Precision Surgery and Minimally Invasive Techniques for the Treatment of Complex Biliary Stones Closely Associated...

Hepatectomy is widely used for complex hepatobiliary stones, but when diseased bile ducts involve adjacent vessels, traditional methods, relying on extensive dissection or energy devices, often fail to ensure both complete resection and vascular protection, raising risks of bleeding, bile leakage, and liver dysfunction. This protocol introduces a "blunt-and-sharp combination" technique guided by vascular protection, integrating preoperative imaging and intraoperative ultrasound. In a laparoscopic left hemihepatectomy for complex stones, preoperative scans mapped stone distribution and the middle hepatic vein (MHV) course; intraoperative ultrasound localizes the MHV trunk and branches in real time. Sharp dissection of the fibrous bile duct's outer layer is performed with an ultrasonic scalpel, dense MHV-adherent tissue is bluntly peeled away, and low-power electrocoagulation minimizes thermal injury. After exposing the MHV trunk, separate the liver along its sheath plane, clip small branches with biologic clips, and preserve the main trunk. Steps include ultrasound-guided MHV identification, first porta hepatis dissection, selective left liver inflow occlusion, parenchymal splitting along the ischemic line, alternating blunt and precise coagulation to free adhesions, complete removal of the left hemiliver and diseased bile duct tree, and choledochoscopic stone clearance verification. The results of this case include that the operative time was 180 min, blood loss was 50 mL, no bile leakage, and liver function normalized on post-operative day 1. This approach achieves precise anatomical control, fulfilling dual aims of complete biliary resection and vessel preservation. It offers a standardized, minimally invasive, and safe solution for laparoscopic management of complex hepatobiliary stones with vascular involvement, with strong potential for clinical adoption.