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 p....

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 pat....

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