Middle hepatic vein - landmark structure for safe anatomic laparoscopic liver resection

Abstract

Background: The middle hepatic vein (MHV) represents the landmark structure for the anatomic hemihepatectomy. Intraoperative visualization and exposure of the MHV and it’s branches during laparoscopic liver resection is key to anticipate potential bleeding hotspots and allows for delicate bloodless vessel sealing and dissection.

Material Methods: On the basis of a representative right and left laparoscopic hemihepatectomy-video, we demonstrate the importance of the intraparenchymal identification of the MHV for anatomic major liver resection.

Technique: In standrdized french position hilar vessels are exposed first and the inflow ins controlled. Parenchymal transection is performed along the demarcation line (Seg 4 and 5+8, Cantli line) using ultrasonic shears and the laparoscopic CUSA. Intraparenchymal identification of the MHV is facilitated by intraoperative ultrasound.

Clips or ligatures are used for vessel sealing. The hilar plate is transected with a laparoscopic stapler. The MHV is exposed and preserved in demonstrated videos. The left hepatic or right hepatic vein is again sealed using a laparoscopic stapler.

Conclusions: Guidance and navigation according to the anatomy of the MHV helps to anticipate inflowing major branches thus possible major hotspots of bleeding. This might help to prevent injury to the future liver remnant and facilitates laparoscopic major liver resection at a good pace. Intraoperative Indocyanine green (ICG) fluorescence detection by the “counter perfusion method” is a useful tool to identify hepatic segments and intersegmental planes during anatomic liver resection.

We report of a 54-year old patient with recurrent cholangitis due to Caroli disease, who underwent a laparoscopic hemihepatectomy. To determine the resection line and resection plane, we injected ICG intravenously after clamping/ligating the left hepatic artery and left portal vein. Before and during resection the liver was observed under visible light and under near-infrared (NIR) light. This method allowed for precise anatomical resection of non-perfused liver segments 2,3 and 4. ICG Visualisation is useful tool in laparoscopic liver resection.