Abstract
Background
Achieving a precise transection plane during laparoscopic anatomical left hemihepatectomy (LLH) remains technically demanding. This study evaluated the effectiveness and safety of a cranial–dorsal approach guided by Arantius’ ligament.
Methods
In this single-center retrospective cohort (June 2023–June 2025), 54 patients undergoing LLH were analyzed. Patients were divided into cranial–dorsal (n = 18) and caudal–ventral (n = 36) groups. Outcomes included operative time, blood loss, drain removal, liver function, inflammation markers, and complications.
Results
All procedures were completed laparoscopically without conversion. The cranial–dorsal group showed shorter operative time, less blood loss, earlier drain removal, and better postoperative liver function, with lower overall complication rates (P < 0.05).
Conclusions
The cranial–dorsal approach enables full-length middle hepatic vein (MHV) exposure, provides a precise transection plane, reduces blood loss, and facilitates early liver function recovery. It is a safe and effective technique.
Keywords: Laparoscopy, Left hemihepatectomy, Cranial–dorsal approach, Arantius’ ligament, Middle hepatic vein
Introduction
Laparoscopic liver resection (LLR) has evolved substantially over the past three decades, progressing from peripheral wedge resections for benign lesions to complex segmentectomies and major hepatectomies. Its safety and feasibility have been widely validated across multiple centers [1–3]. Among these procedures, laparoscopic left hemihepatectomy (LLH) has become one of the most standardized and widely accepted forms of anatomical liver resection [4, 5].
A major technical challenge during LLH lies in achieving a precise hepatic transection plane. Deviation from the true anatomical boundary may result in ischemic necrosis of the remnant liver, excessive intraoperative bleeding, postoperative bile leakage, or even compromised oncologic margins [6, 7]. Because the hepatic veins delineate true segmental boundaries, exposing the middle hepatic vein (MHV) during parenchymal transection is critical for ensuring anatomical precision, reducing complications, and preserving postoperative liver function [8].
However, because the MHV runs deep within the dorsal parenchyma, conventional caudal–ventral approaches often provide limited visualization, making it difficult to expose the full length of the vein and increasing the risk of transection plane deviation [9]. To overcome these limitations, anatomical and clinical studies have demonstrated that the hepatic parenchyma located dorsal to the MHV is relatively thin, providing a shorter and safer route for dissection [10, 11]. Consequently, dorsal or cranial–dorsal approaches guided by Arantius’ ligament have been developed to enable early exposure of the left hepatic vein (LHV) and MHV trunk while minimizing bleeding and venous injury. These techniques allow parenchymal transection along the MHV from cranial to caudal and dorsal to ventral directions, thereby improving precision and safety [12–14].
Although several studies have explored dorsal or Arantius-first approaches for LLH, most prior work has focused primarily on malignant tumors and lacked standardized descriptions of key operative steps. In addition, heterogeneity in surgical techniques and inconsistent outcome definitions have limited the comparability and reproducibility of results. The present study provides additional evidence by defining a standardized, reproducible cranial–dorsal approach guided by Arantius’ ligament, applicable to both benign and malignant hepatic conditions. This operative framework—emphasizing anatomical precision, controlled inflow and outflow management, and early exposure of the MHV—may help enhance procedural safety, improve consistency, and facilitate broader clinical adoption of laparoscopic anatomical hepatectomy.
Since June 2023, our center has adopted the cranial–dorsal approach guided by Arantius’ ligament for laparoscopic anatomical left hemihepatectomy. This study aimed to evaluate whether this approach could improve intraoperative precision, reduce blood loss, and accelerate postoperative recovery compared with the traditional caudal–ventral approach.
Methods
Study design and patients
This single-center retrospective cohort study was conducted at a high-volume hepatobiliary referral center (Xuzhou Central Hospital) between June 2023 and June 2025. A total of 54 anatomical laparoscopic hepatectomy (LLH) cases were included, reflecting the team’s extensive experience and technical expertise. For patients meeting the inclusion criteria, the surgical approach was determined based on comprehensive preoperative imaging assessment, with particular attention to liver anatomy and the lesion’s relationship with major vascular structures, and was performed following a standardized intraoperative decision-making protocol consistently applied throughout the study period. The surgical planning and execution were guided by the dual objectives of achieving precise intraoperative anatomical dissection and facilitating rapid postoperative recovery. Patients were categorized into a cranial–dorsal approach group (n = 18) and a caudal–ventral approach group (n = 36). The study protocol was approved by the institutional ethics committee, and written informed consent was obtained from all patients. Inclusion criteria were as follows:
Disease confined to the left hemiliver, including intrahepatic bile duct stones, hepatic hemangioma, or hepatocellular carcinoma.
Normal liver function or Child–Pugh class A liver function; in patients with cirrhosis, an ICG-R15 < 0.10 was required.
Absence of cardiopulmonary insufficiency.
For intrahepatic bile duct stone cases, absence of extrahepatic bile duct stones and negative pathological findings for malignancy.
Exclusion criteria included
Severe cardiopulmonary or cerebrovascular comorbidities precluding laparoscopic surgery.
Child–Pugh class B or C liver function.
Previous hepatic surgery.
Tumors invading the second hepatic hilum or adjacent to the middle hepatic vein (MHV) that precluded safe margins.
Intraoperative change in resection strategy preventing anatomical hepatectomy; or.
Age ≥ 80 years.
The rationale for specific exclusion criteria was as follows: The term ‘second hepatic hilum’ refers to the confluence of the left, middle, and right hepatic veins into the inferior vena cava. Tumors invading this area were excluded because such involvement typically necessitates an extended resection, incorporating the hepatic vein confluence, a procedure that exceeds the technical scope of a pure anatomical left hemihepatectomy. Including these complex cases would introduce significant technical heterogeneity, thereby confounding the comparative analysis of the two surgical approaches for a standard procedure. Furthermore, tumors adjacent to the MHV that precluded safe margins were excluded to maintain a focused comparison; their presence would dictate a tumor-specific resection strategy rather than allowing for a standardized approach to MHV dissection, which is the primary technical focus of this study; Patients aged ≥ 80 years were also excluded due to their very limited representation in the cohort during the study period, which would have compromised statistical power and cohort homogeneity for the comparative analysis.
Perioperative management and anesthesia
All patients were placed in the supine position under combined intravenous and inhalational anesthesia. A five-port layout was adopted (Fig. 1). Intraoperative ultrasonography was used as needed. The Pringle maneuver, a nonselective inflow occlusion technique of the hepatoduodenal ligament, was applied intermittently with a 15-minute clamp and 5-minute release cycle. A comprehensive low central venous pressure (LCVP) anesthetic strategy was employed to minimize blood loss during parenchymal transection. This strategy, which serves as a primary method for outflow control, comprised fluid restriction, the use of vasodilators (e.g., nitroglycerin) when necessary, and a lung-protective ventilation protocol with low tidal volume. Specifically, the tidal volume was maintained at 6–8 mL/kg of predicted body weight to avoid high intrathoracic pressure. The combined effect of lowering the central venous pressure and tidal volume served as outflow control, effectively reducing pressure in the hepatic veins and subsequent bleeding from the transection surface. Throughout the critical phase of hepatic resection, the anesthesia team meticulously maintained the CVP at a low level between 0 and 5 mmHg.
Fig. 1.
Port layout in laparoscopic anatomical left hemihepatectomy. (a) 10-mm camera port; (b) 12-mm main working port; (c) 5-mm left-hand port; (d) 10-mm right-hand assistant port; (e) 5-mm left-hand assistant port
Surgical technique
Following diagnostic laparoscopy to rule out peritoneal metastasis, adhesions were released and the gallbladder removed. The falciform, coronary, and left triangular ligaments were divided to mobilize the left liver. The Pringle tourniquet was pre-positioned. The left Glissonean pedicle (LGP) was dissected extrahepatically using the Laennec’s capsule technique (Fig. 2) and divided close to the umbilical plate using a linear stapler with a vascular cartridge (Fig. 3a and b), delineating the ischemic demarcation line on the diaphragmatic and visceral surfaces.
Fig. 2.
Transection of the caudal end of the ligamentum venosum (Arantius), followed by limited ventral parenchymal dissection. The blue triangle indicates the caudal end of the ligamentum venosum (Arantius). LGP, left Glissonean pedicle; S, Spiegel lobe; LLS, left lateral section
Fig. 3.
Anatomical steps of the left Glissonean pedicle (LGP) transection. a Isolation of the left Glissonean pedicle. The left Glissonean pedicle (LGP) was isolated extrahepatically. GB fossa, gallbladder fossa; LGP, left Glissonean pedicle; LLS, left lateral section. b Division of the left Glissonean pedicle. The left Glissonean pedicle (LGP) with a stapler applied, immediately prior to division. The black triangle indicates the left Glissonean pedicle.LLS, left lateral section; S, Spiegel lobe; ST, stomach
Cranial–dorsal approach (experimental group)
Using Arantius’ ligament as the key landmark, limited cranial parenchymal dissection was performed to expose and divide the root of the left hepatic vein (LHV) or its common trunk with the MHV (Fig. 4). When feasible, the structure was divided with a linear stapler (vascular cartridge); otherwise, it was securely ligated with non-absorbable sutures or polymer locking clips before division, particularly in cases of a short or fragile vein. The MHV trunk was then exposed from the dorsal side along the plane between the divided LGP and Arantius’ ligament (Fig. 5). Hepatic parenchymal transection proceeded cranial-to-caudal and dorsal-to-ventral using an ultrasonic dissector (Fig. 6). Small vessels (< 3 mm) were coagulated or clipped, and larger vessels were ligated. Oozing from venous foramina was managed with bipolar coagulation or 4 − 0 vascular sutures. Drains were placed at the transection surface and in the foramen of Winslow.
Fig. 4.
Exposure and division of the left hepatic vein (LHV) at its root. The LHV is exposed near its root and divided under direct vision. The hollow arrowhead indicates the left hepatic vein (LHV)
Fig. 5.
Dorsal exposure of the middle hepatic vein (MHV) trunk along the Arantius-guided transection plane. The MHV trunk is exposed from the dorsal side by limited parenchymal dissection following the Arantius-guided plane in a cranial-to-caudal direction. The blue shaded area indicates the Arantius-guided transection plane. IVC, inferior vena cava; MHV, middle hepatic vein; LHV stump, left hepatic vein stump
Fig. 6.
Parenchymal transection along the middle hepatic vein (MHV) plane. Parenchymal transection was performed along the MHV plane from cranial to caudal and dorsal to ventral directions to complete the anatomical left hemihepatectomy. MHV, middle hepatic vein
Caudal–ventral approach (control group)
Port placement and hepatic pedicle management were identical. After dividing the LGP, parenchymal transection proceeded caudal-to-cranial and ventral-to-dorsal, guided by intraoperative ultrasonography to identify the MHV trunk. The left hepatic vein (LHV) was divided under direct vision after being securely ligated with non-absorbable sutures or polymer locking clips. If sufficient and safe length was attainable, a linear stapler was used as the preferred method for division. Hemostasis and drain placement were performed in the same manner as in the cranial–dorsal group.
Outcome measures
Perioperative data were compared between the two groups, including: operative time (min), intraoperative blood loss (mL), postoperative drain removal time (days), rate of intraoperative MHV repair, postoperative day (POD) 3 liver function parameters (ALT, AST, TBIL, ALB), inflammatory markers (WBC, CRP), and postoperative complications (surgical-site effusion, bile leakage, intra-abdominal infection).
Complications were graded using the Clavien–Dindo classification [4], and bile leakage was defined according to the International Study Group of Liver Surgery (ISGLS) criteria [15]. For patients with hepatocellular carcinoma, resection margin status (R0 or R1) was recorded.
Statistical analysis
Data were analyzed using R software version 4.5.1 (R Core Team, 2025, https://www.R-project.org/). Categorical variables were compared with Fisher’s exact test, and continuous variables with the Wilcoxon rank-sum test. All tests were two-sided, and P < 0.05 was considered statistically significant. Continuous variables are presented as mean ± standard deviation, and categorical variables as counts (percentage).
Results
Baseline characteristics
All 54 patients successfully underwent laparoscopic anatomical left hemihepatectomy (LLH) without conversion to open surgery. The same experienced surgical team performed all procedures. Eighteen patients were assigned to the cranial–dorsal approach group and 36 to the caudal–ventral approach group. Baseline demographic and clinical characteristics were comparable between the two groups (Table 1).
Table 1.
Baseline characteristics of patients. N, means ± SD or median (range)
| All | Cranial–Dorsal | Caudal–Ventral | P-value | ||
|---|---|---|---|---|---|
| N | 54 | 18 | 36 | ||
| Age |
57.4 ± 10.4 58 (29–74) |
56.3 ± 12.9 58 (29–74) |
57.9 ± 9.1 58 (37–73) |
0.99 | |
| Sex | Male | 28 | 8 | 20 | 0.57 |
| Female | 26 | 10 | 16 | ||
| Composition | Intrahepatic Bile Duct Stones | 17 | 6 | 11 | 1 |
| Cavernous Hemangioma | 12 | 5 | 7 | 0.51 | |
| Hepatocellular Carcinoma | 25 | 7 | 18 | 0.57 | |
| ALT (U/L) |
31.2 ± 36.3 20.8 (7.1-242.9) |
33.1 ± 53.5 18.7 (7.2-242.9) |
30.2 ± 24.5 21.1 (7.1–113.0) |
0.35 | |
| AST (U/L) |
25.7 ± 13.8 20.8 (10.6–88.8) |
24.7 ± 14.0 19.8 (10.6–54.4) |
26.2 ± 13.8 21.3 (13.7–88.8) |
0.35 | |
| TBIL (µmol/L) |
13.2 ± 11.4 11.3 (4.4–86.9) |
12.3 ± 5.2 11.5 (5.2–26.1) |
13.6 ± 13.5 11.1 (4.4–86.9) |
0.7 | |
| ALB (g/L) |
41.6 ± 3.8 41.3 (33.1–52.7) |
40.9 ± 4.4 41.2 (33.1–49.0) |
42.0 ± 3.5 41.3 (35.3–52.7) |
0.46 | |
| WBC (x109/L) |
5.4 ± 1.6 5.2 (3.2–11.4) |
5.3 ± 1.2 5.2 (3.6–7.6) |
5.5 ± 1.7 5.1 (3.2–11.4) |
0.85 | |
| CRP (mg/L) |
8.6 ± 8.8 6.1 (1.2–46.4) |
11.3 ± 12.5 6.4 (1.2–46.4) |
7.2 ± 5.8 6.1 (1.4-38.24) |
0.33 | |
The overall cohort included 28 men and 26 women, with a mean age of 57.4 ± 10.4 years. The distribution of underlying diseases—comprising intrahepatic bile duct stones, cavernous hemangioma, and hepatocellular carcinoma—did not differ significantly between groups (P > 0.05), and the histopathological examination confirmed the final diagnoses in all resected specimens. All patients had preserved liver function (Child–Pugh A) and satisfactory preoperative ICG-R15 < 0.10. Baseline liver function markers (ALT, AST, TBIL, ALB) and inflammatory indices (WBC, CRP) were similar (P > 0.05). No patients had severe cardiopulmonary comorbidities or prior hepatectomy. These findings indicate that the two cohorts were well balanced and suitable for comparative analysis of surgical approach–related outcomes.
Perioperative outcomes
All patients completed LLH uneventfully. For those with hepatocellular carcinoma, R0 resection (negative margin) was achieved in every case according to postoperative histopathology.
Compared with the caudal–ventral group, the cranial–dorsal group demonstrated clear intraoperative advantages (Tables 2 and 3, Fig. 7). Mean operative time was significantly shorter, and intraoperative blood loss was markedly reduced. The mean time to drain removal was also earlier in the cranial–dorsal group.
Table 2.
Perioperative outcomes. N, means ± SD or median (range)
| All | Cranial–Dorsal | Caudal–Ventral | P-value | |
|---|---|---|---|---|
| N | 54 | 18 | 36 | |
| Operation Time (min) |
205.0 ± 45.7 195 (140–310) |
176.8 ± 35.8 163.5 (140–260) |
219.2 ± 43.8 200 (150–310) |
0.00033 |
| Intraoperative Blood Loss (mL) |
271.4 ± 105.7 300 (50–550) |
177.8 ± 94.3 175 (50–350) |
318.2 ± 76.4 300 (200–550) |
1.1 × 10−5 |
| Postoperative Tube Removal Time (d) |
8.0 ± 2.6 7.5 (4–13) |
6.3 ± 2.5 6 (4–13) |
8.8 ± 2.2 8 (5–13) |
0.00013 |
| MHV Repair Rate (%) | 6/54 (11.1%) | 1/18 (5.6%) | 5/36 (13.9%) | 0.65 |
| ALT (U/L) |
111.3 ± 69.2 105.6 (15.9-301.2) |
62.7 ± 39.0 51.3 (23.6–171.0) |
135.6 ± 68.5 132.7 (15.9-301.2) |
0.00013 |
| AST (U/L) |
60.8 ± 43.4 47.2 (9.0-212.9) |
38.2 ± 26.8 29.1 (15.3-130.6) |
72.2 ± 45.8 62.3 (9.0-212.9) |
0.00093 |
| TBIL (µmol/L) |
20.4 ± 9.6 17.2 (7.6–44.9) |
14.1 ± 3.9 14.8 (7.6–21.8) |
23.6 ± 10.0 21.6 (7.6–21.8) |
0.00069 |
| ALB (g/L) |
36.0 ± 4.1 35.7 (29.6–45.0) |
38.4 ± 3.8 37.5 (30.6–45.0) |
34.8 ± 3.8 34.0 (29.6–42.0) |
0.047 |
| WBC (x109/L) |
8.3 ± 2.6 8.3 (3.5–15.0) |
7.4 ± 2.4 7.9 (3.5–10.5) |
8.7 ± 2.7 8.3 (3.6–15.0) |
0.23 |
| CRP (mg/L) |
63.3 ± 41.5 59.7 (8.3-160.2) |
63.9 ± 49.0 52.0 (9.3-160.2) |
62.9 ± 38.0 63.5 (8.3-131.9) |
0.85 |
Table 3.
Multivariable regression of perioperative indices
| Response Variable | P-value of Explanatory Variables | ||
|---|---|---|---|
| Sex | Age | Surgical Approach | |
| ALT (U/L) | 0.014 | 0.66 | 3.4 × 10⁻⁵ |
| AST (U/L) | 0.072 | 0.87 | 0.0033 |
| TBIL (µmol/L) | 0.66 | 0.71 | 0.03 |
| ALB (g/L) | 0.48 | 0.029 | 0.0003 |
| WBC (×10⁹/L) | 0.93 | 0.18 | 0.098 |
| CRP (mg/L) | 0.59 | 0.7 | 0.82 |
Fig. 7.
Distribution of pre- and postoperative liver function and inflammatory markers. a ALT; b AST; c TBIL; d ALB; e WBC; f CRP. Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; TBIL, total bilirubin; ALB, albumin; WBC, white blood cell count; CRP, C-reactive protein
Postoperative recovery of liver function was more favorable in the cranial–dorsal group on postoperative day 3 (POD 3). Serum ALT, AST, and TBIL were significantly lower in the cranial–dorsal group, whereas ALB was higher.
Inflammatory markers (WBC and CRP) did not differ significantly between groups (P > 0.05). The rate of intraoperative MHV repair—a surrogate for venous injury—was slightly lower in the cranial–dorsal group but without statistical significance (P > 0.05).
Overall, the cranial–dorsal approach provided superior surgical efficiency, reduced blood loss, and faster restoration of hepatic function compared with the conventional caudal–ventral approach, suggesting better hemodynamic control and less parenchymal trauma. Multivariate linear regression confirmed that surgical approach was an independent predictor of lower postoperative transaminase levels, whereas age and sex showed no significant influence (Table 3).
Postoperative complications
No patient in either group experienced a severe complication of Clavien–Dindo grade III or higher [4]. The spectrum of minor complications included bile leakage, intra-abdominal infection, and localized fluid collections (Table 4).
Table 4.
Postoperative complication rates
| Cranial–Dorsal | Caudal–Ventral | P-value | |
|---|---|---|---|
| Total Sample | 3/18 (16.7%) | 19/36 (52.8%) | 0.01 |
| Bile Leak | 1/18 (5.6%) | 5/36 (13.9%) | 0.65 |
| Surgical Site Fluid Collection | 1/18 (5.6%) | 10/36 (27.8%) | 0.077 |
| Intra-abdominal Infection | 1/18 (5.6%) | 4/36 (11.1%) | 0.65 |
Bile leakage occurred in six patients in total—one (5.6%) in the cranial–dorsal group and five (13.9%) in the caudal–ventral group—classified as ISGLS grade B events managed successfully by drainage and supportive therapy. Intra-abdominal infection developed in two patients (one per group) and resolved with antibiotics and percutaneous drainage.
Surgical-site effusion occurred in one patient (5.6%) in the cranial–dorsal group versus ten (27.8%) in the caudal–ventral group, showing a decreasing trend though not statistically significant (P = 0.077). Importantly, the overall postoperative complication rate was significantly lower in the cranial–dorsal group than in the caudal–ventral group (16.7% vs. 52.8%, P = 0.01).
No mortality or reoperation occurred. Postoperative imaging confirmed the absence of MHV stenosis or right liver congestion in all cases. The cranial–dorsal approach thus yielded a lower morbidity profile without compromising oncologic safety, supporting its feasibility and safety for anatomical LLH.
Discussion
This study demonstrates that the cranial–dorsal approach enables antegrade, full-length exposure of the middle hepatic vein (MHV), achieving a precise transection plane and measurable advantages in surgical efficiency and safety. Anatomically, the MHV lies deep on the dorsal side of the liver parenchyma, and the dorsal pathway provides the shortest and safest route for exposure. This principle is consistent with the anatomical findings reported by Okuda et al. [12] and Ueno et al. [16], who demonstrated that the hepatic parenchyma dorsal to the MHV is relatively thin, providing a natural dissection plane for precise exposure. All cases in the present series were successfully completed laparoscopically without conversion or modification of approach, further supporting the feasibility and stability of this technique.
The extrahepatic Glissonean pedicle approach, performed close to the umbilical plate, ensures clear isolation of the left portal pedicle, reduces bleeding, and aligns with the portal territory theory proposed by Takamoto and Makuuchi [8]. In our practice, the left Glissonean pedicle was divided near the umbilical plate to avoid injury to the caudate bile ducts or right posterior segmental bile ducts draining into the left hepatic duct [17, 18]. However, in patients whose tumors are located close to the left Glissonean pedicle, this technique should be applied with particular caution [19]. Combining this approach with intermittent Pringle occlusion shortens the total clamping time, thereby minimizing ischemia–reperfusion injury to the remnant liver and protecting residual parenchymal function. Preoperative MRCP and three-dimensional reconstruction further assist in identifying biliary and vascular variations and in planning the transection line. For outflow control, our team prioritized early division of the left hepatic vein (LHV) to interrupt hepatic venous drainage. This step, together with maintaining a low central venous pressure (2–3 mmHg, a key component of outflow control) and controlled tidal volume (6–8 mL/kg), effectively reduced venous oozing from the transection surface.In addition, this method does not cause injury to other organs and can reduce the risk of intraoperative tumor cell metastasis through the left hepatic vein (LHV) [20, 21]. However, this technique should be applied cautiously in cases with a long common LHV–MHV trunk or a short extrahepatic course of the LHV to prevent venous congestion or technical difficulty during reconstruction [3].
Beyond these technical considerations, we also summarized the key procedural advantages of this approach. First, early division of the left Glissonean pedicle allows precise control of inflow to the left liver, creating a clear ischemic demarcation line on the liver surface. Using both the demarcation and the MHV as anatomical landmarks enables accurate parenchymal transection, improving efficiency while maintaining alignment with the portal territory theory that underlies true anatomical hepatectomy. Second, because the MHV lies posterior to the hilar plate, dividing the LHV and left Glissonean pedicle establishes an anatomical plane between the Arantius’ ligament and the portal plate. Gentle rightward traction or suspension of the left liver enlarges the operative field, facilitating safer and more comprehensive exposure of the entire MHV trunk. Third, for tumors located on the dorsal aspect of the medial segment, the traditional caudal–ventral approach often fails to provide adequate visualization of the dorsal margin. In contrast, the dorsal approach allows direct exposure of the tumor’s posterior boundary along the MHV trunk, ensuring sufficient oncologic margins and minimizing injury to the hilar structures [13, 22, 23]. In this series, all patients with hepatocellular carcinoma achieved R0 resection with histologically negative margins.
The cranial–dorsal approach allows antegrade dissection from cranial to caudal and from dorsal to ventral directions, providing direct visualization of the middle hepatic vein (MHV) and its tributaries. This facilitates controlled ligation of MHV branches and prevents avulsion injuries, which are a common source of bleeding in conventional caudal–ventral dissections. The reduced incidence of MHV trunk and branch injury consequently lowers the need for venous repair, shortens operative time, and minimizes blood loss [24]. In addition, the cranial–dorsal approach enables gravity-assisted venous drainage at the transection plane, maintaining a clear operative field and reducing parenchymal congestion—an issue frequently encountered with the caudal–ventral approach [12].
Benefiting from improved visual orientation and a well-exposed operative field, our team implemented a fine dissection and preventive strategy to minimize intraoperative bleeding and postoperative complications. Small venous tributaries and Glissonean branches (≤ 3 mm) were sequentially identified and clipped along the MHV trajectory, effectively reducing both intra- and postoperative bleeding and the risk of tumor dissemination [25, 26]. For larger sieve-like bleeding points, precise suturing rather than clipping was performed, whereas bipolar coagulation and gentle compression were preferred for minor oozing. Two drains were routinely placed—at the transection plane and the foramen of Winslow—to ensure efficient postoperative fluid management and early detection of bile leakage or hemorrhage. In our cohort, all postoperative bile leakages were classified as ISGLS grade B and were successfully managed conservatively with ultrasound-guided drainage, demonstrating the overall safety of the procedure. Our findings also revealed that, owing to rapid MHV exposure and efficient parenchymal transection, the cranial–dorsal approach was superior to the caudal–ventral route in shortening operative time and enhancing postoperative recovery through refined dissection and preventive techniques.
In laparoscopic hepatectomy, tearing of the MHV trunk or avulsion of its branches can lead to massive, uncontrollable bleeding and even gas embolism. However, intracorporeal suturing under laparoscopy is technically demanding and may enlarge venous tears or cause MHV stenosis and congestion of the remnant liver—issues that have been documented in prior reports [27]. The cranial–dorsal approach offers a more intuitive visual alignment and optimized operative view, reducing technical difficulty and facilitating efficient venous repair. This orientation minimizes traction-related vascular injury and improves overall surgical safety. In our series of patients undergoing the cranial-dorsal approach, only one case required intraoperative MHV repair. The repair was completed within five minutes without enlargement of the tear or additional bleeding. Although blood loss in this case was slightly higher (350 mL) than in other cases, it remained within a controllable range. Postoperative contrast-enhanced CT revealed no MHV stenosis or congestion in the right hemiliver. These findings confirm that the cranial–dorsal approach enables safe and efficient venous suturing under magnified laparoscopic vision, effectively reducing intraoperative bleeding, improving surgical precision, maintaining adequate venous outflow, and promoting rapid postoperative liver function recovery.
However, most previous studies primarily involved malignant lesions, whereas our series included both benign and malignant conditions, showing that the cranial–dorsal approach can be safely applied beyond oncologic cases. Moreover, our complication rate (16.7%) was lower than those in several prior reports, underscoring the technical safety and reproducibility of this approach.
To further evaluate the procedural consistency and technical maturity of the cranial–dorsal approach, a learning-curve analysis was performed. The cohort was chronologically divided into early and late phases, and operative time, blood loss, and drain removal time were compared. As illustrated in Fig. 8, no significant differences were observed between phases, suggesting that efficiency and reproducibility can be achieved even during the early adoption stage when performed by surgeons experienced in advanced laparoscopy. This finding implies a moderate learning curve and good translatability of the technique to other centers. These findings further indicate that once the surgical team masters the anatomical landmarks of Arantius’ ligament and the MHV, procedural consistency can be rapidly achieved.
Fig. 8.
Learning-curve analysis of the cranial–dorsal approach: (a) operative time, (b) intraoperative blood loss, and (c) drain removal time between the early and late phases; no significant differences were found.
In addition to these findings, several strengths of the present study merit emphasis. First, we systematically adopted a standardized and reproducible cranial–dorsal operative framework guided by Arantius’ ligament, with clearly defined key steps for inflow and outflow control and antegrade exposure of the middle hepatic vein, which enhances technical consistency and facilitates adoption by other centers. Second, all procedures were performed by the same experienced laparoscopic hepatobiliary team at a high-volume referral center, minimizing variability related to surgeon experience and perioperative management.Third, we applied a standardized and comprehensive set of endpoints to evaluate clinically relevant perioperative outcomes, including operative efficiency, blood loss, drain removal, liver function recovery, and inflammatory markers, and postoperative complications using established definitions (Clavien–Dindo and ISGLS). Finally, the inclusion of both benign and malignant indications broadens the clinical applicability of our findings across common scenarios encountered in anatomical left hemihepatectomy.
Several limitations should be acknowledged. The present study was a retrospective, single-center analysis with a limited sample size, which may affect the generalizability of the findings. However, the consistency of baseline characteristics and surgical outcomes supports the internal validity of our results. Although long-term oncologic outcomes were not evaluated due to limited follow-up, all patients achieved R0 resection with satisfactory short-term recovery, indicating the safety and feasibility of this approach. Furthermore, while the technique should be applied with caution in cases of complex anatomical variations or advanced cirrhosis, the clear anatomical orientation provided by the cranial–dorsal approach suggests good adaptability in selected patients. Future studies with larger cohorts and extended follow-up will help further validate these findings.
Conclusions
The cranial–dorsal approach guided by Arantius’ ligament provides reliable and antegrade exposure of the middle hepatic vein, enabling precise anatomical parenchymal transection and effective control of intrahepatic vessels. Compared with the traditional caudal–ventral approach, it results in reduced intraoperative blood loss, faster postoperative recovery, and fewer complications. The technique is safe, reproducible, and technically feasible for surgeons experienced in advanced laparoscopy. Future multicenter prospective studies are warranted to validate its long-term outcomes and broader clinical applicability.
Authors’ contributions
XZ conceived and designed the study. XZ and BY collected the clinical data. XZ performed data analysis and interpretation. XZ drafted the manuscript. ZN and YL supervised the study and approved the final manuscript. All authors read and approved the final manuscript.
Funding
This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Data availability
Available on request.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee of Xuzhou Central Hospital (Approval No. XZXY - LK -20230801-0125) and conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all patients.
Consent for publication
Written informed consent was obtained from the patients involved.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
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Contributor Information
Yangsui Liu, Email: yangsui-liu@163.com.
Zhongpeng Ni, Email: 767759220@qq.com.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Available on request.