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 resection for hepatolithiasis necessitates anatomic resection based on hepatic segments or lobes. This approach is fundamental for reducing residual stones, decreasing recurrence rates, and preventing cholangiocarcinoma^6,7,8.

Unlike patients with liver tumors, those with hepatolithiasis present unique clinical and anatomic challenges due to chronic recurrent inflammation and prior biliary surgery. These include dense perihepatic adhesions, distorted anatomy, hepatic inflammatory edema, biliary dilation and atrophy, atrophy-hypertrophy complex, and hilar rotation, making hilar structures difficult to identify and dissection planes unclear^9,10. Consequently, the conventional Glissonean approach is often impractical in hepatolithiasis cases.

The "Landmark Vein approach" offers an alternative strategy. This technique uses a major hepatic vein, identified on preoperative imaging and intraoperative ultrasound, as a consistent intraoperative guide for the parenchymal transection plane. Dissection proceeds along the projected course of the vein, ensuring a true anatomic resection even when hilar anatomy is compromised. This approach is suitable for patients with stones confined to a hemiliver or liver segments requiring anatomic liver resection, especially in those needing left or right hemihepatectomy. This technical note demonstrates the feasibility of the Landmark Vein approach for performing a laparoscopic anatomic hepatectomy in a patient with complex hepatolithiasis, focusing on the key surgical steps.

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.
   2. Confirm that the patient has undergone preoperative biliary drainage (e.g., PTCD) if presenting with acute cholangitis, severe hyperbilirubinemia (e.g., total bilirubin >200 µmol/L), or sepsis.
   3. Confirm that acute infection is controlled (e.g., afebrile status, normalized or declining white blood cell count, and procalcitonin level) and ensure that jaundice has significantly improved before proceeding with surgery.
2. Assess surgical risk and volumetry
   1. Perform liver function assessment. Evaluate the Child–Pugh score (ensure Class A), measure the Indocyanine Green Retention Rate at 15 min (ICG-R15; ensure <10%–15% for major hepatectomy), and assess performance status (ensure PS 0–1).
   2. Perform volumetric analysis of the liver using 3D reconstruction software. Calculate the total liver volume and the future liver remnant (FLR) volume. Ensure that the FLR is adequate (e.g., FLR/SLV >30–40% in a normal liver and >50% in a cirrhotic liver).
3. Obtain informed consent
   1. Discuss the surgical indications, the specific procedure (e.g., right hemihepatectomy with hepaticojejunostomy), potential risks (e.g., bleeding, bile leak, liver failure), expected benefits, and alternative treatment options with the patient and family. Obtain and document written informed consent.
4. Conduct preoperative investigations
   1. Laboratory tests: Order a complete blood count (CBC), liver function tests (LFTs), coagulation profile, renal function tests, procalcitonin (PCT), C-reactive protein (CRP), alpha-fetoprotein (AFP), and carcinoembryonic antigen (CEA).
   2. Imaging and 3D reconstruction
      1. Perform contrast-enhanced computed tomography (CT) of the upper abdomen and magnetic resonance cholangiopancreatography (MRCP) to assess stone burden and biliary anatomy and to rule out malignancy.
      2. Perform three-dimensional reconstruction using dedicated software. (e.g., Hisense Computer Assisted Surgery System).
      3. Import CT DICOM data into the software. Segment the liver, tumors, and vasculature semi-automatically, followed by manual correction. Reconstruct the biliary tree.
      4. Measure the total liver volume, the future liver remnant volume, and the volume of the segments to be resected. Assess the anatomical relationships among the bile ducts, hepatic arteries, portal veins, and hepatic veins. Identify and document any anatomical variants (e.g., a G7 branch draining into the inferior vena cava).

2. Procedural setup

1. Anesthesia and patient positioning
   1. Induce general anesthesia following institutionally approved protocols.
   2. Place the patient in the supine lithotomy position.
2. Trocar placement
   1. Establish a five-port technique.
   2. Insert a 10 mm trocar for the laparoscope superior and to the right of the umbilicus.
   3. Insert a 12 mm trocar in the subxiphoid region.
   4. Insert a 5 mm trocar in the midline.
   5. Insert a 12 mm trocar in the right midclavicular line below the costal margin.
   6. Insert a 5 mm trocar in the right anterior axillary line below the costal margin.

3. Surgical technique

1. Adhesiolysis and hilar dissection
   1. Establish pneumoperitoneum.
   2. Divide any abdominal adhesions to fully expose the liver.
   3. Dissect the hepatoduodenal ligament.
   4. Extract stones from the common bile duct (CBD), then divide the CBD and close the stump if performing concomitant hepaticojejunostomy.
   5. Ligate and divide the right hepatic artery.
2. Hepatic mobilization
   1. Divide the round, falciform, and right coronary ligaments to fully mobilize the right liver.
   2. Identify the short hepatic veins draining anterior to the inferior vena cava (IVC).
   3. Ligate and divide the short hepatic veins sequentially from caudal to cephalad.
   4. Expose the fossa between the middle hepatic vein (MHV) and the right hepatic vein (RHV) to identify their anatomical positions.
3. Establish inflow control
   1. Fashion a tourniquet (e.g., from a trimmed 14 F T-tube).
   2. Place the tourniquet around the hepatoduodenal ligament at the first hilum.
   3. Prepare to perform the intermittent Pringle maneuver.
4. Perform Intraoperative Ultrasound (IOUS)
   1. Scan the liver to confirm the position of the MHV.
   2. Mark the projected course of the MHV on the liver surface using electrocautery.
5. Perform anatomic resection (Landmark Vein approach)
   1. Initiate the Pringle maneuver using cycles of 15 min occlusion followed by 5 min reperfusion.
   2. Begin parenchymal transection between segments S4b and S5 and through the caudate process. Proceed from caudal to cephalad using the harmonic scalpel.
   3. Identify a peripheral branch of the target landmark vein (MHV).
      NOTE: Maintain a low central venous pressure (CVP) to ensure hepatic vein collapse and absence of active bleeding from the transection plane.
   4. Dissect along the MHV branches toward the trunk. Expose the MHV meticulously throughout the dissection plane.
   5. Manage encountered structures as follows:
      1. Coagulate fine structures (<2 mm) using bipolar energy.
      2. Apply Hem-o-lok or titanium clips to larger structures (>2 mm) before division.
   6. Clip the peripheral end of a thick G7 branch near the IVC using a Hem-o-lok, then divide it with the harmonic scalpel.
   7. Fully expose the angle between the MHV and RHV.
   8. Divide the RHV using a powered linear stapler (e.g., Model: ID30TANB).
      NOTE: Operational detail: Select the appropriate stapler cartridge based on tissue thickness and vessel diameter.
   9. Divide the right portal vein (RPV) using the powered linear stapler.
   10. Divide the transverse portion of the left hepatic duct using the harmonic scalpel. Extract any residual stones.
   11. Complete the right hemihepatectomy.
       NOTE: Confirm full exposure of the MHV on the cut surface and absence of bleeding from the vein after vascular filling. Perform Roux-en-Y hepaticojejunostomy as indicated.
6. Remove specimen and place drains
   1. Place the resected specimen in a retrieval bag and extract it.
   2. Place closed-suction drains in the resection bed and the subhepatic space.

4. Postoperative care

1. Monitor vital signs and laboratory parameters
   1. Monitor vital signs regularly.
   2. Perform daily or as-needed laboratory tests, including complete blood count (CBC), liver function tests (LFTs), coagulation profile, renal function tests, electrolyte levels, and procalcitonin (PCT).
2. Manage drains
   1. Record the daily drain output volume and character.
   2. Irrigate the drains if necessary.
3. Manage pain and encourage mobilization.
   1. Administer appropriate analgesia.
   2. Encourage early ambulation.
4. Schedule follow-up
   1. Arrange telephone follow-up after discharge.
   2. Arrange outpatient clinic follow-up to assess liver function and wound healing.

5. Documentation and quality control

1. Maintain a detailed operative report
   1. Document the preoperative diagnosis, intraoperative findings, surgical techniques used, challenges encountered, and solutions implemented.
2. Review outcomes
   1. Review treatment outcomes and complications in a structured manner.
   2. Incorporate the findings into future quality improvement initiatives.

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