A Stepwise Approach to Laparoscopic Mesohepatectomy: From Complexity to Standardization with Video Demonstration

Mesohepatectomy is indicated for centrally located tumors when parenchymal-sparing strategies are unfeasible.¹ The procedure requires two converging transection planes, management of two major hepatic veins-the right hepatic vein (RHV) and middle hepatic vein (MHV)-and control of two sectorial inflows (right anterior and left medial). Mesohepatectomy can be performed with minimally invasive approach, including both laparoscopic^2,3 and robotic techniques,^4,5 with differences in the sequence of surgical steps reported in the literature. We describe a standardized laparoscopic technique, providing a stepwise approach to safely perform this complex procedure.

The procedure is performed using five trocars without liver mobilization and structured in five sequential steps: (1) intrahepatic Glissonean approach^6,7 to Sg4 pedicles. The section cranially reaches the MHV and caudally the hilar plate. (2) Intrahepatic Glissonean approach to Sg5-8 pedicle. The dissection slides along the hilar plate to isolate G5-8. Once occluded, indocyanine green (ICG) is injected, and the remnant liver is stained. (3) Intrahepatic section of the MHV. Venous congestion is avoided thanks to complete inflow occlusion. (4) Cranio-ventral dissection of the RHV. Venous branches draining Sg5-8 are sequentially divided. (5) ICG-guided right intersectional parenchymal transection.⁸ The lack of anatomical landmarks between Sg6-7 and Sg5-8 is compensated by ICG guidance.

The attached video demonstrates the technique in a 75-year-old patient with hepatocellular carcinoma. Postoperative recovery was uneventful, with the patient discharged on postoperative day 4.

Laparoscopic mesohepatectomy can be safely performed in selected patients. Standardization into sequential steps is essential to improve safety and reproducibility.