Name: Laparoscopic Anatomical Right Anterior Sectionectomy with a Hepatic Pedicle-first Approach: Technical Details and Representative Case Illustration (Video) | JoVE Journal
Uploaded: 2025-10-24T14:40:00.000+00:00
Duration: 3 min 23 s
Description: Learn laparoscopic right anterior sectionectomy using a hepatic pedicle-first approach guided by Laennec's capsule. This protocol enhances safety, precision, and reproducibility in complex liver resections.

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5 minutes

The work was supported by the Natural Science Foundation of Hunan Province (2025JJ40100 and 2024JJ6728), Health Commission of Hunan Province (Z2023100).

This protocol adhered to the ethical guidelines of Zhuzhou Hospital Affiliated with Xiang Ya Medical College, and written informed consent was obtained from patients for the publication of this article and associated video materials.
NOTE: The list of materials and instruments, including their specifications, is presented in the Table of Materials.
1. Patient selection
<ol>
	<li>Select patients with hepatocellular carcinoma (HCC) located in the right anterior section of the liver.</li>
	<li>Ensure that these patients have no invasion of the portal vein, hepatic vein, or bile duct, and no distant metastasis.</li>
	<li>Anatomical variants: Portal pedicles of segment 6 or 7 not originating from the AP.</li>
</ol>
2. Patient introduction
<ol>
	<li>Note that the patient has a long-standing history of hepatitis B and received antiviral therapy starting 1 week preoperatively. Confirm Child-Pugh A liver function and a 15 min indocyanine green (ICG) retention rate of &#60; 10%.</li>
	<li>Perform preoperative three-dimensional (3D) reconstruction. Calculate a standard liver volume (SLV) of 1079 mL. Estimate the future liver remnant (FLR) volume as 724 mL following right anterior sectionectomy with preservation of both the RHV and MHV, yielding an FLR/SLV ratio of 67.1%.</li>
</ol>
3. Surgical technique
<ol>
	<li>Patient positioning: Position the patient supine with legs apart, and elevate the right torso at 45&#176;. Suspend and secure the right upper limb. Ensure the primary surgeon stands on the patient&#39;s right, the first assistant on the left, and the second assistant between the legs.</li>
	<li>Trocar placement: Make a skin incision below the umbilicus to establish pneumoperitoneum, and insert a 10 mm Trocar here as the observation port. Additionally, make skin incisions at the following sites respectively: 5 cm above the umbilicus on the right midaxillary line, below the costal margin on the right anterior axillary line, below the xiphoid process, and slightly left of the midpoint of the line connecting the umbilicus and xiphoid process. Insert 12 mm, 5 mm, 12 mm, and 5 mm Trocars at these incisions as working ports (Figure 1).</li>
	<li>Abdominal exploration: Perform diagnostic laparoscopy and confirm that the tumors are located at the right anterior section, with no distant metastases in the left hemiliver or the upper/lower abdomen.</li>
	<li>Cholecystectomy: Begin the retrograde dissection of the gallbladder bed from the base. Clearly expose Calot&#39;s triangle, and carefully isolate the cystic artery and duct. Before clipping and dividing these structures with Hemo-lock clips, confirm the anatomical relationships between the cystic duct, common bile duct, and hepatic duct.</li>
	<li>Liver mobilization: Divide the round and falciform ligaments. Then, expose and lower the second hepatic hilum to access the caval fossa. Next, dissect the hepatorenal, right triangular, and right coronary ligaments to fully mobilize the right liver.</li>
	<li>Hepatic inflow occlusion: Use a 16-Fr Foley catheter to perform the Pringle maneuver for effective hepatic inflow control.</li>
	<li>Anterior pedicle dissection: Perform an anatomical right anterior sectionectomy using a pedicle-first approach. Lower the hilar plate along the Laennec&#39;s capsule, then dissect the anterior pedicle (AP) extrafascially. Using the &#34;Gate&#34; theory as a guide, connect Gates IV and V, then ligate the pedicle (Figure 2A,B). Establish an ischemic demarcation to define the right anterior section.</li>
	<li>Resection plane marking and adjustment: Mark the ischemic boundary on the liver surface. Confirm alignment of the left resection plane with the trunk of MHV by intraoperative ultrasound, ensuring an adequate left tumor margin (Figure 3A,B). 
	NOTE: As the right ischemic plane does not fully encompass the tumor, ultrasound-guided localization of the trunk of RHV is used to adjust the right resection plane, securing a safe tumor margin.</li>
	<li>Liver parenchyma transection: Incise the liver parenchyma along the left marked line using an ultrasonic scalpel. Expose the MHV trunk at point B and divide the ventral hepatic vein branches of segment 5 (V5v). Continue the incision cephalad under the guidance of preoperative 3D reconstruction to address the V5v and ventral hepatic vein branches of segment 8 (V8v) (Figure 3C-F). Incise the right resection plane to fully expose the anterior pedicle (AP) (Figure 4A). Divide the AP using a cutting stapler while preserving the RHV trunk within the &#34;APR triangle&#34;14. Following the trunk of RHV from cephalad and caudad directions, then manage the dorsal venous branches of the right anterior section (Figure 4B-F). Fully expose the vein trunk to ensure a wide right tumor margin (Figure 4G, H). Completely resect the right anterior section, including the tumor.</li>
	<li>Specimen retrieval and hemostasis: Place the liver specimen and gallbladder into a specimen bag and extract them through an extended sub-umbilical incision. Suture the incision, then re-establish pneumoperitoneum. Use bipolar coagulation to achieve meticulous hemostasis of the liver cut surface. After confirming the absence of bleeding or bile leakage, place drainage tubes at the foramen of Winslow and along the liver transection surface. Close all incisions to complete the procedure.</li>
	<li>Specimen inspection: Verify that the specimen has negative margins. Inspect the tumor capsule to confirm its integrity. Ensure the distance from the tumor to the resection margin exceeds 1 cm (Figure 5).</li>
</ol>

<ol><li>Shin, S. W., Kim, T. S., Ahn, K. S., Kim, Y. H., Kang, K. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effect+of+anatomical+liver+resection+for+hepatocellular+carcinoma%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Int+J+Surg%22%5BJournal%5D)">Effect of anatomical liver resection for hepatocellular carcinoma: a systematic review and meta-analysis.</a> Int J Surg. 109 (9), 2784-2793 (2023).</li>
<li>Wei, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Fluorescent+laparoscopic+central+hepatectomy+for+liver+cancer+using+indocyanine+green+negative+staining%5BTitle%5D)+AND+%22J+Vis+Exp%22%5BJournal%5D)">Fluorescent laparoscopic central hepatectomy for liver cancer using indocyanine green negative staining.</a> J Vis Exp. (193), e64869(2023).</li>
<li>Tan, L., Liu, F., Liu, Z. L., Xiao, J. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Meta-analysis+of+risk+factors+for+bile+leakage+after+hepatectomy+without+biliary+reconstruction%5BTitle%5D)+AND+%22Front+Surg%22%5BJournal%5D)">Meta-analysis of risk factors for bile leakage after hepatectomy without biliary reconstruction.</a> Front Surg. 8, 764211(2021).</li>
<li>Sakai, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Safety+and+feasibility+of+laparoscopic+anatomical+liver+resection+for+hepatocellular+carcinoma%3A+a+propensity+score-matched+study%5BTitle%5D)+AND+%22Anticancer+Res%22%5BJournal%5D)">Safety and feasibility of laparoscopic anatomical liver resection for hepatocellular carcinoma: a propensity score-matched study.</a> Anticancer Res. 44 (8), 3645-3653 (2024).</li>
<li>Siow, T. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+central+hepatectomy%3A+feasibility+and+safety%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Laparoscopic central hepatectomy: feasibility and safety.</a> Surg Endosc. 39 (1), 545-553 (2025).</li>
<li>Ide, T., Matsunaga, T., Tanaka, T., Noshiro, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Feasibility+of+purely+laparoscopic+right+anterior+sectionectomy%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Feasibility of purely laparoscopic right anterior sectionectomy.</a> Surg Endosc. 35 (1), 192-199 (2021).</li>
<li>Zheng, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+central+hepatectomy+using+a+parenchymal-first+approach%3A+how+we+do+it%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Laparoscopic central hepatectomy using a parenchymal-first approach: how we do it.</a> Surg Endosc. 36 (11), 8630-8638 (2022).</li>
<li>Yu, D. C., Wu, X. Y., Sun, X. T., Ding, Y. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Glissonian+approach+combined+with+major+hepatic+vein+first+for+laparoscopic+anatomic+hepatectomy%5BTitle%5D)+AND+%22Hepatobiliary+Pancreat+Dis+Int%22%5BJournal%5D)">Glissonian approach combined with major hepatic vein first for laparoscopic anatomic hepatectomy.</a> Hepatobiliary Pancreat Dis Int. 17 (4), 316-322 (2018).</li>
<li>Jeung, I. H., Choi, S. H., Kim, S., Kwon, S. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+central+bisectionectomy+and+right+anterior+sectionectomy+using+two+retraction+methods%3A+technical+aspects+with+video%5BTitle%5D)+AND+%22World+J+Surg%22%5BJournal%5D)">Laparoscopic central bisectionectomy and right anterior sectionectomy using two retraction methods: technical aspects with video.</a> World J Surg. 43 (12), 3120-3127 (2019).</li>
<li>Chen, H. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Extra-Glissonian+approach+for+laparoscopic+liver+right+anterior+sectionectomy%5BTitle%5D)+AND+%22JSLS%22%5BJournal%5D)">Extra-Glissonian approach for laparoscopic liver right anterior sectionectomy.</a> JSLS. 23 (2), e2019.00009(2019).</li>
<li>Sugioka, A., Kato, Y., Tanahashi, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Systematic+extrahepatic+Glissonean+pedicle+isolation+for+anatomical+liver+resection+based+on+Laennec%E2%80%99s+capsule%3A+proposal+of+a+novel+comprehensive+surgical+anatomy+of+the+liver%5BTitle%5D)+AND+%22J+Hepatobiliary+Pancreat+Sci%22%5BJournal%5D)">Systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection based on Laennec’s capsule: proposal of a novel comprehensive surgical anatomy of the liver.</a> J Hepatobiliary Pancreat Sci. 24 (1), 17-23 (2017).</li>
<li>Hanzawa, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((How-I-do-it%3A+laparoscopic+left+medial+sectionectomy+utilizing+a+cranial+approach+to+the+middle+hepatic+vein+and+Laennec%E2%80%99s+capsule%5BTitle%5D)+AND+%22Langenbecks+Arch+Surg%22%5BJournal%5D)">How-I-do-it: laparoscopic left medial sectionectomy utilizing a cranial approach to the middle hepatic vein and Laennec’s capsule.</a> Langenbecks Arch Surg. 406 (6), 2091-2097 (2021).</li>
<li>Liu, T. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Application+of+controlled+low+central+venous+pressure+during+hepatectomy%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22J+Clin+Anesth%22%5BJournal%5D)">Application of controlled low central venous pressure during hepatectomy: a systematic review and meta-analysis.</a> J Clin Anesth. 75, 110467(2021).</li>
<li>Chen, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+APR+triangle%3A+a+practical+zone+in+the+Glissonean+approach+to+laparoscopic+anatomical+right+hepatectomy%5BTitle%5D)+AND+%22iLiver%22%5BJournal%5D)">The APR triangle: a practical zone in the Glissonean approach to laparoscopic anatomical right hepatectomy.</a> iLiver. 1 (3), 176-180 (2022).</li>
<li>Araki, K., Conrad, C., Ogiso, S., Kuwano, H., Gayet, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraoperative+ultrasonography+of+laparoscopic+hepatectomy%3A+key+technique+for+safe+liver+transection%5BTitle%5D)+AND+%22J+Am+Coll+Surg%22%5BJournal%5D)">Intraoperative ultrasonography of laparoscopic hepatectomy: key technique for safe liver transection.</a> J Am Coll Surg. 218 (2), e37-e41 (2014).</li>
<li>Ferrero, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+right+posterior+anatomic+liver+resections+with+Glissonean+pedicle-first+and+venous+craniocaudal+approach%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Laparoscopic right posterior anatomic liver resections with Glissonean pedicle-first and venous craniocaudal approach.</a> Surg Endosc. 35 (1), 449-455 (2021).</li>
<li>Shindoh, J., Mise, Y., Satou, S., Sugawara, Y., Kokudo, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+intersegmental+plane+of+the+liver+is+not+always+flat%E2%80%94tricks+for+anatomical+liver+resection%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">The intersegmental plane of the liver is not always flat—tricks for anatomical liver resection.</a> Ann Surg. 251 (5), 917-922 (2010).</li>
<li>Hosokawa, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Right+intersectional+transection+plane+based+on+portal+inflow+in+left+trisectionectomy%5BTitle%5D)+AND+%22Surg+Radiol+Anat%22%5BJournal%5D)">Right intersectional transection plane based on portal inflow in left trisectionectomy.</a> Surg Radiol Anat. 41 (5), 589-593 (2019).</li>
<li>Kamiyama, T., Kakisaka, T., Orimo, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Current+role+of+intraoperative+ultrasonography+in+hepatectomy%5BTitle%5D)+AND+%22Surg+Today%22%5BJournal%5D)">Current role of intraoperative ultrasonography in hepatectomy.</a> Surg Today. 51 (12), 1887-1896 (2021).</li>
<li>Hu, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Efficacy+and+safety+of+indocyanine+green+fluorescence+navigation+versus+conventional+laparoscopic+hepatectomy+for+hepatocellular+carcinoma%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Efficacy and safety of indocyanine green fluorescence navigation versus conventional laparoscopic hepatectomy for hepatocellular carcinoma: a systematic review and meta-analysis.</a> Surg Endosc. 39 (3), 1681-1695 (2025).</li>
<li>Qi, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effectiveness+and+safety+of+indocyanine+green+fluorescence+imaging-guided+hepatectomy+for+liver+tumors%3A+a+systematic+review+and+first+meta-analysis%5BTitle%5D)+AND+%22Photodiagnosis+Photodyn+Ther%22%5BJournal%5D)">Effectiveness and safety of indocyanine green fluorescence imaging-guided hepatectomy for liver tumors: a systematic review and first meta-analysis.</a> Photodiagnosis Photodyn Ther. 28, 346-353 (2019).</li>
<li>Tangsirapat, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Surgical+margin+status+outcome+of+intraoperative+indocyanine+green+fluorescence-guided+laparoscopic+hepatectomy+in+liver+malignancy%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22BMC+Surg%22%5BJournal%5D)">Surgical margin status outcome of intraoperative indocyanine green fluorescence-guided laparoscopic hepatectomy in liver malignancy: a systematic review and meta-analysis.</a> BMC Surg. 24 (1), 181(2024).</li>
<li>Felli, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+anatomical+liver+resection+for+malignancies+using+positive+or+negative+staining+technique+with+intraoperative+indocyanine+green-fluorescence+imaging%5BTitle%5D)+AND+%22HPB+%28Oxford%29%22%5BJournal%5D)">Laparoscopic anatomical liver resection for malignancies using positive or negative staining technique with intraoperative indocyanine green-fluorescence imaging.</a> HPB (Oxford). 23 (11), 1647-1655 (2021).</li>
</ol>

The authors have nothing to disclose.

Currently, three primary approaches are employed for right anterior sectionectomy6. Firstly, parenchymal-first approach: dissecting hepatic parenchyma before identifying vascular and biliary structures, which carries a higher bleeding risk7. Secondly, hepatic vein-first approach: involving early exposure and control of hepatic veins, suitable for tumors adjacent to major veins but demanding advanced anatomical dissection skills<sup class='xr...

Anatomical liver resection (ALR) is widely regarded as a safe and effective procedure for hepatocellular carcinoma (HCC)1. Central hepatectomy remains highly challenging in minimally invasive surgery, due to the complex hepatic anatomy and the requirement for preserving segmental portal inflow and outflow during resection2. Despite advancements in surgical techniques and instruments expanding their application, intraoperative hemostasis and prevention of complications like bile leakage remain key hurdles3.
Laparoscopic anatomical resection offers distinct advantages, including shorter postoperative recovery, fewer complications, maximal preservation of healthy liver parenchyma, and complete tumor removal, critical for HCC patients. Additionally, it enables complete excision of the tumor-bearing portal venous territory, reducing recurrence risk and improving long-term survival, compared with non-anatomical resection4.
Right anterior sectionectomy, involving resection of segments V and VIII, is a central hepatic procedure that engages major branches of the middle hepatic vein (MHV), right hepatic vein (RHV), and the right anterior hepatic pedicle (AP). Laparoscopic anatomical right anterior sectionectomy presents three main challenges: hemorrhage control during parenchymal transection and exposure of the trunks of MHV and RHV, optimal management of the AP, and precise control of the hepatic transection plane to ensure a wide tumor margin2,5. 
Currently, three primary approaches are used in right anterior sectionectomy6. First is the parenchymal-first approach: dissecting hepatic parenchyma before identifying vascular and biliary structures, which has a higher bleeding risk7. Second is the hepatic vein-first approach: it involves early control of hepatic veins, but requiring advanced anatomical dissection skills8. Third is the Glissonean pedicle-first approach: isolating and controlling the target Glissonean pedicle first, then transecting the parenchyma along the ischemic demarcation line9,10. 
This article presents our center's standardized protocol for applying Glissonean pedicle-first approach guided by Laennec's membrane and the "Gate" theory11,12. Integrated with intraoperative ultrasonography and controlled low central venous pressure (CLCVP), this technique aims to simplify workflow, minimize blood loss, secure safe margins, and reduce the risk of portal vein dissemination in HCC13. However, this approach is not recommended when tumors compress the first porta hepatis or invade the bile duct or vascular branches. Under such circumstances, to mitigate the risks of iatrogenic tumor dissemination, such as hematogenous spread due to intraoperative compression or peritoneal seeding from tumor rupture, alternative strategies should be employed. These include liver parenchyma-first dissection or intra-Glissonean sheath dissection, rather than the extra-Glissonean sheath dissection and "Gate" theory-based strategy described in our protocol.

<table><tbody><tr><td>3D reconstruction software</td><td>United Imaging</td><td>uSurgiPlan Abdomen 200</td><td>3D reconstruction of liver and surgical planning</td></tr><tr><td>Absorbable Hemostat (SURGICEL SNOW)</td><td>Ethicon</td><td>2082</td><td>Oxidized regenerated cellulose hemostatic agent.</td></tr><tr><td>Electrosurgical Unit</td><td>Covidien</td><td>Force FX-8C</td><td>High-frequency electrosurgical generator for cutting and coagulation.</td></tr><tr><td>Endo-GlA stapler</td><td>Golden Stapler Surgical</td><td>EC-160</td><td>Disposable laparoscopic stapler for tissue transection and stapling</td></tr><tr><td>Hem-o-lok</td><td>Changzhou Kefeng Medical Technology</td><td>ZJS&lt;br/&gt; ZJM&lt;br/&gt; ZJL</td><td>Single-use clip cartridge for vessel/tissue ligation</td></tr><tr><td>Insufflator&amp;nbsp;</td><td>OLYMPUS</td><td>UHI-4</td><td>Used to create pneumoperitoneum during laparoscopic surgery</td></tr><tr><td>Laparoscopic system / Video system</td><td>OLYMPUS</td><td>OTV-S300</td><td>Video processor and light source system for laparoscopic visualization.</td></tr><tr><td>Leparoscopic ultrasound</td><td>BK Medica</td><td>BK2300</td><td>High-resolution ultrasound system for intraoperative imaging.</td></tr><tr><td>Non-absorbable Suture (Prolene)</td><td>Ethicon</td><td>W8556</td><td>5-0 polypropylene suture, 17mm RB-1 needle, 90 cm, non-absorbable.</td></tr><tr><td>Non-absorbable Suture (Surgipro II)</td><td>Covidien</td><td>VP-521-X</td><td>4-0 monofilament polypropylene suture, 26mm V-20 taper needle, 90 cm.</td></tr><tr><td>Ultrasonic Surgical System</td><td>Mindray</td><td>UP700</td><td>Ultrasonic energy system for tissue dissection and hemostasis in surgery.</td></tr></tbody></table>

laparoscopic anatomical right anterior sectionectomy with a hepatic pedicle-first approach: technical details and representative case illustration

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

Laparoscopic anatomical right anterior sectionectomy remains technically demanding due to intricate hepatic anatomy and the need to preserve segmental portal inflow and outflow during resection. Key challenges include intraoperative hemostasis, prevention of bile leakage, and lack of standardized approaches across segments. The hepatic pedicle-first technique offers a promising solution to simplify the procedure and reduce risks. This article presents a clinical case to illustrate our institutional approach, which involves lowering the hepatic portal plate along Laennec&#39;s capsule, then extra-capsularly dissecting and ligating the right anterior pedicle (AP) to create an ischemic demarcation in its drainage territory. The left transection plane follows preoperative planning with precise ligation of the middle hepatic vein (MHV) branches. For tumors near the dorsal of the right anterior section, intraoperative ultrasonography refines the right transection along the right hepatic vein (RHV) plane, exposing the entire RHV to ensure a wide margin. The innovations for this approach include: (1) Laennec&#39;s capsule and &#34;portal&#34; theory-guided resection, simplifying steps and reducing cancer spread via excision of the tumor-bearing portal territory; (2) intraoperative ultrasonography for dynamic transection plane adjustment, ensuring precision and margin adequacy. This case presentation demonstrates the potential of the approach to enhance safety and efficacy in laparoscopic right anterior sectionectomy and highlights its feasibility as a reproducible framework for complex hepatic surgeries.

Intraoperative details 
The procedure lasted 150 min, with four intermittent Pringle maneuver occlusions totaling 70 min. Intraoperative blood loss was 50 mL (Table 1).
Postoperative Management and Follow-Up 
Postoperatively, the patient received hepatoprotective therapy, antibiotics, intravenous fluid resuscitation, and albumin supplementation. A computed tomography (CT) scan on postoperative day 5 revealed no significant peritoneal eff...

This article aims to present a novel Laennec's capsule-guided laparoscopic approach for right anterior sectionectomy, highlighting its potential to improve safety, precision, and reproducibility in complex liver resections.

Laparoscopic anatomical right anterior sectionectomy remains technically demanding due to intricate hepatic anatomy and the need to preserve segmental ...

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.

laparoscopic-anatomical-right-anterior-sectionectomy-with-hepatic

Research

JoVE Journal

Medicine

This video describes a right hemihepatectomy with intrahepatic transection of the right hemipedicle leaving the hepatoduodenal ligament completely untouched.

Right Hemihepatectomy by Suprahilar Intrahepatic Transection of the Right Hemipedicle using a Vascular Stapler

Numerous studies have demonstrated the advantages of anatomic resection. Nonetheless, whether anatomic resection can increase R0 resection rates remains controversial. Consequently, the present study describes an innovative procedure involving the en bloc concept combined with anatomic resection in laparoscopic hepatectomy, which can reduce postoperative recurrence and metastasis.

Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy

Here we present a step-by-step protocol for conducting laparoscopic anterior right hepatectomy and compare its clinical effects and postoperative outcomes with those of conventional hepatectomies. Analysis of the data of 82 patients with hepatocellular carcinoma revealed that laparoscopic anterior right hepatectomy had better clinical outcomes and survival rates than the conventional hepatectomy.

Laparoscopic Anterior Right Hepatectomy: A Single-Center Experience

Here, we present a protocol to perform laparoscopic right posterior sectionectomy, focusing on two key aspects: the intrahepatic Glissonian approach for inflow control and a parenchymal transection technique using an ultrasonic surgical aspirator.

Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

This protocol involves a laparoscopic anatomical resection of liver segment VII with liver parenchymal transection following a priority approach. This technique is unaffected by anatomical variations.

Laparoscopic Anatomical Liver Segment VII Resection with Liver Parenchymal Transection Following a Priority Approach

This protocol describes a laparoscopic anatomical right anterior sectionectomy utilizing the Laennec capsule concept, combined with comprehensive preoperative therapy. The approach enables precise tumor resection in hepatocellular carcinoma (HCC) cases closely associated with major vascular structures, improving surgical safety, efficacy, and long-term patient outcomes.

Laparoscopic Anatomical Resection of the Right Anterior Lobe Based on the Laennec Capsule Technique

Here, we present a protocol for laparoscopic anatomical hepatectomy using Takasaki's approach and indocyanine green fluorescence navigation in S4/5/7/8 resection.

Laparoscopic Anatomical Hepatectomy Using Takasaki's Approach and Indocyanine Green Fluorescence Navigation

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 Anatomical Right Hemihepatectomy via the In Situ Anterior Approach

We present a laparoscopic technique for anatomic S7+S8d resection with right hepatic vein transection, preserving the inferior right hepatic vein and segment S6. Relying on meticulous anatomical landmarks without intraoperative ultrasound, this approach offers a precise and parenchyma-sparing option for dorsally located right-liver tumors, particularly in settings with limited advanced navigation resources.

Laparoscopic Anatomic S7+S8d Resection Preserving Inferior Right Hepatic Vein and S6 with Right Hepatic Vein Transection

Herein we describe the methods to construct, visualize, and quantify the bioluminescent reactions of both firefly and renilla luciferase enzymes expressed in metastatic breast cancer cells during their growth and metastasis in vivo.

In vivo Dual Substrate Bioluminescent Imaging

Learn laparoscopic right anterior sectionectomy using a hepatic pedicle-first approach guided by Laennec's capsule. This protocol enhances safety, precision, and reproducibility in complex liver resections.

Laparoscopic Anatomical Right Anterior Sectionectomy with a Hepatic Pedicle-first Approach: Technical Details and Representative Case Illustration (Video) | JoVE Journal

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

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