A 3-step dorsal approach with the extracorporeal ventral traction method for laparoscopic hemihepatectomy

Major laparoscopic hepatectomy along the major hepatic veins requires accurate orientation to the transection plane and safe management of the hepatic venous branches. We developed an extracorporeal ventral traction (EVT) method combined with a 3-step dorsal approach (3SDA) to standardize laparoscopic hemihepatectomy. In EVT, a traction suture secured on the caudal edge of the transection line is brought out through the epigastrium and pulled extracorporeally, elevating the liver parenchyma ventrally and allowing dorsal access under the caudal laparoscopic view. In 3SDA, the transection plane containing the major hepatic vein is divided into three areas: Area A, caudal to the hilum; Area B, dorsal to the hepatic vein; and Area C, ventral to the hepatic vein. These areas are approached sequentially to open the caudal view, maintain anatomical landmarks, and reduce venous injury. EVT and 3SDA provide a reproducible framework for laparoscopic hemihepatectomy.