Caudal approach to the middle hepatic vein as a resection pathway in difficult major hepatectomies under laparoscopic approach

As highlighted during the II Consensus Conference on Laparoscopic Liver Surgery, the caudal approach is the main conceptual change in laparoscopic liver resection in contrast with the “anterior” approach in open liver surgery.1

This caudal approach has led to technical approaches specifically designed to be performed laparoscopically2-4; characteristically, a dorsal approach to the middle hepatic vein (MHV) has been described.5

Considering that MHV runs cranial and anterior, but close to the portal bifurcation,6 and thanks to the unique laparoscopic caudal view, a caudal approach to the MHV can be performed in this location.

This approach is particularly useful in difficult major hepatectomies: an early identification of the MHV above the hilum at the beginning of the transection ensures a safe and reliable pathway. The transection is safely continued in a vein‐guided fashion.

This concept is demonstrated in two examples: an extended (to MHV) left and a right hepatectomy, both difficult due to giant hepatocellular carcinomas occupying the left and the right hemiliver respectively. In both cases, a caudal approach to the MHV initiates the transection that is continued in a vein‐guided fashion. This results in a safe pathway thus facilitating the procedure and warranting secure anatomical and oncological margins. 

CITA DEL ARTÍCULO  J Surg Oncol . 2020 Aug 3.doi: 10.1002/jso.26150