D)">Technical essentials of laparoscopic right hemihepatectomy: standardization of surgical procedures.</a> Chin J Pract Surg. 37 (5), 481-485 (2017).</li>
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<li>Wang, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Safety+and+effectiveness+of+laparoscopic+intratumoral+resection+facilitated+by+coagulation+of+giant+hepatic+hemangioma%3A+a+matched+casecontrol+study+and+literature+review%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Safety and effectiveness of laparoscopic intratumoral resection facilitated by coagulation of giant hepatic hemangioma: a matched casecontrol study and literature review.</a> Surg Endosc. 36 (7), 5149-5159 (2022).</li>
<li>Aziz, H., Brown, Z. J., Baghdadi, A., Kamel, I. R., Pawlik, T. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+comprehensive+review+of+hepatic+hemangioma+management%5BTitle%5D)+AND+%22J+Gastrointest+Surg%22%5BJournal%5D)">A comprehensive review of hepatic hemangioma management.</a> J Gastrointest Surg. 26 (9), 1998-2007 (2022).</li>
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<li>Donati, M., Stavrou, G. A., Donati, A., Oldhafer, K. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+risk+of+spontaneous+rupture+of+liver+hemangiomas%3A+a+critical+review+of+the+literature%5BTitle%5D)+AND+%22J+Hepatobiliary+Pancreat+Sci%22%5BJournal%5D)">The risk of spontaneous rupture of liver hemangiomas: a critical review of the literature.</a> J Hepatobiliary Pancreat Sci. 18 (6), 797-805 (2011).</li>
<li>Ibrahim, A. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Giant+sclerosing+hepatic+hemangioma+presenting+as+BornmanTerblancheBlumgart+syndrome%3A+a+case+report+and+review+of+the+literature%5BTitle%5D)+AND+%22Med+Arch%22%5BJournal%5D)">Giant sclerosing hepatic hemangioma presenting as BornmanTerblancheBlumgart syndrome: a case report and review of the literature.</a> Med Arch. 77 (4), 314-318 (2023).</li>
<li>Xia, F., Li, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Multidisciplinary+expert+consensus+on+the+diagnosis+and+treatment+of+hepatic+hemangioma+%282019+edition%29%5BTitle%5D)+AND+%22Chin+J+Pract+Surg%22%5BJournal%5D)">Multidisciplinary expert consensus on the diagnosis and treatment of hepatic hemangioma (2019 edition).</a> Chin J Pract Surg. 39 (8), 761-765 (2019).</li>
<li>Nguyen, K. T., Gamblin, T. C., Geller, D. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((World+review+of+laparoscopic+liver+resection2%2C804+patients%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">World review of laparoscopic liver resection2,804 patients.</a> Ann Surg. 250 (5), 831-841 (2009).</li>
<li>Martin, R. C., Scoggins, C. R., McMasters, K. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+hepatic+lobectomy%3A+advantages+of+a+minimally+invasive+approach%5BTitle%5D)+AND+%22J+Am+Coll+Surg%22%5BJournal%5D)">Laparoscopic hepatic lobectomy: advantages of a minimally invasive approach.</a> J Am Coll Surg. 210 (5), 627-634 (2010).</li>
<li>Jinhuan, Y., Gang, D., Binyao, S., Huan, M., Bin, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Is+laparoscopic+hepatectomy+suitable+for+giant+hepatic+hemangioma+larger+than+1+in+diameter%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Is laparoscopic hepatectomy suitable for giant hepatic hemangioma larger than 1 in diameter.</a> Surg Endosc. 34 (3), 1224-1230 (2020).</li>
<li>Liu, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Location+affects+the+management+of+liver+haemangioma%3A+a+retrospective+cohort+study%5BTitle%5D)+AND+%22Int+J+Surg%22%5BJournal%5D)">Location affects the management of liver haemangioma: a retrospective cohort study.</a> Int J Surg. 48, 110-115 (2017).</li>
<li>Sunakawa, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Deep+learningbased+automatic+bleeding+recognition+during+liver+resection+in+laparoscopic+hepatectomy%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Deep learningbased automatic bleeding recognition during liver resection in laparoscopic hepatectomy.</a> Surg Endosc. 38 (12), 7656-7662 (2024).</li>
<li>Zheng, S., Kuang, Y., Zheng, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+key+techniques+to+ensure+the+safety+of+laparoscopic+liver+surgery%5BTitle%5D)+AND+%22Chin+J+Pract+Surg%22%5BJournal%5D)">The key techniques to ensure the safety of laparoscopic liver surgery.</a> Chin J Pract Surg. 45 (1), 75-79 (2025).</li>
<li>Xiao, L., Zhou, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Recognition+of+liver+membrane+structure+and+its+application+in+laparoscopic+hepatectomy%5BTitle%5D)+AND+%22Chin+J+Gen+Surg%22%5BJournal%5D)">Recognition of liver membrane structure and its application in laparoscopic hepatectomy.</a> Chin J Gen Surg. 31 (1), 1-7 (2022).</li>
<li>Liu, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+hepatectomy+produces+better+outcomes+for+hepatolithiasis+than+open+hepatectomy%3A+an+updated+systematic+review+and+metaanalysis%5BTitle%5D)+AND+%22Int+J+Surg%22%5BJournal%5D)">Laparoscopic hepatectomy produces better outcomes for hepatolithiasis than open hepatectomy: an updated systematic review and metaanalysis.</a> Int J Surg. 51 (10), 151-163 (2018).</li>
<li>Yang, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Application+and+prospect+of+%26%2334%3Bgate+theory%26%2334%3B+in+minimally+invasive+anatomical+hepatectomy%5BTitle%5D)+AND+%22Chin+J+Pract+Surg%22%5BJournal%5D)">Application and prospect of &#34;gate theory&#34; in minimally invasive anatomical hepatectomy.</a> Chin J Pract Surg. 44 (3), 341-345 (2024).</li>
<li>Kasai, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+versus+open+major+hepatectomy%3A+a+systematic+review+and+metaanalysis+of+individual+patient+data%5BTitle%5D)+AND+%22Surgery%22%5BJournal%5D)">Laparoscopic versus open major hepatectomy: a systematic review and metaanalysis of individual patient data.</a> Surgery. 163 (5), 985-995 (2018).</li>
<li>Zheng, B., Zheng, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Current+status+and+thinking+of+laparoscopic+anatomical+hepatectomy+for+hepatocellular+carcinoma%5BTitle%5D)+AND+%22Electron+J+Liver+Cancer%22%5BJournal%5D)">Current status and thinking of laparoscopic anatomical hepatectomy for hepatocellular carcinoma.</a> Electron J Liver Cancer. 8 (4), 1-5 (2021).</li>
<li>Liao, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+anatomical+versus+nonanatomical+hepatectomy+in+the+treatment+of+hepatocellular+carcinoma%3A+a+randomised+controlled+trial%5BTitle%5D)+AND+%22Int+J+Surg%22%5BJournal%5D)">Laparoscopic anatomical versus nonanatomical hepatectomy in the treatment of hepatocellular carcinoma: a randomised controlled trial.</a> Int J Surg. 102, 106652(2022).</li>
<li>Zheng, S., Wang, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Risk+factors+and+strategies+for+intraoperative+bleeding+in+laparoscopic+hepatectomy%5BTitle%5D)+AND+%22Chin+J+Pract+Surg%22%5BJournal%5D)">Risk factors and strategies for intraoperative bleeding in laparoscopic hepatectomy.</a> Chin J Pract Surg. 42 (9), 970-974 (2022).</li>
<li>Chen, Y., Zhou, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Attention+should+be+paid+to+the+safety+of+laparoscopic+hepatectomy%5BTitle%5D)+AND+%22Chin+J+Pract+Surg%22%5BJournal%5D)">Attention should be paid to the safety of laparoscopic hepatectomy.</a> Chin J Pract Surg. 42 (9), 965-969 (2022).</li>
<li>Chinese expert consensus on procedures and technical standards for laparoscopic anatomic liver resection (2023 edition). <a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=%22Chin+J+Digest+Surg%22">Chin J Digest Surg</a>. 22 (7), Hepatobiliary and Pancreatic Surgery Committee of the Chinese Association of Research Hospitals. 810-823 (2023).</li>
</ol>

All authors have disclosed any and all conflicts of interest.

Hepatic hemangioma, the most common benign liver tumor in adults, has a reported incidence ranging from 0.4% to 20.0%11. Giant hepatic hemangiomas (defined as &#8805; 10 cm in diameter) frequently cause symptoms such as abdominal pain, distension, and poor appetite due to their mass effect12. Progressive enlargement may lead to severe complications, including Kasabach-Merritt syndrome, spontaneous rupture, or hemorrhage13,14. Current guidelines recommend surgical intervention for cases with concomitant symptoms. Transcatheter arterial embolization (TAE) represents an effective intervention for hepatic hemangiomas, offering advantages including minimal invasiveness, cost-effectiveness, rapid postoperative recovery, and well-documented short-term efficacy. However, the central hypovascularity of giant hemangiomas (&#8805;10 cm) compromises therapeutic outcomes, resulting in suboptimal long-term control with elevated recurrence rates (25-60% at 5 years) and frequent requirement for reintervention. Significant procedure-related complications may occur, such as acute cholecystitis, post-embolization biloma, hepatic necrosis, severe biliary cast syndrome, and liver abscess formation. Alternatively, TAE may be employed as a bridge therapy to achieve tumor volume reduction prior to staged surgical resection15.
The two primary radical treatment options -- partial hepatectomy and tumor enucleation -- achieve complete lesion removal and are considered the most effective therapeutic approaches for hepatic hemangioma10. Laparoscopic hepatectomy, increasingly favored over open surgery due to its minimally invasive nature and faster postoperative recovery, has become a widely accepted technique16,17. However, laparoscopic resection of giant hemangiomas presents unique challenges, including a restricted surgical field, diminished tactile feedback, and heightened difficulty in intraoperative bleeding control18. The risks are further amplified when hemangiomas are adjacent to major hepatic vasculature or located in the right lobe or caudate lobe, where numerous short hepatic veins communicate with the inferior vena cava. Inadequate management of these vessels may precipitate massive hemorrhage, potentially necessitating conversion to open surgery18,19.
Given that surgical risk correlates primarily with intraoperative blood loss, meticulous hemorrhage prevention and control are critical to ensuring procedural safety and success19. Three key technical principles underpin safe laparoscopic liver resection: (1) effective intraoperative bleeding control, (2) precise management of critical vascular structures, and (3) maintenance of an optimal liver transection plane. These principles remain central throughout the entire surgical process20. Despite advances, the safe and precise execution of laparoscopic hepatectomy for complex cases continues to pose significant challenges.
Laparoscopic anatomical right hemihepatectomy was successfully performed via an in situ anterior approach for a giant right hepatic lobe hemangioma. Capitalizing on laparoscopy&#39;s unique caudal and dorsal visualization, the surgeon achieved precise exposure of local anatomy, facilitating meticulous dissection through standardized procedural steps. The transection plane was meticulously defined along the right border of the middle hepatic vein and retrohepatic inferior vena cava, with parenchymal division proceeding systematically from caudal to cephalad to completely separate the hemilivers while maintaining anatomical positioning, culminating in en bloc resection of the right hemiliver.
During the procedure, the gallbladder plate was lowered following Laennec&#39;s capsule anatomy and the &#34;portal theory,&#34; with systematic dissection of Gates III-VI. The right hepatic pedicle was then isolated and clamped via the extrathecal approach to establish the ischemic demarcation line. Recent advancements in Laennec&#39;s capsule-based anatomy and standardized portal theory classification have transformed extrathecal dissection into a mainstream technique for laparoscopic hilar dissection21,22,23. This method optimally leverages laparoscopic advantages by enabling precise, safe pedicle control while significantly reducing both operative duration and intraoperative blood loss24, demonstrating superior efficacy in modern minimally invasive liver surgery25.
In laparoscopic anatomical hepatectomy, two critical technical challenges are controlling the liver transection plane and managing deep hepatic vessels. The optimal parenchymal dissection plane should follow an avascular or minimally vascular interface to maximize surgical safety while providing oncological and minimally invasive benefits26,27. The hepatic vein serves as the natural anatomical boundary between segments, with its course closely corresponding to the ischemic demarcation line after target pedicle occlusion. Transection along this venous pathway minimizes Glisson system encounters, reduces bleeding risk, and allows proactive exposure of major venous trunks to prevent catastrophic injury28. The classic approach combines three key landmarks: the surface ischemic line, intrahepatic guide veins, and the retrohepatic Inferior Vena Cava (IVC) to precisely control the dissection plane29. Regarding vascular management, after achieving safe dissection and adequate working space, the right hepatic pedicle and right hepatic vein root should be sequentially divided using staplers only after complete mobilization ensures sufficient length for secure application. This method of controlled transection with vascular staplers on fully liberated structures represents the safest and most effective technique for major vascular control30.
This protocol demonstrates the successful execution of an anatomical right hemihepatectomy, meeting all established technical standards30. The procedure involved meticulous dissection of the right hepatic pedicle followed by selective occlusion to achieve clear ischemic demarcation. Intraoperative management included controlled division of middle hepatic vein branches with complete exposure of its main trunk. The final transection plane revealed four critical anatomical landmarks: (1) the preserved middle hepatic vein, (2) the divided right hepatic pedicle, (3) the secured stumps of the right hepatic vein, and (4) the exposed right aspect of the retrohepatic vena cava (Figure 4A-D). This systematic approach ensured precise vascular control and complete anatomical resection.
The laparoscopic in situ anterior approach for anatomical right hemihepatectomy demonstrates significant advantages in managing giant hepatic hemangiomas. This technique combines precise hilar dissection with controlled parenchymal transection, achieving dual objectives: complete tumor resection while eliminating risks associated with tumor manipulation (including rupture and hemorrhage). The approach consequently reduces perioperative complications, accelerates postoperative recovery, and improves overall patient outcomes. When implemented with appropriate patient selection and standardized operative protocols, the procedure demonstrates enhanced safety and reproducibility. This approach is also applicable to other massive space-occupying lesions in the right hepatic lobe (such as malignant liver tumors, etc.) requiring surgical intervention. Combining minimally invasive benefits with radical resection principles, this method fully aligns with Enhanced Recovery After Surgery (ERAS) protocols. We recommend its clinical adoption for suitable candidates, contingent upon strict adherence to indication criteria and performance by experienced hepatobiliary surgeons.

As a representative surgical procedure in minimally invasive liver surgery, laparoscopic hepatectomy has consistently demonstrated its safety and clinical efficacy1,2.&#160;However, the clinical application of this technique continues to face two significant challenges. First, the three-dimensional variability of liver anatomy combined with tissue remodeling characteristics under pathological conditions substantially increases the complexity of surgical planning. Second, limited stereoscopic perception and restricted instrument maneuverability in laparoscopy remain major obstacles to the widespread adoption of laparoscopic anatomical hepatectomy3,4. Particularly noteworthy is the considerable variation in technical standardization among different surgeons, which significantly hinders the standardized dissemination of this surgical approach5.
Regarding the selection of approaches for right hemihepatectomy, two primary technical paradigms exist: the traditional free approach and the anterior approach6,7. The traditional approach involves complete mobilization of the perihepatic ligaments (including the right triangular ligament, coronary ligament, and hepatorenal ligament) to achieve liver displacement, which facilitates exposure of the deep surgical field and hemorrhage control. However, frequent intraoperative traction in this approach may result in mechanical dissemination of tumor cells or tumor rupture and bleeding. In contrast, the anterior approach preserves the perihepatic ligaments, maintaining the liver in situ, and when combined with regional blood flow occlusion of Glisson&#39;s sheath (the fibrous sheath of portal triads within the liver), it further ensures surgical safety and adherence to the tumor-free resection principle8. Nevertheless, the laparoscopic anterior approach presents certain limitations, particularly in hemorrhage control during liver transection. The restricted visual field of laparoscopy may lead to disorientation during parenchymal division, posing technical challenges.
Hepatic hemangioma represents the most prevalent benign space-occupying lesion of the liver, with treatment decisions requiring strict adherence to the symptom-size dual-dimensional evaluation system9. In most cases, clinical intervention is unnecessary, with regular follow-up serving as the primary management strategy. However, surgical resection emerges as the most effective therapeutic approach for massive tumors that either cause clinical symptoms or demonstrate progressive enlargement, leading to complications such as Kasabach-Merritt syndrome (a consumptive coagulopathy complicating aggressive vascular tumors in infancy). Drawing upon the clinical implementation of laparoscopic anatomical right hemihepatectomy via the anterior approach for giant liver hemangioma management, this article specifically addresses three critical technical aspects: anatomical plane preservation, hemorrhage control strategies, and optimization of tumor-free surgical techniques10.
CASE PRESENTATION:
A 62-year-old male patient presented with a 2-year history of right upper quadrant abdominal pain. His medical history was unremarkable, with no chronic diseases or prior surgical interventions.
Diagnosis, Assessment, and Plan: 
Preoperative imaging confirmed the diagnosis of a giant hepatic hemangioma occupying the right liver lobe (Figure 1A-D). Preoperative imaging demonstrated a solitary, large expansile hemangioma in the right hepatic lobe, causing significant compression of the proximal segments of both right anterior and posterior hepatic pedicles. The lesion showed close proximity to the inferior vena cava with partial encasement of the middle hepatic vein origin. Given that conventional surgical approaches requiring right liver mobilization carry substantial risks of intraoperative hemorrhage from tumor rupture and potential conversion to open surgery, we preoperatively planned to perform a laparoscopic in situ anterior approach right hemihepatectomy.

<table><tbody><tr><td>3D laparoscope</td><td>KARL STORZ SE &amp;amp; Co. KG</td><td>26605BA</td><td></td></tr><tr><td>Absorbable ligation clips</td><td>Hangzhou Sunstone Technology Co.,Ltd</td><td>K12</td><td></td></tr><tr><td>Laparoscopic instruments</td><td>Tonglu youshi medical equipment co., Ltd</td><td></td><td></td></tr><tr><td>Latex T-shape Catheter&amp;nbsp;</td><td>Zhenjiang Star Enterprise Co.,Ltd</td><td>16Fr</td><td></td></tr><tr><td>Non-absorbable surgical sutures</td><td>Johnson &amp;amp; Johnson</td><td>PROLENE 3-0</td><td>W8522</td></tr><tr><td>Powered Articulating&amp;nbsp; Endoscopic&amp;nbsp; Linear Cutter&amp;nbsp; and nail bin</td><td>Johnson &amp;amp; Johnson</td><td>ECHELONE FLEX&amp;nbsp; 60/CECR60W</td><td></td></tr><tr><td>SURGICEL Absorbable Hemostat</td><td>Johnson &amp;amp; Johnson</td><td>1962</td><td></td></tr><tr><td>Ultrasound knife</td><td>Miconvey Technologies Co.,Ltd</td><td>MSUS36</td><td></td></tr></tbody></table>

laparoscopic anatomical right hemihepatectomy via the in situ anterior approach

Laparoscopic Anatomical Right Hemihepatectomy via the In Situ Anterior Approach

Laparoscopic hepatectomy has gained widespread acceptance as a minimally invasive alternative to open liver resection, offering reduced postoperative pain, shorter hospital stays, and faster recovery. Among its various techniques, laparoscopic right hemihepatectomy via the in situ anterior approach represents a significant advancement in oncological and surgical safety. Unlike conventional methods requiring full mobilization of perihepatic ligaments, this approach preserves the liver&#39;s anatomical position throughout resection. By avoiding excessive rotation or compression of the liver parenchyma, it mitigates the risks of iatrogenic tumor dissemination, capsular rupture, and hemorrhage, critical concerns in malignancy surgery. This technique is especially advantageous for high-risk scenarios: (1) exophytic tumors with fragile capsules susceptible to rupture during manipulation, (2) large tumors (&#62;10 cm) where mobilization may compromise vascular control, and (3) cases with venous tumor thrombus where dislodgement could lead to catastrophic embolism. The in situ strategy aligns with the principles of tumor-free surgery (no-touch technique) and precision hepatectomy, as it enables direct visualization of deep vasculobiliary structures without destabilizing the liver. Early clinical studies report lower transfusion rates and reduced conversion to open surgery compared to traditional approaches. Given its technical feasibility and oncological rigor, the in situ anterior approach should be prioritized for complex liver resections, particularly in centers with advanced laparoscopic expertise. Further multicenter studies are warranted to standardize its procedural steps and validate long-term oncologic outcomes. Nonetheless, current evidence supports its adoption as a first-line minimally invasive strategy for large or high-risk liver space-occupying lesions.

The procedure was successfully completed in 380 min with an estimated blood loss of 350 mL, without requiring transfusion. No postoperative complications occurred, including bleeding, bile leakage, surgical site effusion, abdominal infection, or liver failure. Follow-up chest CT revealed minimal bilateral pleural effusion that resolved spontaneously, while repeat liver CT showed normal vascularization and venous drainage of the left lobe (Figure 3A-D). The patient was discharged on postoperative day 10, with final pathology confirming a diagnosis of hepatic cavernous hemangioma.
<img alt="Abdominal CT scan sequence; diagram showing liver and surrounding organs for diagnostic analysis." class="xfigimg" src="/files/ftp_upload/68610/68610fig1.jpg" data-altupdatedat="1762509930000" data-alt="Figure 1"> 
Figure 1: Preoperative liver CT. (A) Non-contrast period. (B) Arterial phase. (C) Venous phase. (D) Equilibrium Period. <a href="https://www.jove.com/files/ftp_upload/68610/68610fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Liver resection surgery procedure images, surgical tools, tissue incision, clinical method documentation." class="xfigimg" src="/files/ftp_upload/68610/68610fig2.jpg" data-altupdatedat="1762509930000" data-alt="Figure 2"> 
Figure 2: The main steps of the surgery. (A) Extrathecal dissection and clamping of the right anterior and right posterior hepatic pedicles. (B) Marking of the liver surface ischemia line. (C) Superficial liver parenchyma is dissected according to the ischemic line. (D) Locate point B, revealing the middle hepatic vein. (E) Dissection of the liver parenchyma by the middle hepatic vein. (F) Cutting and closing the right pedicle of the liver. (G) The right side of the inferior vena cava is a sign of hepatic parenchyma. (H) The root of the right hepatic vein is fully exposed. (I) Cutting and closing the root of the right hepatic vein. <a href="https://www.jove.com/files/ftp_upload/68610/68610fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Laparoscopic surgery procedure, showing surgical instruments and tissue dissection in a clinical setup." class="xfigimg" src="/files/ftp_upload/68610/68610fig4.jpg" data-altupdatedat="1762509930000" data-alt="Figure 4"> 
Figure 4: Liver section. (A) Middle hepatic vein. (B) Broken end of the right hepatic pedicle. (C) Right hepatic vein severance; (D) Right portion of inferior vena cava. <a href="https://www.jove.com/files/ftp_upload/68610/68610fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="CT scan images, abdominal cross-sections, radiology analysis, diagnostic comparison." class="xfigimg" src="/files/ftp_upload/68610/68610fig3.jpg" data-altupdatedat="1762509930000" data-alt="Figure 3"> 
Figure 3: Postoperative liver CT. (A) Non-contrast period. (B) Arterial phase. (C) Venous phase. (D) Equilibrium Period. <a href="https://www.jove.com/files/ftp_upload/68610/68610fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

To evaluate the clinical benefits of laparoscopic right hemihepatectomy via the in situ anterior approach, emphasizing its advantages in minimizing tumor dissemination risks, reducing bleeding, and enhancing surgical safety, particularly for complex liver tumors.

Laparoscopic hepatectomy has gained widespread acceptance as a minimally invasive alternative to open liver resection, offering reduced postoperative ...

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.

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Laparoscopic Anatomical Right Hemihepatectomy via the In Situ Anterior Approach

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