Laparoscopic Anatomic Liver Resection Using the Landmark Vein Approach for Hepatolithiasis: A Technical Note

Summary

This protocol describes a retrospective evaluation of the technical feasibility and perioperative safety of laparoscopic anatomical hepatectomy using the Landmark Vein approach for intrahepatic bile duct stones in a single case.

Abstract

Laparoscopic anatomic liver resection is the optimal treatment for intrahepatic bile duct stones confined to a liver segment or lobe. However, recurrent inflammation often obscures the first hepatic hilum, making traditional dissection approaches challenging. The "Landmark Vein approach," using a major hepatic vein as a real-time intraoperative guide for the parenchymal transection plane, offers a technical strategy to facilitate precise anatomic resection in this context. This technical note demonstrates the feasibility of this approach in a patient with complex hepatolithiasis undergoing a right hemihepatectomy. We detail the critical steps: preoperative 3D reconstruction for venous mapping, intraoperative ultrasound for confirmation, and a caudal-to-cephalad parenchymal transection meticulously guided along the middle hepatic vein. This report aims to provide a structured description of the technique, highlighting its potential utility in managing hepatolithiasis with distorted hilar anatomy. While the approach may contribute to improved surgical outcomes, further studies with larger cohorts are needed to validate its broader applicability and impact.

Introduction

With advancements in liver surgery, minimally invasive anatomic liver resection (MIALR) has gained widespread clinical application^1,2. Among these approaches, anatomic hepatectomy via the Glissonean approach was first proposed by Takasaki K³ in 1998 and has since gained recognition and widespread adoption by minimally invasive liver surgery experts worldwide^2,4,5. As intrahepatic bile duct stones exhibit strict segmental distribution along the affected biliary tree, laparoscopic liver ....

Protocol

This study was approved by the Ethics Committee of Guangdong Provincial Hospital of Traditional Chinese Medicine, which waived the requirement for informed consent due to its anonymous, retrospective design. The reagents and the equipment used are listed in the Table of Materials.

1. Patient selection and preoperative assessment

1. Confirm surgical indications
   1. Confirm the presence of complex hepatolithiasis with indications for major hepatectomy, including but not limited to unilateral intrahepatic bile duct stones with parenchymal atrophy, stricture, or suspected cholangiocarcinoma.

Results

A 72-year-old patient with a history of recurrent cholangitis due to complex right intrahepatic duct stones and atrophy of the right hemiliver underwent a laparoscopic right hemihepatectomy using the Landmark Vein approach with a Roux-en-Y hepaticojejunostomy. The primary technical goal was to perform a true anatomic resection despite significant inflammation and hilar distortion from prior interventions.

The Landmark Vein approach facilitated the procedure by providing a consistent anatomical.......

Discussion

The "Landmark Vein" is not a single anatomical structure but a conceptual term for using a target hepatic vein as the primary intraoperative guide during anatomic liver resection. This vein, such as the middle hepatic vein (MHV) for a hemihepatectomy or the umbilical fissure vein for a left lateral sectionectomy, provides a consistent and reliable landmark for the parenchymal transection plane, particularly when traditional hilar landmarks are distorted.

The primary challenge in surger.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Computer Assisted Surgery System	Hisense Medical	https://medical.hisense.com/	5.04
harmonic scalpel	Sound Reach	https://www.genesismedtech.com/product/sr7-series-shears/	/
powered linear stapler	iReach	https://www.genesismedtech.com/product/ireach-omnia/	Model: ID30TANB, ID45TAN