Laparoscopic modular extended right posterior sectionectomy for hepatocellular carcinoma guided by projection plane extension from the right hepatic vein

BackgroundExtended right posterior sectionectomy (ERPS) preserves more liver parenchyma than right hepatectomy when hepatocellular carcinoma (HCC) is in the right posterior section (RPS) and part of the right anterior section (RAS), but the difficulty lies in the precise determination of the cutting plane, especially under laparoscopy.[Torzilli et al. in Annals of surgery. 247:603-611, 2008] If the right hepatic vein (RHV) is not invaded by the tumor, it can help to divide the ventral and dorsal plane (VP, DP) as surgical landmark.[Makuuchi in International Journal of Surgery. 11:S47-S49, 2013] (Fig. 1) This study presented a laparoscopic modular ERPS (LMERPS) guided by projection plane extension from the RHV. Fig. 1Projection plane extending from the right hepatic vein. a & b: The VP was bounded by the RHV and its projection; c & d: The DP was bounded by the RHV, IVC, and DL of the RPS and RAS. RHV, right hepatic vein; VP, ventral plane; DP, dorsal plane; IVC, inferior vena cava; DL, demarcation line; RPS, right posterior section; RAS, right anterior sectionMethods A 56-year-old man was seen with HCC in the (RPS) and segment 8 following two laparotomies. After releasing intraperitoneal adhesions, the short hepatic veins were severed to expose the inferior vena cava (IVC). The right posterior Glission pedicle (RPGP) was clamped to control RPS inflow and allow determination of the demarcation line (DL) between the RPS and RAS using ICG fluorescence staining.[Chen et al. in Annals of surgical oncology. 29:2034-2040, 2022] Intraoperative ultrasound identified the RHV projection to satisfy the requirements of oncologic treatment. The VP and DP were incised along the DL and RHV projection. The RHV was exposed fully on the cutting plane and the tumor was completely removed finally.Results The operation was completed in 265 min, with a blood loss of 50 ml. The diagnosis was HCC with a negative resection margin. The patient was discharged on postoperative day 8 without any complications.Conclusion LMERPS guided by a projection plane extending from the RHV is feasible and effective.