Advanced liver dissection with left triangular ligament section for enhanced surgical access to right posterior...

Laparoscopic liver resection (LLR) has gained worldwide acceptance over the past decade, though its adoption remains incomplete due to technical challenges. These challenges, particularly in replicating traditional open surgery techniques, make controlling hemostasis and liver mobilization more difficult. The IWATE scoring system classifies the complexity of LLR, with expert-level procedures involving difficult-to-access segments. This study investigates whether extensive dissection around the inferior vena cava (IVC), including sectioning the left triangular ligament, improves liver rotation and access to right posterior lesions, potentially enhancing surgical exposure in LLR.

Dissections were performed at the Laboratory of Anatomy of the French Alps University. A formalin-preserved cadaveric model was developed to establish steps for liver dissection and liver rotation measurement, considering the inferior vena cava (IVC) as the vertical axis. Three key dissection steps were defined, focusing on the ligaments and the IVC. Liver rotation was measured using 30 newtons traction applied via the round ligament.

30 dissections were conducted. The rotation angles, measured before and during the three surgical dissection steps, progressively increased with median values of 36°, 45°, 71°, and 87°. Angulation gains of 9° [6-13], 19° [17-31], and 13° [10-21] were observed between each surgical step, with a negative correlation found between liver weight and the angle of rotation during the later steps.

Extensive dissection of the IVC, combined with sectioning of the left triangular ligament, is a useful surgical maneuver to increase liver rotation, providing better access to posterior liver segments during laparoscopy.