Ventral Approach to the Middle Hepatic Vein During Laparoscopic Hemihepatectomy

The caudal approach constitutes a conceptual change in laparoscopic hepatectomy.1^-4 The middle hepatic vein (MHV) located in the midplane of the liver serves as a landmark during hemihepatectomy.5 However, it is difficult to expose the MHV from its peripheral branches toward the main root via the caudal approach because of anatomical variations in branching patterns.6 We present the ventral approach to the MHV during laparoscopic hemihepatectomy.

The ventral approach involves liver transection from the ventral to the dorsal aspect using a flexible laparoscope, similar to an open hepatectomy.7 The key characteristic of the ventral approach is early transection of the cranial portion of the liver, which facilitates accurate transection and maintains an open cutting plane. After achieving a wide surgical plane, the MHV is exposed from the main root toward its peripheral branches. The plane of parenchymal transection is easily modified based on the type of hemihepatectomy.

This technique was used in 15 patients between March 2016 and July 2018, of whom 7 underwent right hemihepatectomy and 8 underwent left hemihepatectomy. The median operative time was 240 min (range 180-410), and the intraoperative blood loss was 150 mL (range 80-310). The median postoperative hospital stay was 8 days (range 5-14). No major postoperative morbidity or mortality was reported.

The ventral approach to the MHV involving exposure of the vein from the main trunk toward its peripheral branches may be an effective and feasible technique during laparoscopic hemihepatectomy.