Supplementary materials can be found via https://doi.org/10.7602/jmis.2023.26.3.162.

Approximately 20% of hepatocellular carcinomas (HCC) occur in noncirrhotic livers [1]. Resection may be considered for patients with HCC, provided sufficient future liver remnant is available, regardless of the tumor size. Laparoscopic liver resection is a technically challenging procedure that requires a thorough understanding of the liver anatomy and advanced laparoscopic surgical skills. The surgeon has to overcome inadequate exposure, and difficulties associated with parenchymal transection while performing resection of the posterior and superior parts of the liver. Several successful laparoscopic liver resections have been recently reported due to advancements in technology and expertise [2–5]. We report the management of large HCC located in segments 6 and 7, splaying the right hepatic vein (RHV) and abutting the inferior vena cava (IVC) using laparoscopic right posterior sectionectomy (Supplementary Video 1).

A 60-year-old gentleman presented with vague pain in the right upper abdomen, without accompanying symptoms such as anorexia and weight loss. There was no evidence of jaundice or gastrointestinal bleeding. He was moderately built with a body mass index of 21 kg/m². An initial ultrasound evaluation revealed the presence of a large space occupying the lesion in the right lobe of liver. A subsequent positron emission tomography-computed tomography showed a space-occupying lesion in the right posterior section, 10 × 8 cm in size having features consistent with HCC. The mass was compressing and splaying the RHV, and the right inferior hepatic vein appeared prominent. The patient had type III portal anatomy with early branching of the right posterior portal vein. There were no features of cirrhosis. The patient had normal liver function test, alpha-fetoprotein levels and was seronegative for hepatitis B and C viruses. The patient also had a fluorodeoxyglucose-avid left common iliac node measuring 2.0 × 1.5 cm. Staging laparoscopy and lymph node biopsy demonstrated inflammatory features. A total laparoscopic right posterior sectionectomy was planned.

Operative procedure

Under general anesthesia, the patient was placed in a supine position and the right flank was elevated using a sandbag. The right shoulder was abducted and the legs were split (French position). The operator stood in between the patient’s legs and the assistant holding the camera stood to the right of the patient. The pneumoperitoneum was introduced with a Veress needle at Palmer’s point. A 10-mm port was inserted at the right upper quadrant 5-cm cephalad to the right of umbilicus. Two 12-mm ports were placed as working ports on either side and slightly cephalad to the first port. Two 5-mm ports were placed on the right subcostal region at mid axillary line and the epigastric region. The preparation for the Pringle maneuver was performed with umbilical tape around porta, snugged into a 24-French chest tube from the left flank. The camera scope used was a nonflexible 30° scope.

The falciform ligament and gastrohepatic ligament were taken down. Inflow control was performed with the camera at a 10-mm port. The hepatoduodenal ligament was dissected and the right posterior artery was clipped, and divided. The right posterior sectoral portal vein was looped and a bulldog clamp was applied. Inflow control reduced the size of tumor. A line of demarcation appeared between the right anterior and posterior sections. The camera was shifted to the right 12-mm port. Stay sutures were placed on either side of the planned transection. Parenchymal dissection was performed with the crush clamp technique and Thunderbeat (Olympus Medical Systems Corp.). We proceeded in a caudocranial approach. Smaller pedicles caudally were taken down with bipolar energy, while the larger pedicles as we move cephalad were taken down between clips. In view of plenty of tumor-draining veins close to the tumor, as we progress cranially, some ooze was there. We took the parenchyma down anteroposteriorly leaving a small amount of parenchyma surrounding major vessels, which could be taken down with staplers. Dissecting individual vessels would be difficult as we moved cranially in view of the ooze. Primary inflow pedicle, right inferior hepatic vein, and RHV were taken down with three Endo GIA staplers (Medtronic). Once transection was completed, the right triangular and coronary ligaments were divided and the specimen was retrieved through a Pfannenstiel incision with a wound protector. Hemostasis was achieved and a 24-Fr chest tube drain was placed.

The duration of surgery was 360 minutes and the blood loss was 400 mL. The total Pringle time was 34 minutes. The patient was discharged uneventfully on postoperative day 3. Histopathologic examination of the specimen revealed moderately differentiated HCC with intact capsule and free resection margins. The patient was doing well at the 2-month postoperative review.

Resections involving the posterosuperior part of the liver are technically complex and hence categorized as major resections [5]. A right posterior sectionectomy is preferred in comparison to a right hepatectomy for a deep-seated large tumor in segment 7 because the former can preserve the volume of the anterior section. Laparoscopic right posterior sectionectomy poses challenges such as horizontally faced transection surfaces and large vessels adjacent to IVC that can be laborious to control if injured. Modified patient positioning technique, use of advanced energy devices, and appropriate staplers helped us manage these challenges effectively. Early control of the right posterior portal vein was possible because the vein branched out proximal to bifurcation of the portal vein (type III anatomy).

The first step in conventional laparoscopic anatomical hepatectomy of the right lobe is the mobilization of the right liver [3]. An alternative posterior approach was described by Cheng et al. [6] for the resection of HCC involving segment 7. This technique also includes mobilization of the right liver. Mobilization was not initially feasible in our patient because of the large size of the tumor. The anterior approach technique was first described by Ozawa [7] in 1992. It was used to avoid manipulation of the liver and reduce tumor handling. An extrapolation of a similar technique in laparoscopy is called the “caudal approach” because of the caudocranial visual orientation. Liddo et al. [8] developed the “hanging maneuver” to refine this technique, utilizing a tape passed anteriorly to the IVC and posteriorly to the liver that is suspended with control cephalad and caudal. Owing to the large size of the tumor and its prominent inferior RHV drainage, a caudal approach was taken without using the hanging maneuver in our patient. This technique is commonly employed during open surgeries for large tumors located near IVC, known as the “transhepatic approach” [9].

The RHV drains a significant portion of the parenchyma of the right anterior section. A division of the RHV may result in congestion of segments 8 and 5, necessitating a right hepatectomy. A study by Fisher et al. [10] compared right hepatectomy with right posterior sectionectomy for posterior tumors. The results reveal that in 53.6% of patients, the division of RHV during posterior sectionectomy does not lead to postoperative implications. In our case, a sizable tumor was present that caused RHV splaying and relied on an enlarged inferior RHV for drainage. This suggests gradual compression of the vessel over time may have resulted in segment 5 and 8 drainage diversion to the middle hepatic vein. This is supported by a lack of congestion in the right anterior segments following the division of RHV.

To conclude, we have described a step-by-step caudal approach for the management of a large tumor located close to RHV and IVC. Notably, we performed this without hanging maneuver and with a division of RHV. Meticulous preoperative planning using imaging modalities to track the inflow and draining vessels would facilitate smooth surgery.

Ethical statements

This study was approved by the Institutional Review Board of Apollo Main Hospital with a waiver of informed consent (No. AMH-C-S-030/04-223).

Authors’ contributions

Conceptualization: SA

Validation: LJ, SSTE

Writing–original draft: SA

Writing–review & editing: JKAJ, PKR

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Data availability

The data presented in this study are available on request from the corresponding author.