Feasible laparoscopic left trisectionectomy by Arantius' ligament approach (with video)

BackgroundLaparoscopic trisectionectomy is a technically challenging procedure with high rate of postoperative morbidity 1,2]. Arantius' ligament approach is useful to expose the root of middle hepatic vein, which is required in left trisectionectomy 3].MethodsThis video illustrates laparoscopic left trisectionectomy using Arantius' ligament approach. A 63-year-old man, with chronic kidney disease, had intrahepatic cholangiocarcinoma with a diameter of 8 cm, located in the segment 4 and anterior section of the liver. The tumor was close to the umbilical portion of the left portal vein and future liver remnant was 770 ml (49.5% of the whole liver) after left trisectionectomy.VideoAfter the pneumoperitoneum and the mobilization of the left lateral segment, the root of left and middle hepatic vein was exposed by division of Arantius’ ligament and parenchymal transection of dorsal surface around the root of left hepatic vein. Next, the left Glissonian pedicle was controlled and divided. The Glissonean pedicle for the anterior section was then isolated and divided. Demarcation line was then observed using indocyanine green negative counterstaining. Parenchymal transection was completed followed by the division of the common trunk of the left and middle hepatic veins.ResultsThe operation time was 294 min, and the blood loss was 400 g. The patient was discharged on postoperative day 16 after conservative treatment for temporary kidney injury. Pathological examination revealed intrahepatic cholangiocarcinoma with negative surgical margin.ConclusionThe Arantius’ ligament approach could be a feasible procedure for left trisectionectomy.