Outcomes of bile duct-guided right hepatic inflow occlusion and extended procedures in laparoscopic liver surgery

Abstract

Objective

This study aimed to assess the safety and feasibility of bile duct-guided right hepatic inflow occlusion and associated extended procedures in laparoscopic liver surgery (LLS).

Methods

A cohort of 23 patients who underwent laparoscopic right hemihepatectomy, which involved laparoscopic dissection and occlusion of the right hepatic artery and right portal vein using the bile duct-guided approach (primary procedure) were included in this study. Ten additional patients with insufficient future liver remnant (FLR) volume in the left hemiliver, as determined by preoperative assessment, underwent a staged approach. In the first stage, laparoscopic right portal vein ligation (LRPVL) was performed via the bile duct-guided approach (extended procedure). Following an observation interval, and upon confirmation of sufficient hypertrophy of the left hemiliver, either laparoscopic or open right hemihepatectomy, with or without combined procedures, was performed as the second stage.

Results

All procedures were completed without major postoperative complications. In the primary procedure cohort, the mean operative duration was 4.2 ± 0.4 h, the mean right hepatic portal occlusion time was 18 ± 8 min, intraoperative blood loss ranged from 200 to 400 ml, and the length of hospital stay was 7–12 days. For the first-stage extended procedure, the mean operative duration was 1.2 ± 0.3 h, the mean right portal vein occlusion was 14 ± 5 min, intraoperative blood loss ranged from 20 to 80 ml, and the length of hospital stay was 3–5 days. The second-stage procedure was performed 3 to 5 days after the most recent three-dimensional imaging assessment. The mean left liver volume increased from 456.14 ± 84.42 cm³ before the first-stage procedure to 649.06 ± 102.26 cm³ before the second-stage procedure, corresponding to a 44 ± 18% increase.

Conclusion

Bile duct-guided right hepatic inflow occlusion and its extended procedures demonstrated safety and feasibility in the context of LLS.

Introduction

Laparoscopic liver surgery (LLS) is a minimally invasive surgical approach performed through small incisions using a laparoscope. It is primarily indicated for the management of liver tumors, intrahepatic bile duct stones, and traumatic liver injuries. Compared with conventional open surgery, LLS has been associated with reduced surgical invasiveness, shorter postoperative recovery time, decreased hospital stay, and lower intensity of postoperative pain [1]. Advancements in surgical techniques and instrumentation have progressively expanded the indications for LLS. Its application now includes procedures expanding to hemihepatectomy and trisectionectomy, establishing it as an important component of contemporary surgical treatment for liver diseases [2]. Despite these advances, laparoscopic right hemihepatectomy remains technically demanding [3]. This procedure requires precise dissection of complex anatomical structures, meticulous vascular control, and a high level of surgical expertise. It is associated with considerable risks, including intraoperative hemorrhage, postoperative bile leakage, and liver failure.

To address these challenges, a novel technique, laparoscopic bile duct-guided right hepatic inflow occlusion, was developed. By standardizing the surgical process and simplifying the surgical process, this approach aims to reduce technical difficulty, enhance procedural safety, and broaden the applicability of laparoscopic right hemihepatectomy in clinical practice.

Laparoscopic bile duct-guided right hepatic inflow occlusion enables effective hepatic inflow occlusion by leveraging bile duct anatomy as a guiding structure under laparoscopic visualization. Precise localization under laparoscopy allows occlusion of blood flow along a predefined anatomical pathway. During this process, selection of an appropriate point of entry into the liver minimizes the need for extensive parenchymal exposure, thereby reducing operative trauma when compared with conventional techniques. Enhanced vascular control also improves visualization of the surgical field, facilitating accurate hepatic dissection and resection. This approach was associated with shorter operative duration and a higher likelihood of procedural success. Furthermore, reduced perfusion to the occluded hepatic region lowers the risk of intraoperative hemorrhage, enhances surgical safety, and decreases the incidence of hemorrhage-related complications.

In certain cases, right hemihepatectomy is indicated based on underlying hepatic pathology. Preoperative evaluation, however, may reveal insufficient future liver remnant (FLR) volume in the left hemiliver after right hemihepatectomy, placing the patient at considerable risk for postoperative complications, such as liver failure. Portal vein embolization (PVE) has been widely applied in clinical practice to reduce right hepatic inflow and increase left hepatic inflow, thereby promoting hypertrophy of the left hemiliver, thereby improving surgical candidacy for major hepatectomy [4]. Building upon this concept, a novel surgical technique was developed: laparoscopic right portal vein ligation (LRPVL), an extended procedure associated with laparoscopic bile duct-guided right hepatic inflow occlusion. In this staged approach, LRPVL is performed initially to promote hypertrophy of the left hemiliver. Once adequate hypertrophy is achieved, right hemihepatectomy, laparoscopic or open, is carried out in the second stage. Additional disease-specific procedures may be incorporated during the second stage, including bile duct exploration with stone extraction and T-tube drainage for extrahepatic bile duct stones, or extrahepatic bile duct resection with lymphadenectomy and biliary-enteric anastomosis in cases of hilar cholangiocarcinoma.This staged, minimally invasive strategy enables safe right hemihepatectomy in patients with insufficient FLR volume while allowing tailored surgical management based on the underlying disease.

The bile duct-guided right hepatic inflow occlusion technique and its extended applications represent a novel advancement in LLS, contributing to the refinement and broader dissemination of technically complex hepatic procedures. The present study provides a comprehensive overview of this novel technique, outlines its key technical considerations, presents preliminary clinical data, and evaluates associated outcomes and potential benefits.

Materials and methods

Baseline characteristics

This study received approval from the institutional ethics committee, and written informed consent was obtained from all participants. Between January 2022 and December 2023, 23 patients diagnosed with either hepatocellular carcinoma or hepatolithiasis underwent laparoscopic right hemihepatectomy using the bile duct-guided right hepatic inflow occlusion technique (designated as the primary procedure).

During the same period, 10 additional patients (6 males and 4 females; age range 31–71 years; mean age 49.2 ± 8.5 years) were identified as requiring right hemihepatectomy for various hepatic conditions at the time of admission. However, preoperative assessment indicated insufficient FLR volume in the left hemiliver, indicating a high risk of postoperative hepatic failure. As a result, LRPVL, an extended procedure associated with the bile duct-guided technique, was performed as the first stage. Following a period of observation, once sufficient hypertrophy of the left hemiliver was confirmed, either laparoscopic or open right hemihepatectomy with or without combined procedures was undertaken as the second stage.

All patients underwent routine preoperative investigations, including contrast-enhanced magnetic resonance imaging (MRI) or computed tomography (CT), to evaluate the feasibility of laparoscopic right hemihepatectomy and to exclude surgical contraindications. For those undergoing extended procedures, 3D-CT or MRI was additionally performed to evaluate the morphology and volume of both hepatic lobes and to determine eligibility for LRPVL. Preoperative assessment included detailed measurements of hepatic anatomy, confirmation of insufficient FLR volume in the left hemiliver, and evaluation of potential hypertrophy to support a subsequent resection. Postoperatively, patients were followed at regular intervals with 3D-CT imaging to measure hepatic lobe volumes, with particular attention to hypertrophy of the left hemiliver. Second-stage right hemihepatectomy was performed only after the left hemiliver had reached the predefined volumetric threshold.

Baseline demographic and clinical characteristics, operative duration, right hepatic portal occlusion time (defined as the time required for dissection and complete occlusion of the right hepatic artery and right portal vein), intraoperative blood loss, and postoperative complications were recorded. For patients undergoing the extended procedure, right portal vein occlusion time (defined as the time required for the dissection and complete occlusion of the right portal vein) and volumetric changes in hepatic segments on preoperative and postoperative 3D imaging were also documented. Data were reported as mean ± standard deviation (SD).

Detailed description of surgical procedures

Laparoscopic right hemihepatectomy (primary procedure)

The primary procedure consisted of the following steps:

1. Routine laparoscopic antegrade cholecystectomy was performed;

2. The right hepatic artery was dissected along the left wall of the extrahepatic bile duct and subsequently occluded;

3. Dissection was extended superiorly along the right wall of the common hepatic duct, using the right hepatic duct as a reference, to expose and occlude the right portal vein. The right hepatic duct was identified through meticulous anatomical dissection after cholecystectomy by first tracing the cystic duct medially to locate the common hepatic duct, then dissecting along its right border and anterior wall cephalad to expose the hilar bifurcation. The right duct was confirmed by its characteristic upward and rightward course into the liver parenchyma. Intraoperative indocyanine green fluorescence cholangiography was not used in this series;

4. The perihepatic ligaments were transected to achieve complete mobilization of the right hepatic lobe; and

5. Hepatic parenchymal transection was performed along the ischemic line, followed by completion of the right hemihepatectomy (Figs. 1 and 2).

Fig. 1.

Schematic representation of hilar management during laparoscopic right hemihepatectomy (primary procedure). A, B Right hepatic artery occlusion: The common hepatic duct was gently retracted to the right. Dissection was performed along the left wall of the extrahepatic bile duct to isolate the right hepatic artery. After identification of the branches of the left hepatic artery, the right hepatic artery was occluded using a Hem-o-lok^® clip to interrupt arterial inflow to the right hepatic lobe. C to E Right portal vein occlusion: The right portal vein followed a relatively consistent anatomical course, located posterior to the right hepatic duct. The right margin of the common hepatic duct was mobilized, and the duct was gently retracted superiorly and to the left. The Glisson’s capsule was opened along the posterior-lateral aspect of the common hepatic duct to expose the portal vein. Following mobilization of the right portal vein, a 1 − 0 silk suture was passed through, tied, and retracted anteriorly and to the right to achieve full exposure. Following confirmation of the portal vein bifurcation and identification of the contralateral (left) portal branch, the right portal vein branch was occluded using either an absorbable clip or a Hem-o-lok^® clip to block portal venous inflow

Fig. 2.

Intraoperative procedure for hilar management. A, B Right hepatic artery ligation. C, D Right portal vein ligation. E Confirmation of selective right hepatic inflow occlusion: following successful occlusion of the right hepatic artery and portal vein, a clear ischemic demarcation line appeared along the liver surface. The affected region demonstrated a dusky red discoloration, which contrasted distinctly with adjacent well-perfused parenchyma, thereby confirming adequate intraoperative vascular inflow control

Laparoscopic Right Portal Vein Ligation (LRPVL)

The extended procedure (LRPVL) involved the following steps:

1. Routine laparoscopic antegrade cholecystectomy was performed;

2. Dissection was extended superiorly along the right wall of the common hepatic duct, using the right hepatic duct as a reference, to expose and occlude the right portal vein;

3. The perihepatic ligaments were transected to achieve complete mobilization of the right hepatic lobe; and

4. After sufficient hypertrophy of the left hemiliver was confirmed based on volumetric imaging, a second-stage right hemihepatectomy, either laparoscopic or open, was performed, with or without combined procedures.

Partial description of surgical details

Arterial variations and their management

Following cholecystectomy, the right hepatic artery was initially occluded. In most cases, the bifurcation of the proper hepatic artery was located at a relatively low anatomical level, and limited dissection was sufficient to expose the left and right hepatic arteries together with their bifurcation (Fig. 1A and B A and B). Variations in the origin and extrahepatic course of the right hepatic artery are illustrated in Fig. 3. These anatomical variations increased the complexity of intraoperative dissection, underscoring the importance of detailed preoperative evaluation and careful intraoperative adjustment.

Fig. 3.

Schematic representation of right hepatic artery variants. A Normal origin of the right hepatic artery with reference to the abdominal aorta and celiac trunk. B to E Type I variants: origin from the celiac trunk system; B simultaneous branching of the left and right hepatic arteries and gastroduodenal artery, without a distinct proper hepatic artery; C origin of the right hepatic artery from the common hepatic artery; D direct origin from the celiac trunk; E origin from the gastroduodenal artery. F, G Type II variants: origin from the superior mesenteric artery system: F direct origin of the right hepatic artery from the superior mesenteric artery; G origin from the superior mesenteric artery with the gastroduodenal artery arising from the variant right hepatic artery. H Type III variant: direct origin the right hepatic artery from the abdominal aorta. I variations in intrahepatic course of the right hepatic artery. The artery traversed either anterior or posterior to the bile duct, with a wide range of arcuate trajectories (indicated by the dashed line)

Based on anatomical characteristics, three principal types of right hepatic artery variants were observed: Type I: originating from the celiac arterial system (Figs. 3B to E), such as from the common hepatic artery or gastroduodenal artery; Type II: originating from the superior mesenteric artery system (Figs. 3F and G), the most common variant, typically arising 1.5–2.5 cm from the root of the superior mesenteric artery; and Type III: originating directly from the abdominal aorta (Fig. 3H). In addition, the extrahepatic course of the right hepatic artery demonstrated considerable variation, with trajectories located either anterior or posterior to the bile duct (Fig. 3I). Despite this variability, a consistent feature was the entry of the right hepatic artery into the right liver via the left side of the extrahepatic bile duct, which served as a reliable anatomical landmark for dissection.

During the primary procedure, dissection was performed along the left wall of the extrahepatic bile duct to isolate and expose the right hepatic artery. This approach was employed as the standard initial maneuver for cases with conventional anatomy, following confirmation on preoperative imaging of the absence of arterial variants that would place a critical artery to the future liver remnant (e.g., a segment IV artery originating from the right anterior sectoral artery) at risk during left-sided dissection. After confirming the anatomy and ensuring preservation of left hepatic artery branches, the right hepatic artery was precisely occluded. When preoperative imaging identified variants that could compromise the future liver remnant supply with a left-sided approach, the dissection plane was adjusted intraoperatively to a right-sided or posterior approach relative to the bile duct to ensure safe preservation of the FLR blood supply. In contrast, during extended procedures, preservation of right hepatic arterial inflow was required. Meticulous dissection and precise identification of the vascular anatomy were essential to prevent injury to the right hepatic artery, which could otherwise result in severe postoperative complications such as right hepatic lobe necrosis or liver abscess, thereby compromising the feasibility of the second-stage procedure.

In certain anatomical variants, such as when the right hepatic artery originated from the superior mesenteric artery (Fig. 4A), the vessel crossed the bile duct at a relatively low level, which increased the complexity of dissection. In these scenarios, routine dissection and occlusion along the left wall of the extrahepatic bile duct were not feasible, as the intersection between the right hepatic artery and the left margin of the extrahepatic bile duct was frequently located inferior to the duodenal bulb. In such cases, dissection and occlusion of the right hepatic artery were performed along the right wall or, in some instances, the posterior wall of the extrahepatic bile duct. Meticulous preoperative evaluation of contrast-enhanced CT or MRI imaging was essential for determining the origin and course of the right hepatic artery. When indicated, three-dimensional reconstruction was performed to delineate the spatial relationships between the various vascular structures (Fig. 4B), thereby facilitating accurate intraoperative planning and execution.

Fig. 4.

Three-dimensional reconstruction of a right hepatic artery originating from the superior mesenteric artery. A Anatomical course and branching pattern of the right hepatic artery arising from the superior mesenteric artery, with direct arterial inflow to the right hemiliver. B Visualization of hepatic vascular and biliary structures without overlying liver parenchyma or surrounding tissues

Portal vein management

The right portal vein generally followed a consistent anatomical course, typically located posterior to the right hepatic duct. A systematic dissection technique was employed to ensure precise and safe identification of vascular structures. Dissection commenced at the right margin of the common hepatic duct (CHD), proceeding posterolaterally along the CHD to incise the Glisson’s sheath and expose the main portal vein (MPV). The dissection then proceeded anteriorly and superiorly along the portal vein to the bifurcation of the left and right portal branches, followed by further dissection in a right-superior direction to expose the origin of the right portal vein.

The right portal vein was dissected in a medial-to-lateral direction, while the main trunk was simultaneously isolated along the right margin of the hepatoduodenal ligament, after which lateral-to-medial dissection was completed. The right hepatic duct served as a key anatomical reference point to guide the dissection toward the right portal vein. For improved exposure, the CHD was retracted laterally. Once dissection from both sides converged, the right portal vein was fully mobilized (Figs. 1C and 2C). After mobilization, a No.1 silk ligature was placed and secured around the vessel (Fig. 2D). The ligature was then retracted anterolaterally to enhance exposure of the right portal vein (Fig. 1D). Depending on intraoperative requirements, occlusion was achieved using either an absorbable clip or a Hem-o-lok^® clip (Fig. 1E).

Prior to vascular control, the integrity of the portal vein bifurcation and the contralateral (left) portal branch was confirmed to ensure preservation of normal inflow to the left hemiliver. Manipulation of the right portal vein was performed with extreme caution. Adequate laparoscopic visualization was critical to maintain a clear surgical field and prevent injury to the main portal vein, left portal branch, or peri-hilar short branches. Complete occlusion of right-sided portal inflow was essential for procedural success, as incomplete occlusion could result in intraoperative or postoperative hemorrhage, inadequate left portal venous inflow, and delayed hypertrophy following extended procedures. Precise dissection, meticulous technique, and appropriate instrumentation facilitated complete occlusion, thereby supporting postoperative compensatory hypertrophy and functional recovery of the left hemiliver.

Management of the second hepatic hilum

Management of the second hepatic hilum was approached with extreme caution due to the thin walls of the hepatic veins. Improper handling could result in venous tearing, potentially leading to air embolism and, in severe cases, life-threatening complications. Premature dissection of the second hepatic hilum prior to hepatectomy was generally avoided.

In most cases, exposure of the right hepatic vein was performed intrahepatically during the later stage of hepatectomy, after parenchymal transection, followed by clamping or direct transection of the vessel. In selected cases with relatively loose anatomical structures at the second hepatic hilum, direct extrahepatic dissection and occlusion of the right hepatic vein were safely performed. During hepatic parenchymal transection, the middle hepatic vein was identified, and dissection proceeded along its main trunk. Maintenance of low central venous pressure was essential to minimize hemorrhage from the hepatic venous system [5].

Bile duct management

During laparoscopic surgery, meticulous attention was required to prevent bile duct injury. The bile duct, as a critical structure within the abdominal cavity, was susceptible to complications such as bile leakage, biliary tract infection, or obstructive jaundice if injured. To preserve its structural integrity and facilitate favorable postoperative outcomes, excessive traction, compression, or inadvertent resection was avoided. Furthermore, given the high variability of bile duct anatomy, preoperative imaging was meticulously reviewed to identify potential bile duct variations. Intraoperatively, preservation of bile drainage from the left hemiliver was prioritized. Ligation and transection of the right hepatic duct were deferred until parenchymal transection reached the level of the first hepatic hilum, ensuring accurate identification of all hilar structures. In certain circumstances, partial preservation of the right hepatic duct or its branches was considered appropriate based on intraoperative findings.

To specifically preserve the peribiliary vascular supply and prevent ischemic injury, dissection around the bile duct was minimized. Exposure was limited to the anterior surface necessary for identification, deliberately avoiding circumferential skeletonization. Dissection at the critical 3- and 9-o’clock positions was avoided to protect the axial blood vessels, and a margin of peribiliary soft tissue was maintained. Gentle retraction was achieved with a soft vessel loop. Ultrasonic shears or scissors were preferred over electrocautery hooks to minimize thermal injury to the peribiliary plexus. Additionally, understanding that a portion of the ductal supply originates from the right hepatic artery, perihilar dissection was minimized to allow collateral compensation from the preserved caudal blood supply after right hepatic artery ligation.

Postoperative follow-up

All patients were enrolled in a structured long-term follow-up protocol extending to 36 months postoperatively. Scheduled clinic visits occurred at 1, 2, 3, 6, 9, 12, 18, 24, and 36 months. Surveillance specifically for late biliary complications included clinical assessment, serial liver function tests (with emphasis on cholestatic markers), and cross-sectional imaging. A cornerstone of this surveillance was the routine use of contrast-enhanced magnetic resonance imaging with magnetic resonance cholangiopancreatography (MRCP) to proactively evaluate the biliary tract for stricture or dilation, even in asymptomatic patients.

Results

Basic outcomes

All 23 patients who underwent the primary procedure completed the surgery without intraoperative mortality. The mean operative duration was 4.2 ± 0.4 h, with a mean right hepatic portal occlusion time of 18 ± 8 min. Estimated intraoperative blood loss ranged from 200 to 400 mL. The postoperative hospital stay ranged from 7 to 12 days. Six patients developed mild postoperative complications, including seroperitoneum, bile leakage, wound oozing, and infection. These complications improved with appropriate management, and the patients were subsequently discharged. The remaining patients were discharged without adverse events.

All 10 patients who underwent the extended, staged procedure also completed the surgery without intraoperative mortality. The mean duration of the first-stage procedure was 1.2 ± 0.3 h, with a mean right portal vein occlusion time of 14 ± 5 min. Estimated intraoperative blood loss ranged from 20 to 80 mL, and the postoperative hospital stay ranged from 3 to 5 days.

Laparoscopic or open right hemihepatectomy, as well as combined procedures, was performed during the second stage, which took place 3–5 days after the final three-dimensional imaging assessment. Intraoperative findings demonstrated hypertrophy of the left hepatic lobe and atrophy of the right hepatic lobe. Perihepatic adhesions were mild and could be dissected without technical difficulty. All surgeries were completed successfully. No postoperative complications, such as severe hepatic dysfunction or hepatic failure, were observed.

Impact of LRPVL (right branch) on volumetric changes in hepatic segments

Postoperative changes in hepatic segmental volume were assessed in 10 patients who underwent LRPVL. Individual data for each group are presented in Table 1, and the intergroup statistical outcomes are summarized in Table 2.

Table 1.

Volumetric changes in hepatic segments before and after right portal vein ligation time is reported in days; volume is measured in cubic centimeters (cm³); volume ratio = postoperative volume ÷ preoperative volume. Liver volume was calculated excluding vascular structures and space-occupying lesions. Interval refers to the number of days between the two three-dimensional volumetric assessments

		Total liver volume change			Left liver volume change			Right liver volume change			Space-occupying lesion volume change
No.	Interval	Preop	Postop	Volume ratio	Preop	Postop	Volume ratio	Preop	Postop	Volume ratio	Preop	Postop	Volume ratio
1	56	1280.86	1409.42	1.10	412.40	649.94	1.58	868.46	759.48	0.87	82.62	91.17	1.10
2	23	1426.84	1365.20	0.96	607.72	742.80	1.22	819.12	622.40	0.76	70.56	70.60	1.00
3	15	1013.34	1130.01	1.12	432.15	707.82	1.64	581.19	422.19	0.73	162.92	157.28	0.97
4	16	1034.25	1378.20	1.33	490.24	786.22	1.60	544.01	591.98	1.09	45.54	38.37	0.84
5	46	1033.31	1189.68	1.15	448.90	686.97	1.53	584.41	502.71	0.86	328.43	229.06	0.70
6	22	1370.27	1470.47	1.07	422.76	571.40	1.35	947.51	899.07	0.95	279.80	369.37	1.32
7	64	1216.86	1201.63	0.99	381.78	499.25	1.31	835.08	702.38	0.84	511.46	534.77	1.05
8	37	1151.21	1044.81	0.91	568.81	631.59	1.11	582.40	413.22	0.71	51.56	69.59	1.35
9	26	1057.61	1110.50	1.05	322.72	486.16	1.51	734.89	624.34	0.85	7.50	5.09	0.68
10	23	1585.05	1814.67	1.14	473.93	728.43	1.54	1111.12	1086.24	0.98	33.57	19.16	0.57

Table 2.

Changes in liver segment volumes following laparoscopic right portal vein ligation (n = 10)

Index	Preoperative (cm3)	Postoperative (cm3)	Liver volume ratio (postoperative/preoperative)
Total volume of liver	1216.96 ± 195.91	1311.46 ± 227.73	1.08 ± 0.12
volume of left liver	456.14 ± 84.42	649.06 ± 102.26	1.44 ± 0.18
volume of right liver	760.82 ± 188.85	662.40 ± 210.81	0.86 ± 0.12

Compared with preoperative measurements, the total liver volume (TLV) demonstrated an increase of 8% (p = 0.027), the left liver volume (LLV) increased by 44 ± 18% (p < 0.001), while the right liver volume (RLV) showed a reduction of approximately 14%.

Discussion

Liver surgery poses significant challenges for hemorrhage control due to its dual blood supply—a difficulty magnified in laparoscopic procedures by restricted vision and operative space [6]. Selective hemihepatic inflow occlusion offers advantages over total inflow occlusion in suitable cases, reducing intraoperative blood loss, providing a clear ischemic demarcation line to guide transection (Fig. 2E), and minimizing ischemia-reperfusion injury [7–9].

This study introduces a bile duct-guided technique for laparoscopic right hepatic inflow occlusion. By using the extrahepatic bile duct as a consistent anatomical landmark, this approach allows precise dissection and occlusion of the right hepatic artery and portal vein. Although traditional methods often avoided direct biliary manipulation to prevent injury [10], advances in laparoscopic visualization have demonstrated the feasibility and safety of this method. The high-resolution, magnified view and multi‑angle exposure of laparoscopy enhance anatomical identification and vascular control. Outcomes in our cohort—including decreased intraoperative blood loss, a lower incidence of postoperative bile leakage, and accelerated recovery—support its effectiveness and reliability for laparoscopic right hemihepatectomy [11, 12].

For selecting the bile duct, rather than relying solely on direct vascular identification, as the primary guide warrants elaboration. This approach is not presented as superior to conventional vessel-oriented techniques, but as an alternative and complementary anatomical pathway. In the extrahepatic region, the bile duct often provides a consistent and visually distinct landmark under laparoscopic magnification, potentially offering a direct route to the deeper vascular structures without requiring extensive preliminary vascular dissection. It serves as an additional technical option, particularly useful in complex hilar anatomy. The ultimate goal is to equip surgeons with the flexibility to integrate or alternate between duct-based and vessel-based approaches based on intraoperative findings.

However, the potential for bile duct ischemia and late stricture—a risk inherent to any perihilar dissection—must be acknowledged. Our technique emphasizes minimal dissection to preserve the axial blood supply ("Bile duct management" section), yet the risk persists. Intraoperative signs of ischemia may prompt preventive measures (e.g., T-tube placement with omental wrapping). Postoperative surveillance includes liver function tests and MRCP if cholestasis occurs. A key limitation of this study is its short-to-medium term focus, which precludes definitive assessment of this late complication; extended follow-up is needed to evaluate long-term biliary safety.

During laparoscopic right hemihepatectomy, several critical considerations are essential to ensure surgical safety and favorable outcomes. Careful case selection is required; patients presenting with lesions adjacent to the hepatic hilum, abundant hilar collateral circulation, or severe hilar fibrosis are not suitable candidates for this approach. Preoperative imaging must be thoroughly evaluated to delineate the anatomy and potential variations of the hepatic artery and portal vein. Intraoperative dissection should be performed with precision and caution, avoiding excessive force, while prioritizing blunt dissection techniques to minimize the risk of vascular or bile duct injury. Anatomical variants, such as an aberrant right hepatic artery, should be accurately identified, and blood supply to the diseased region should be selectively occluded while preserving critical vascular branches. In cases involving complex vascular or biliary anatomy, timely application of total hepatic inflow occlusion may be warranted to maintain safety [13]. Similarly, timely conversion to open surgery may be considered to ensure safety. Particular attention is warranted when the right hepatic artery arises from the superior mesenteric artery, due to its low and posterior course. In such cases, dissection should be extended along the posterolateral and right walls of the extrahepatic common bile duct, with laparoscopic magnification and multi-angle visualization facilitating accurate exposure of these low-lying vessels. While a primary dissection along the left wall of the bile duct was found to be efficient in standard anatomy, alternative approaches, including an initial right-sided dissection, may be preferable or necessary in the presence of certain arterial variations, as highlighted by thoughtful surgical critique. Comprehensive preoperative planning, intraoperative adaptability, and technical optimization collectively enhance surgical success while reducing the risk of postoperative complications.

LRPVL offers a minimally invasive first-stage strategy for staged hepatectomy in patients with an insufficient FLR. This approach promotes rapid, uniform compensatory hypertrophy of the left hemiliver by mechanically occluding right-sided portal inflow while preserving left-sided perfusion, as supported by existing evidence [14, 15]. In our cohort, LRPVL effectively induced significant left liver hypertrophy (postoperative/preoperative volume ratio > 1.30 in most cases), enabling subsequent right hemihepatectomy in initially ineligible patients. Concurrently, right liver atrophy was observed, reflecting reduced portal inflow.

Compared to PVE, laparoscopic PVL provides several practical advantages: it avoids embolic materials and their associated inflammatory/embolic risks, allows full right lobe mobilization to minimize interim collateral formation, and enables direct anatomical evaluation and adjunctive procedures (e.g., biopsy) during the same operation. Although reported hypertrophy degrees between PVL and PVE are often comparable [16], our data suggest that direct ligation may achieve more consistent and effective FLR growth, possibly due to more complete flow occlusion and the absence of vessel recoil or embolic material dispersion.

A relevant consideration in the context of modern surgical practice is the role of adjunctive navigation technologies, such as indocyanine green (ICG) fluorescence cholangiography. While not utilized in the present study, ICG imaging is a valuable tool that provides real-time, enhanced visualization of the biliary tree, potentially aiding in complex dissections. The technique described herein is fundamentally an anatomical landmark-based approach. Conceptually, it is complementary to ICG navigation; the two can be integrated, with ICG providing a functional luminal map and the described dissection offering a structured anatomical pathway to the vascular pedicle. The absence of such advanced imaging in this series highlights that our technique relies on fundamental and widely accessible anatomical principles. Future refinements and applications of this approach would logically incorporate ICG fluorescence where available to further augment intraoperative precision and safety.

In conclusion, LRPVL represents a minimally invasive, safe, and efficient surgical technique with significant advantages in achieving right portal vein occlusion and promoting compensatory hypertrophy of the FLR. While preliminary outcomes are favorable, further validation in larger patient cohorts remains necessary to further substantiate these findings.

As an innovative minimally invasive technique, bile duct-guided right hepatic inflow occlusion, along with its extended applications, integrates the advantages of laparoscopic surgery with the anatomical precision offered by bile duct-guided dissection. This technique reduces the risk of bile duct injury, enhances the safety and efficiency of inflow occlusion, and plays an important role in surgical control and procedural accuracy. It provides a sound theoretical and practical basis for the advancement of laparoscopic right hemihepatectomy and LRPVL. Given its minimally invasive nature, high precision, favorable safety profile, and adaptability in complex surgical scenarios, this technique has potential for broader clinical use. Future refinements in surgical protocols and validation through large-scale clinical studies are expected to further expand its indications and further establish its role in hepatobiliary surgery.

Abbreviations

LLS

Laparoscopic Liver Surgery

LRPVL

Laparoscopic right portal vein ligation

PVL

Portal Vein Ligation

PVE

Portal Vein Embolizatio

FLR

Future liver remnant

Authors’ contributions

Conception and design of the research: Mingming Fan, Weifeng Tan, Qifei ZouAcquisition of data: Mingming Fan, Zhishi Yang, Zhiying Xu, Zhuangzhi Cong, Hu Liu, Lianwei Peng, Weifeng Tan, Qifei ZouAnalysis and interpretation of the data: Mingming Fan, Zhishi Yang, Zhiying Xu, Zhuangzhi Cong, Hu Liu, Lianwei PengStatistical analysis: Mingming Fan, Zhishi Yang, Zhiying Xu, Zhuangzhi Cong, Hu Liu, Lianwei PengWriting of the manuscript: Mingming Fan, Weifeng Tan, Qifei ZouCritical revision of the manuscript for intellectual content: Mingming Fan, Zhishi Yang, Weifeng Tan, Qifei Zou.

Funding

No external funding received to conduct this study.

Data availability

All data generated or analyzed during this study are included in this article. Further enquiries can be directed to two corresponding authors.

Declarations

Ethics approval and consent to participate

This study was conducted with approval from the Ethics Committee of The Third Affiliated Hospital of Naval Medical University. This study was conducted in accordance with the declaration of Helsinki. Due to the retrospective nature of the study, the requirement of patient consent for inclusion was waived.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.