Laparoscopic Cranial Approach for Anatomical Resection of Liver Segment VIII: A Technical Case Report

Summary

This study details the technical principles of the cranial approach for laparoscopic segment VIII resection. The key step involves meticulous dissection of the second hepatic hilum to expose the roots of the middle hepatic vein and right hepatic vein, thereby establishing a reliable parenchymal transection plane for precise anatomical hepatectomy.

Abstract

Laparoscopic anatomical hepatectomy is an established therapeutic standard for liver malignancies; however, the resection of Segment VIII (S8) remains technically demanding due to its deep cranial location and proximity to the middle hepatic vein (MHV) and right hepatic vein (RHV). This protocol outlines a structured, step-by-step cranial approach to facilitate safe and precise laparoscopic anatomical segmentectomy of S8. The objective is to demonstrate a reproducible surgical strategy that overcomes the exposure difficulties inherent to this segment. The protocol is exemplified through a 65-year-old male patient with a history of hepatitis, Child-Pugh A liver function, and a 4 cm S8 hepatocellular carcinoma (HCC) abutting the MHV and RHV. After confirming adequate future liver remnant (FLR/SLV ratio: 70.5%), the procedure was performed using a systematic cranial-to-caudal workflow. Dissection of the second hepatic hilum is first performed to identify and expose the roots of the MHV and RHV. Using these venous landmarks as anatomical guides, the parenchymal transection plane is then clearly demarcated and developed from the hepatic vein roots downwards. Key steps include the use of intraoperative ultrasound for confirmation, piecemeal in-situ transection, and intermittent Pringle maneuver application under low central venous pressure anesthesia. In this case, the protocol was successfully executed, achieving en bloc resection of S8 with an operative time of 160 min and an estimated blood loss of 100 mL. The patient experienced no postoperative complications and was discharged on day seven. Histopathology confirmed HCC. This report outlines a standardized laparoscopic cranial approach that may assist surgeons in performing anatomically guided resections of deep cranial liver segments.

Introduction

An ideal anatomical hepatectomy can ensure an adequately wide negative resection margin while maximizing the preservation of normal liver parenchyma^1,2, aligning with enhanced recovery after surgery (ERAS) concepts and potentially improving patient outcomes³. Liver segment VIII (S8) is located in the anterosuperior part of the right liver, adjacent to the hepatic hilum and major vasculature⁴. Due to its deep position, S8 resection presents significant exposure challenges.

Anatomical hepatectomy using the hepatic vein as a transection plane provides a reliable landmark, helps ensure adequate margins, preserves functional tissue, and may reduce postoperative recurrence risk⁵. The hepatic vein approach can be performed via caudal, cranial, or dorsal directions⁶. The caudal approach involves retrograde dissection from the distal vein through parenchyma, whereas the cranial approach first exposes the vein root at the second hepatic hilum before proceeding caudally^7,8.

For S8 resections, the cranial approach offers specific advantages over caudal or dorsal alternatives by improving exposure of deep parenchymal planes, facilitating earlier identification of venous landmarks, and providing clearer guidance for transection decisions. This protocol is suitable for experienced hepatobiliary surgeons familiar with intraoperative ultrasound and multidisciplinary coordination but requires specific instrumentation and controlled central venous pressure (CVP). The present protocol demonstrates the key steps of the cranial approach for anatomical S8 resection, detailing its intended use for deeply located tumors and illustrating how it solves the exposure and landmark identification problems inherent to this challenging procedure.

Protocol

This study was approved by the Ethics Committee of Dongguan Tungwah Hospital. Being an anonymous retrospective study, informed consent was waived.

1. Patient selection

1. Include patients with hepatocellular carcinoma located in S8 with preserved liver function (Child-Pugh Class A) and good performance status (ECOG 0–1).
2. Confirm tumor location and relationship to major hepatic veins using contrast-enhanced CT or MRI.
3. Perform liver volumetry to ensure an adequate future liver remnant (FLR/SLV ratio ≥40–50%, depending on liver condition).
   NOTE: In the present case, the patient was a 65-year-old male with a history of hepatitis, preserved liver function (Child-Pugh Class A), and good performance status (ECOG 0). Contrast-enhanced CT and MRI demonstrated a 4.0 cm × 4.0 cm × 5.0 cm lesion in S8 (Figure 1).

2. Preoperative preparation

1. Complete standard preoperative laboratory panels (complete blood count, comprehensive metabolic panel, coagulation profile).
2. Review high-quality cross-sectional imaging for precise tumor localization and 3D reconstruction of hepatic vascular anatomy.

3. Intraoperative setup

1. Anesthesia
   1. Induce general endotracheal anesthesia.
   2. Maintain CVP at <5 mmHg throughout parenchymal transection.
   3. Maintain pneumoperitoneum pressure at 12–14 mmHg.
2. Patient Positioning & Draping
   1. Position the patient supine with arms abducted.
   2. Place a 15° wedge under the right flank to provide leftward tilt.
3. Trocar Placement (5-port technique)
   1. Establish pneumoperitoneum and insert five trocars as shown in Figure 2. Place a 10 mm camera port (Port A) 2 cm above the umbilicus and 2 cm to the right of the midline.
   2. Insert a 5 mm assistant port (Port B) at the left midaxillary line along the costal margin. Place a 10 mm working port (Port C) midway between Ports A and B. Insert a 10 mm working port (Port D) in the subxiphoid region.
   3. Finally, place a 5 mm assistant port (Port E) midway between Ports A and D.
      ​NOTE: Cephalad trocar placement optimizes exposure of the cranial hepatic region.

4. Surgical procedure

1. Abdominal exploration and liver mobilization (Figure 3A).
   1. Systematically inspect the peritoneal cavity for extrahepatic metastases.
   2. Divide the round ligament and falciform ligament up to the suprahepatic inferior vena cava (IVC) using a vessel-sealing device, such as an ultrasonic dissector (power setting: Min for dissection, Max for sealing).
   3. Gently retract the liver inferiorly to expose the suprahepatic IVC and the roots of the hepatic veins.
      ​NOTE: Perform gentle blunt and sharp dissection, employing an electrocautery hook for meticulous, stepwise exposure of the second hepatic hilum, while avoiding excessive traction on the hepatic veins to prevent laceration.
2. Preparation for inflow ccclusion (Pringle Maneuver)
   1. Open the lesser omentum to access the foramen of Winslow.
   2. Pass a No. 8 Fr red rubber catheter around the hepatoduodenal ligament to create a tourniquet for potential inflow occlusion (Figure 3B).
3. Exposure and guidance of the MHV.
   1. Perform intraoperative ultrasound (IOUS) to confirm tumor location in S8, map the course of the MHV from its confluence with the IVC into the parenchyma, and mark the liver surface projection of the MHV using electrocautery (Figure 3C).
   2. Using an ultrasonic dissector, make a superficial parenchymal incision at the junction of the MHV root and IVC (Figure 3D).
   3. Identify the glistening white wall of the MHV.
      NOTE: Visualization of the MHV wall confirms entry into the correct intervascular plane between S8 and S4a (Figure 3E).
   4. Progress caudally along the anterior surface of the MHV.
   5. Sequentially divide V8 tributaries using the ultrasonic dissector or clips (for vessels >2 mm).
      NOTE: To control bleeding, apply intermittent Pringle maneuver (15 min of inflow occlusion followed by 5 min of reperfusion) in case of significant hemorrhage during transection.
4. Isolation and division of the S8 Glissonean pedicle
   1. Use IOUS to identify and mark the surface projection of the S8 pedicle.
   2. Dissect the parenchyma toward this marker using the ultrasonic dissector.
   3. Carefully expose the S8 pedicle (Figure 3F).
   4. Apply a non-crushing clamp to the pedicle and observe for a clear demarcation line on the liver surface encompassing the tumor.
      NOTE: A sharp, congruent ischemic line confirms the correct pedicle.
   5. Divide the pedicle using a laparoscopic vascular stapler.
5. Exposure of the RHV
   1. Continue the parenchymal dissection posteriorly from the root of the MHV toward the IVC fossa and expose the root of the RHV. Dissect the RHV from its cranial root downward to clearly visualize its anatomical structure.
   2. Perform the dissection in a piecemeal fashion using the ultrasonic dissector, avoiding large en bloc tissue division. Under direct vision, carefully identify the anterior fissure vein, short hepatic veins, or other venous branches.
   3. Ligate or clip them individually before dividing to prevent injury and consequent bleeding. Rely on gentle counter-traction to open the surgical field, lifting the liver just enough to expose the operative area.
   4. Maintain the dissection strictly on the anterior surface of the RHV, and perform all maneuvers gently to avoid inadvertent vascular injury.
   5. Expose the anterior and medial aspects of the RHV by continuing the dissection caudally along its length (Figure 3G).
6. Completion of parenchymal transection
   1. Connect the three established planes: along the MHV medially, the stapled S8 pedicle inferiorly, and the RHV laterally. First, complete the medial plane along the MHV to establish a stable anatomical reference.
   2. Subsequently, ligate the S8 pedicle to obtain the inferior ischemic plane. Finally, complete the lateral plane along the RHV, gently retracting the specimen; the assistant applies mild countertraction to avoid excessive tension on the specimen and its surrounding blood vessels.
   3. Complete the transection using the ultrasonic dissector, maintaining a low CVP.
7. Final phase
   1. Inspect the resection bed under low pneumoperitoneum pressure (8 mmHg) for hemostasis and bile leak. This is routinely performed by instilling warm normal saline (37°C) into the abdominal cavity, particularly around the resection margin and the various connection planes.
   2. Subsequently, apply gentle pressure to the liver parenchyma surrounding the resection margin using atraumatic forceps. Fluorescence technology may also be used for this purpose; however, it was not employed in this specific case. If a bile leak is detected (manifested as yellowish-green bile oozing from the resection margin or floating in the saline), immediate suture ligation is performed.
   3. Achieve definitive hemostasis using bipolar cautery (e.g., Maryland, setting: 30–40 W) or fine (4-0/5-0) monofilament suture as needed (Figure 3H).
   4. Place a closed-suction drain adjacent to the resection bed.
      ​NOTE: This drain continuously removes residual bile, blood, delayed hemorrhage, bile leaks, and inflammatory exudate from the resection bed. This helps promote healing of the liver parenchyma and prevents the formation of fluid collections that could potentially induce infection. The drain should be removed promptly once postoperative clinical and imaging examinations show no signs of bile leakage or infection.

5. Postoperative management

1. Monitor vital signs, fluid balance, and perform dynamic liver function tests.
2. Provide multimodal analgesia, including regional nerve block if indicated.
3. Initiate early mobilization and ambulation within 24 h postoperatively.
4. Perform follow-up assessment of liver recovery and postoperative complications.

6. Quality control and documentation

1. Document preoperative diagnosis, intraoperative findings, technical details, and contingency measures in the surgical record.
2. Analyze postoperative outcomes and complications in a structured manner for quality improvement.

Results

In this case, the patient was a 65-year-old male with a history of hepatitis, preserved liver function (Child-Pugh Class A), and good performance status (ECOG 0). Contrast-enhanced CT and MRI demonstrated a 4.0 cm × 4.0 cm × 5.0 cm lesion in S8 (Figure 1). Tumor markers showed elevated PIVKA-II (946.12 mAU/mL; Normal range: 0–40 mAU/mL) with normal AFP (2.5 IU/mL; Normal range: 0–7 IU/mL). Preoperative volumetric analysis revealed a standard liver volume of 1001 mL, total liver volume of 128...

Discussion

Liver Segment S8 (right anterosuperior segment), situated at the dome of the right anterior lobe, is enveloped by complex anatomical structures. Medially, it borders segment S4a, with the MHV forming the natural boundary; laterally, it abuts segment S7, separated by the RHV; inferiorly, it interfaces with segment S5, where demarcation is often indistinct—further complicating surgical localization^9,10,11.

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Disposable Laparoscopic Trocar	Mindray	CW-Z346
Electrosurgical hook	Valleylab	ForceTriad
Laparoscopic system	KARL STORZ	26003AA
Laparoscopic ultrasound	BK Medical	8666-RF
Ultrasonic dissector	Innocare	SG13