Precision Surgery and Minimally Invasive Techniques for the Treatment of Complex Biliary Stones Closely Associated with the Middle Hepatic Vein

Summary

This protocol demonstrates laparoscopic left hepatectomy using a “blunt and sharp combination” dissection technique, guided by intraoperative ultrasound, to safely treat complex biliary stones involving the middle hepatic vein, ensuring precise anatomical dissection, complete stone removal, and vascular protection while minimizing intraoperative bleeding and post-operative complications.

Abstract

Hepatectomy is widely used for complex hepatobiliary stones, but when diseased bile ducts involve adjacent vessels, traditional methods, relying on extensive dissection or energy devices, often fail to ensure both complete resection and vascular protection, raising risks of bleeding, bile leakage, and liver dysfunction. This protocol introduces a “blunt-and-sharp combination” technique guided by vascular protection, integrating preoperative imaging and intraoperative ultrasound. In a laparoscopic left hemihepatectomy for complex stones, preoperative scans mapped stone distribution and the middle hepatic vein (MHV) course; intraoperative ultrasound localizes the MHV trunk and branches in real time. Sharp dissection of the fibrous bile duct’s outer layer is performed with an ultrasonic scalpel, dense MHV-adherent tissue is bluntly peeled away, and low-power electrocoagulation minimizes thermal injury. After exposing the MHV trunk, separate the liver along its sheath plane, clip small branches with biologic clips, and preserve the main trunk. Steps include ultrasound-guided MHV identification, first porta hepatis dissection, selective left liver inflow occlusion, parenchymal splitting along the ischemic line, alternating blunt and precise coagulation to free adhesions, complete removal of the left hemiliver and diseased bile duct tree, and choledochoscopic stone clearance verification. The results of this case include that the operative time was 180 min, blood loss was 50 mL, no bile leakage, and liver function normalized on post-operative day 1. This approach achieves precise anatomical control, fulfilling dual aims of complete biliary resection and vessel preservation. It offers a standardized, minimally invasive, and safe solution for laparoscopic management of complex hepatobiliary stones with vascular involvement, with strong potential for clinical adoption.

Introduction

Complex hepatobiliary stones are a frequent cause of recurrent cholangitis, biliary obstruction, and progressive hepatic atrophy, often requiring hepatectomy when choledochoscopic lithotomy approaches are inadequate¹. However, when diseased bile ducts are closely associated with major vascular structures such as the MHV, conventional surgical techniques relying on large-scale tissue dissection or insufficient resection increase the risk of vascular injury, massive hemorrhage, bile leakage, and post-operative liver dysfunction². Injury to the MHV trunk or its tributaries has been reported to significantly worsen periopera....

Protocol

The protocol was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board at Shenzhen People’s Hospital. The research was performed in compliance with the institutional guidelines of the human research ethics committee at Shenzhen People's Hospital. Informed consent was obtained from the patient to participate in the study. The reagents and the equipment used are listed in the Table of Materials.

1. Preoperative assessment and confirmation of surgical indication

1. Utilize cross-sectional imaging (CT, MRI) to precisely localize the tumor,....

Results

This work reports and validates the proposed surgical protocol and demonstrates its clinical efficiency. In this case, a 59-year-old female who has a long history of hepatitis B and liver function, with a Hild-Pugh Class A, PS score 0, serum Tbil is normal. CT showed Left and right hepatic bile duct stones with left liver atrophy, left hepatic duct stenosis, and extrahepatic bile duct stones, closely associated with the MHV. The 15 min retention rate of ICG is 5.4%. SLV was 932.68 mL; the actual liver volume was 905.15 m.......

Discussion

The management of complex biliary stones closely associated with the MHV presents unique technical challenges. Traditional approaches often rely on extensive parenchymal dissection or insufficient resection, which increases the risks of intraoperative hemorrhage, bile leakage, and vascular injury². This protocol emphasizes a “blunt and sharp combination” dissection strategy guided by intraoperative ultrasound, enabling precise identification of the MHV trunk and its branches. By altern.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Absorbable hemostatic dressing	Ethicon	2082	Surgical  hemostasis
Bipolar coagulating.	YOUSHI	101.017A.3	Electrosurgical hemostasis
Choledochoscope	CHF-P60	CHF-P60	Bile duct exploration/stone extraction
Continuous Firing Clip Applier and Stapling Clips	Johnson &Johnson	LT200	Vessel Ligation
Disposable Urethral Catheter Tray	STAR	20162141618	Pringle's maneuvor
Drainage tube	BAINUS MEDICAL	SY-Fr22-C	Abdominal fluid drainage
ENDOPATH XCEL Trocars	Johnson &Johnson	2CB12LT/2CB5LT	Laparoscopic port access
Endoscopic linear cutting stapler cartridges	Ethicon	GST60W	Vascular stapler cartridge
Endoscopic linear cutting stapler cartridges	Ethicon	GCFLGB	Hepatic pedicle stapler cartridge
Endoscopic retrieval bag	HUANKANG	20162220561	Specimen retrieval
Indocyanine Green for Injection	Yi Chuang	H20055881	intraoperative fluorescence imaging
Intraoperative ultrasound	HITACHI	ALOKA-UST5418	Vessel/tumor localization
Laparoscopic suction irrigation	KANGJI	101.149	Fluid evacuation/blunt dissection
Ligating Clip	Wedu MedicaL	WD-JZ 3S	Vessel ligation
PDS synthetic absorbable surgical sutures	Johnson &Johnson	W9109H	Bile duct closure
Peng's multiple operative dissector, PMOD	SHUYOU SURGICAL	SY-IIIA (N) -1	Tissue dissection/hemostasis
Powered Plus Articulating Endocscopic Linear Cutter	Ethicon	PSEE60A	Laparoscopic stapler
Prolene Polypropylene non-absorbable sutures	Johnson &Johnson	W8761/W8710/W8706	Vessel closure
Retrieval basket	Cook Medical	NTSE-045065-UDH	Bile duct stone extraction
T-tube	GOLD BRIDGE	22Fr	Bile duct drainage
Ultrasonic scalpel	Johnson &Johnson Medical Devices	HAR36	Tissue dissection/hemostasis
Videoendoscope	STORZ	26605BA	Laparoscopic visualization