https://orcid.org/0000-0002-6557-0712
Patients with hepatocellular carcinoma (HCC) and cirrhosis typically face limited resection options1. Advances in minimally invasive surgery2 and immunotherapy have broadened treatment strategies, including neoadjuvant approaches with tremelimumab and durvalumab, as well as 90Y transarterial radioembolization (TARE). The Arantius-first approach3 leverages anatomical landmarks to achieve precise liver resections, being particularly beneficial in complex cirrhotic patients.
The video accompanying this article is from a 78-year-old man with hepatitis B infection who was found to have a 5.8 cm HCC in segment 4a (see Video 1; a video transcript is available as Supplementary material). He was treated with entacavir, neoadjuvant tremelimumab and durvalumab4, and TARE of the left hepatic lobe. The standardized future liver remnant (sFLV)5 was estimated to be 52.9% from 30.7% after TARE, prompting surgical resection.
Laparoscopic left hemihepatectomy by the Arantius-first approach follow 90Y radioembolization and immunotherapy in a cirrhotic patient.
Initial mobilization included division of the falciform, left coronary ligament (Fig. 1) and upturning of the left lateral lobe, allowing for identification of Arantius’ duct between the left lateral lobe and Spiegel’s lobe without opening the lesser omentum to preserve collateral circulation. This exposure provided a clear landmark for the subsequent dissection. See Fig. 2.
Intraoperative view after dissection of the left triangular and coronary ligaments, revealing the trunks of the left hepatic vein and middle hepatic vein
The left diaphragmatic vein is also identified, enhancing visualization of critical vascular structures and facilitating subsequent steps in the Arantius-first approach. LIDV (Defined as a two branch structure draining the diaphragm ending in the left renal or suprarenal vein and IVC); MHV, middle hepatic vein; LHV, left hepatic vein.
Intraoperative view highlighting the Arantius ligament, which delineates the boundary between the left lateral lobe and Spiegel’s lobe, providing a crucial anatomical landmark in the Arantius-first approach
LHV, left hepatic vein; AL, Arantius ligament.
The liver parenchyma was widely opened above Arantius’ duct, spanning from the root of the left hepatic vein (LHV) to the left Glissonean pedicle (Glt)6 (Fig. 3). The posterior aspect of the Glt was carefully exposed, creating a space behind it to allow safe insertion of a stapler from the hepatic hilum side.
Three-dimensional reconstruction illustrating the transection point from gate 3 to gate 1 of the left Glissonean pedicle, following the Sugioka approach
The view is positioned above the insertion of the Arantius ligament, providing a clear anatomical guide for precise transection. G3, gate 3; G1, gate 1.
From the hepatic hilum side, the medial section (segment 4) was separated from the hilar plate and the right aspect of the Glt. This technique allowed for easy encirclement of the Glt by bridging the created gap with the posterior space. Critical attention was given to avoid injury of the Glissonean pedicle or bile ducts, particularly when opening gate 36, prioritizing liver preservation over excessive pedicle manipulation. The Glt was then divided just above the bifurcation of Arantius’ duct using a linear stapler smoothly. This strategic cut minimized the risk to nearby bile ducts.
Dissection of the liver parenchyma began from the caudal-dorsal edge, following the demarcation line on the liver surface. Then, the middle hepatic vein (MHV) was approached dorsally-cephalad by elevating the left lobe, allowing for precise exposure of the vein. Using a Cavitron Ultrasonic Surgical Aspirator (CUSA), the MHV was carefully dissected from its root toward the periphery, avoiding split vein injuries in patients at higher risk due to cirrhotic tissue7. See Fig. 4.
Intraoperative view showing the tumour adhered to the middle hepatic vein
The middle hepatic vein was approached dorsally by elevating the left lobe, allowing for progressive exposure with a Cavitron Ultrasonic Surgical Aspirator (CUSA) from root to periphery to minimize the risk of split vein injuries. MHV, middle hepatic vein.
Branches of the MHV from the left lobe were clipped and divided at their confluence. After exposing the main MHV trunk, parenchymal dissection proceeded smoothly between the MHV and the demarcation line, a plane that theoretically lacks Glissonean branches, ensuring a clean, controlled separation of segments without jeopardizing vascular integrity and successful tumor removal (see Fig. 5).
Macroscopic pathology image of the left lobe specimen, displaying a fibrotic nodule after specimen fixation in formalin
The image highlights the structural characteristics of the resected tissue, aiding in pathological assessment.
While Glissonean approaches are not widely used for laparoscopic liver resections8, the authors consider the Arantius-first approach3 for left hemihepatectomies to be an optimal technique for achieving precise and safe anatomical resections in cirrhotic patients.
Funding
This research was supported by FUJIFILM Corporation through a research loan agreement providing access to Synapses 3D reconstruction software.
Author contributions
William Kawahara (Conceptualization, Data curation, Investigation, Methodology, Software, Visualization, Writing—original draft, Writing—review & editing), Belen Rivera (Conceptualization, Investigation, Writing—review & editing), Jeffrey Roberts (Conceptualization, Data curation, Investigation, Writing—review & editing), Cathleen Huang (Data curation, Investigation, Writing—review & editing), Aishatu Ladu (Conceptualization, Investigation, Writing—review & editing), George P. Sorescu (Conceptualization, Writing—review & editing), Dmitry J. Rabkin (Conceptualization, Investigation, Writing—review & editing), Olga Kozyreva (Conceptualization, Investigation, Writing—review & editing), Fernando Rotellar (Conceptualization, Investigation, Writing—original draft, Writing—review & editing), and Eduardo A. Vega (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Visualization, Writing—original draft, Writing—review & editing)
Disclosure
E.A.V. is a consultant for the FUJIFILM Corporation and Olympus. The authors declare no other conflict of interest.
Supplementary material
Supplementary material is available at BJS online.
Data availability
Data sharing is not applicable to this article as no new data were created or analysed.
