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 perioperative outcomes, underscoring the importance of vascular protection during hepatobiliary procedures³. Meanwhile, the adoption of laparoscopic hepatectomy has revolutionized hepatobiliary surgery, demonstrating reduced blood loss, shorter hospital stay, and comparable long-term outcomes compared with open surgery, provided that precise anatomical dissection can be achieved⁴.

To address these challenges, technical refinements that integrate vascular preservation with minimally invasive approaches have been proposed⁵. Intraoperative ultrasound has become an indispensable adjunct for real-time vascular navigation, enabling accurate identification of the MHV and its branches to guide safe resection⁶. Building on these advances, this protocol develops a “blunt and sharp combination” method as part of a vascular protection strategy to achieve safe laparoscopic hepatectomy for complex biliary stones involving the MHV. This technique combines sharp ultrasonic dissection of the fibrotic bile duct wall with careful blunt separation of adhesions from the MHV sheath, supplemented by low-power electrocoagulation for hemostasis. By maintaining dissection along precise anatomical planes, this method facilitates complete removal of diseased bile ducts while safeguarding vascular integrity, thereby minimizing intraoperative bleeding, reducing post-operative complications, and preserving liver function. Here, we describe the protocol and representative outcomes of this approach, which provides a reproducible, standardized solution for complex biliary surgery in the era of precision, minimally invasive hepatobiliary surgery.

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, determine its size, and assess for features such as bile duct dilation or vascular invasion.
2. Specifically evaluate the tumor's proximity to and potential involvement of major hepatic veins (e.g., MHV) and portal pedicles, as this dictates surgical planning.
3. Evaluate the patient's overall health status, including age, performance status (PS score), and history of underlying liver disease (e.g., hepatitis B/C, cirrhosis).
4. Quantitatively assess liver functional reserve (e.g., Child-Pugh classification, serum bilirubin, ICG-R15 (Detect the retention rate of indocyanine green in the blood 15 min after intravenously injecting ICG (0.5mg/kg), by nasal wing ICG detector).

2. Quantitative evaluation of liver volume and assessment of resectability

1. Perform volumetric analysis based on preoperative imaging to calculate SLV, Actual Total Liver Volume, FLR, FLR/SLV, or SRLVR.
   NOTE: According to expert consensus, a procedure is generally considered safe when the ICG-R15 is <10% and the SRLVR is ≥40%. If the SRLVR is insufficient (e.g., <40%), strategies like portal vein ligation (PVL) or Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) must be considered to induce hypertrophy of the FLR before major resection.

3. Surgical setup

1. Place the patient in the supine position.
2. Administer general anesthesia according to the institutionally approved standard protocols. Maintain the central venous pressure between 0 and 5 cmH₂O.
3. Establish pneumoperitoneum using the open technique. Place one 10 mm camera trocar next to the umbilicus. Set the pneumoperitoneum insufflation pressure at 12 mmHg. Perform a thorough abdominal cavity exploration.
4. Place the remaining four trocars, including 5 mm or 12 mm working trocars, in the left upper quadrants for the main surgeon and in the right upper quadrants for the assistant surgeon (Figure 1).

4. Cholecystectomy

1. Expose the Calot's triangle. Dissect the cystic duct and cystic artery. Double ligate their proximal ends. Transect the vessels and duct.
2. Dissect the gallbladder from the liver bed. Achieve hemostasis on the liver bed surface with electrocautery (Power level: 35 W).

5. Liver mobilization and preparation for bleeding control

1. Dissect the ligament, including the round ligament, falciform ligament, and partial left coronary ligament.
2. Identify the root of the MHV, right hepatic vein (RHV), and left hepatic vein (LHV). Mark the Cantlie’s line using an electrocoagulation hook as the imaginary division of the liver, extending from the middle hepatic vein to the middle of the gallbladder.
3. Perform an intraoperative ultrasound scan (IOUS) to confirm the MHC and the bile duct location (B-mode, 5.0 MHz). Identify the root of MHV as the landmark of MHV, along with which, locate the boundary of the bile duct with mixed echoes. Apply water to expel air and ensure the conduction of sound waves.
4. Implant a 12# Disposable Urethral Catheter at the first hepatic portal for the Pringle’s maneuver. Perform an inflow occlusion for 15 min, then repeat after releasing for 5 min.
5. Dissect and divide the LPV and arteries of the left liver. Confirm the ischemic demarcation line.

6. Liver parenchyma transection

1. Divide parenchyma along the ischemic demarcation line, using an ultrasound scalpel (Power level: MAX) and then clamping, ligating, or bipolar coagulating (Power level: 50 W).
2. The "blunt and sharp combination" method:
3. Sharply separate the outer layer of the inflamed bile duct with the ultrasonic scalpel (Power level: MIN) (Figure 2).
4. Bluntly separate dense tissue adhered to the MHV along the sheath plane with the ultrasonic scalpel or a laparoscopic suction irrigation (Figure 2).
   NOTE: This method is used to separate dense tissue caused by fibrosis due to chronic inflammation rather than tumor invasion.
5. Dissect tributaries of MHV, including V4b, V4a, and V8. In case of injury to the tributaries, apply immediately with an absorbable hemostatic dressing and isolate the CO₂ by adding water to prevent gas from entering the hepatic vein and causing gas embolism. Expose MHV completely (Figure 3).
6. Use an endoscopic linear cutting stapler and vascular stapler cartridge to divide the left portal vein (White staple: Hepatic pedicle stapler cartridge) and left hepatic vein (Blue staple: Vascular stapler cartridge).
7. Complete the transection by dividing the left hepatic bile duct and connective vein surrounding it with an ultrasonic scalpel.

7. Choledocholithotomy

1. Place a 12 mm trocar for a subxiphoid port.
2. Remove the intra/extrahepatic bile duct stones with a retrieval basket through choledochoscopy from the left hepatic bile duct end until complete stone clearance.
3. Close the left bile duct end with PDS synthetic absorbable surgical sutures.

8. Post-resection management

1. Place a T-tube (22 Fr) in the Common Bile Duct (CBD) from the subxiphoid port for external drainage.
2. Final inspection: Post-resection anatomy confirmation, section surface hemostasis, and bile leakage detection with White gauze test (Figure 4).
3. Place one drainage tube next to the section surface and another in the foramen of Winslow to drain blood or bile. Fix them to the skin to prevent it from being dislodged.
4. Retrieve specimen using an endoscopic retrieval bag through the enlarged camera port.
5. Close the abdominal incisions.

9. Follow-up management

1. Short-term follow-up
   1. Test bilirubin daily in drain fluid or T-tube cholangiography/MRCP to exclude occult bile leaks. Remove the drain tube until the drainage fluid without bile is less than 10 mL.
   2. Perform dynamic monitoring of liver function weekly.
   3. After 3 days of liquid diet, follow a semi-liquid diet for one week, and then transition to a low-fat diet.
   4. Perform radiological imaging and T-tube angiography to check residual stones. Remove the T-tube 1.5 months later.
2. Long-term follow-up
   1. Treat with Ursodeoxycholic Acid and adopt a low-fat diet to prevent recurrence.
   2. Test liver function and radiological imaging at 6, 12, and 24 months to document residual stones or new strictures.

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