Cranial-Dorsal Approach Along the Middle Hepatic Vein Facilitating Laparoscopic Left Hemihepatectomy.

The exposure and protection of middle hepatic vein (MHV) is crucial and difficult for anatomic laparoscopic left hemihepatectomy in the treatment of left hepatic tumor. 1, 2 The traditional caudal approach, which the liver is transected from the branch to the main trunk of MHV, is prone to damage the vessels. 3, 4 The ventral approach is easy to expose the main trunk of MHV; however, the risk of vascular laceration caused by the caudal approach cannot be completely avoided, since the direction of endoscopic view and liver dissection are from the foot to the head side. We herein present a cranial-dorsal approach along the middle hepatic vein during laparoscopic left hemihepatectomy.The key point of the cranial-dorsal approach was the hepatic parenchyma transection from the root of MHV toward its distal branches. Briefly, left hepatic blood inflow was blocked, followed by the dissociation and transection from the left hepatic duct and vein. Along the direction of the main trunk of the MHV, the liver resection plane could be clearly exposed from the cranial and dorsal sides, and then the branches of the MHV were managed separately. Owing to the full exposure along the MHV trunk, the remaining liver parenchyma could be quickly transected to complete the anatomic left hepatectomy finally. This technique was performed in 10 patients who underwent laparoscopic left hemihepatectomy from March 2017 to December 2019. The median operative time was 188 min (range 150-265 min), and the intraoperative blood loss was 191 mL (range 100-300 mL). The median postoperative hospital stay was 6 days (range 4-8 days). No major postoperative complications or mortality was reported (Table 1). Cranial-dorsal approach along the MHV may be a feasible and effective technique during laparoscopic left hemihepatectomy, contributing to the process of anatomic left liver resection by full exposure and protection of hepatic veins.