Laparoscopic Anatomical Right Hepatectomy Using a Four-Incision Anterior Approach: Technical Details and Surgical Outcomes (with Video)

Abstract

Abstract Background Laparoscopic hepatectomy, characterized by its complexity, poses distinct challenges compared to other laparoscopic procedures. However, with the continuous advancements in laparoscopic techniques, many surgeons have enhanced the feasibility and safety of this approach for carefully selected patients. The purpose of this study is to offer a comprehensive account of the technical aspects and surgical outcomes associated with laparoscopic anatomical right hepatectomy, specifically utilizing a four-incision anterior approach. Patients and Methods: A total of 9 patients with primary liver cancer located in the right lobe underwent laparoscopic anatomical right hepatectomy using a four-incision anterior approach. Detailed information regarding the surgical procedure and incision locations was provided. Postoperative outcomes and operative techniques were retrospectively evaluated. Between September 2018 and September 2020, nine laparoscopic right anterior hepatectomies using a four-incision approach were performed on patients with primary liver cancer. The surgical procedure involved several maneuvers, including blocking the Glissonean pedicle, ligation of the right hepatic artery, right branch of the portal vein and the right hepatic duct, removal of the liver parenchyma along the ischemic line and determination of the liver section based on four anatomical landmarks: the right anterior Glissonian pedicle, middle hepatic vein, root of the right hepatic vein, and retrohepatic inferior vena cava. These landmarks facilitated identification of vessels requiring ligation, resulting in reduced bleeding. The article provides clear visualization of these anatomical landmarks following right hepatectomy. Results: All patients in this study underwent laparoscopic anatomical right hepatectomy using a four-incision anterior approach for the treatment of liver cancer. The average duration of the operation was 354 minutes, and the estimated blood loss was 250 ml. Importantly, there were no incidents of bile leakage observed post-surgery. Conclusion: Proper patient positioning and precise incision placement are crucial factors for ensuring the success of the laparoscopic right anterior hepatectomy procedure. The separation of the extrahepatic Glissonean pedicle at the liver hilum to determine the hepatic resection ischemia line, as well as the identification of liver sections using four anatomical landmarks, are essential steps in the liver resection process. Additional techniques, such as adjusting the patient's posture during the operation, utilizing suction operated by the surgeon's left hand and an ultrasonic scalpel in the right hand, and suturing bleeding vessels, contribute to the safe completion of the procedure. Furthermore, maintaining a low central venous pressure (CVP) can be beneficial in reducing intraoperative bleeding.