Laparoscopic Anatomical Right Anterior Sectionectomy with a Hepatic Pedicle-first Approach: Technical Details and Representative Case Illustration

This study presents a standardized protocol for implementing the Glissonian pedicle-first approach, guided by Laennec's membrane and the Gate theory. This protocol evaluates the feasibility, safety, and efficacy of laparoscopic right anterior ectomy performed using the hepatic pedicle-first technique, and describes the innovative elements that enable precise and reproducible resection. Current challenges in the procedure include intricate hepatic anatomy, maintaining segmental inflow and outflow, achieving intraoperative hemostasis and preventing bile leakage.

To begin, clearly expose Calot's triangle, and carefully isolate the cystic artery and duct. Remove the gallbladder routinely, then clip and cut the cystic artery and cystic duct. Then, lower the hilar plate along the Laennec membrane plane to expose Gate IV.After Gate V is exposed, dissect the right anterior pedicle extra facially.

Next, ligate the anterior pedicle to establish an ischemic demarcation for the right anterior lobe. Mark the ischemic boundary on the liver surface. After exposing the middle hepatic vein trunk at point B, transect the V5v branch.

Now, divide the anterior pedicle using a cutting stapler. Expose and transect the V8v branch. Follow the trunk of the right hepatic vein from cephalad and caudad directions to handle the V8d branch.

Address the V5d branch to fully expose the trunk of the right hepatic vein, and ensure a wide right tumor margin. Finally, after resection, ensure the stump of the anterior pedicle and the trunk of the right hepatic vein are fully exposed. The procedure lasted 150 minutes, with four intermittent Pringle maneuver occlusions, totaling 70 minutes, and intraoperative blood loss was 50 milliliters.

The patient was discharged on postoperative day eight, following progressive removal of drainage tubes and satisfactory recovery. One month postoperatively, alpha-fetoprotein and protein induced by vitamin K absence or antagonist II levels decreased to normal and remained normal thereafter. A computed tomography scan at the six month postoperative follow-up showed no evidence of tumor recurrence or metastasis.

This protocol simplifies resection using Laennec's capsule and portal theory, simplifies the surgical process, and removes the tumor-bearing portal venous drainage area to reduce the spread of liver cancer along portal veins.