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

This study aims to develop accessible surgical techniques for complex liver tumors using anatomical landmarks instead of advanced technology in resource-limited settings. The challenge is to perform precise resection without navigation because of poor visibility, unclear boundaries, and specific anatomical requirements. To begin, divide the round and falciform ligaments following abdominal access using a monopolar energy device.

Dissect the second hilum to expose the caval fossa, achieving full visualization of the right hepatic vein. Employ a 14 French catheter at the first hepatic hilum to preposition the Pringle maneuver tourniquet. Divide the right triangular ligament and fully mobilize the right liver from its dorsal inferior aspect to expose the inferior vena cava by carefully separating the areolar tissue.

Now dissect the dorsal superior border of the right liver toward the right hepatic vein. Divide the Makuuchi ligament, permitting circumferential exposure of the right hepatic vein, which is then encircled with a silk ligature. With a temporary Pringle occlusion, bluntly dissect the Glissonean pedicle to the dorsal S7 subsegment along the avascular plane of Laennec's capsule and encircle it with silk.

After releasing the Pringle clamp, apply a non-crushing vascular clamp to the Glissonean pedicle of dorsal S7.Observe and mark clear ischemic demarcation of the dorsal S7 territory with electrocautery. Identify Cantlie's line, the midplane of the liver, as the right and left hemiliver boundary by tracing the course of the middle hepatic vein and marking it, concurrently delineating the cranial and caudal right liver division. Then using non-traumatic forceps, adjust and mark the ventral resection line for segment 7 and dorsal segment 8.

Mark a point 2.5 centimeters lateral to the middle hepatic vein, guided by intraoperative visual estimation and preoperative imaging fusion, ensuring more than two centimeters resection margins while preventing exposure of the middle hepatic vein. Now expose and transect the right hepatic vein root using a vascular stapler after confirming safe circumferential dissection, revealing ischemic discoloration in segment 7 and congested areas in partial segments 6 and 5. Extra hepatically dissect the right hepatic pedicle from portal branch 4 to 6 along Laennec's capsule and implement silk loop-guided right hemihepatic inflow occlusion to demonstrate a sharp Cantlie's line.

Proceed with parenchymal transection along both the modified ventral resection line at the segment 7 ischemic boundary and the modified dorsal resection line at the horizontal limb of the reverse-L plane using a combination of ultrasonic aspirator and bipolar sealer. Finally, with both the planes established, perform progressive parenchymal dissection, encountering and transecting the middle right hepatic vein, the superior right hepatic vein, the secondary Glissonean segment 7 branch, and the ventral segment 8 vein between clips or with staplers. Maintain meticulous preservation of the inferior right hepatic vein throughout by direct visualization and avoid traction.

Preoperative imaging revealed a tumor abutting the right hepatic vein, two dominant Glissonean pedicles to segment 7, identified as G71 and G72, and a substantial inferior right hepatic vein draining segment 6. Postoperative imaging confirmed a hepatic defect with a preserved patent inferior right hepatic vein. On postoperative day one, alanine aminotransferase and aspartate aminotransferase levels were elevated at 460 units per liter and 499 units per liter, respectively.

By postoperative day three, alanine aminotransferase decreased to 305 units per liter and aspartate aminotransferase to 114 units per liter. Perioperative bilirubin levels remained within normal limits. Coagulation profiles remained consistently normal before and after surgery.

Preoperative alpha-fetoprotein measured 9.6 nanograms per milliliter and normalized after resection. This landmark-based protocol enables precise functional liver preservation without advanced navigation in resource-limited settings. Future multicenter studies will compare outcomes and explore integrating augmented reality for advancing the surgeries.