Evolution of Techniques in Laparoscopic Right Hepatectomy: Towards a Vein-Guided, Glissonean-Based Standard

As minimally invasive liver surgery has matured, techniques have evolved toward caudal, vein-guided, and parenchyma-sparing strategies that better leverage the laparoscopic view and improve operative control.^1,2 METHODS: This technical report describes the progressive evolution of our laparoscopic right hepatectomy approach.³ Major refinements included transition from supine to left semidecubitus positioning, delayed right liver mobilization until after parenchymal transection, continued use of an extraglissonean hilar approach with selective extrahepatic anterior inflow dissection, and adoption of a caudal-first transection strategy guided by the middle hepatic vein and inferior vena cava.^4,5 Selective late stapling of the right portal pedicle was incorporated in chosen cases to improve definition of the transection plane.

These modifications shifted the operation from an "open-translated" procedure to a more distinctly minimally invasive strategy. Left semidecubitus positioning improved exposure of the hepatocaval junction, whereas post-transection mobilization minimized traction on the hepatic veins and retrohepatic vena cava.^6,7 Early and continuous identification of the middle hepatic vein and inferior vena cava provided stable anatomic landmarks,⁸ facilitating safer vein-guided transection,⁹ improved orientation, and more controlled handling of venous tributaries and inflow structures. Selective late pedicle stapling further enhanced anatomic precision in appropriately selected cases.

The evolution of laparoscopic right hepatectomy reflects adaptation to the strengths of minimally invasive liver surgery. In selected patients, a caudal, vein-guided approach with delayed mobilization and individualized hilar control may improve anatomic orientation, definition of the transection plane, and technical precision.