Clinical Application of the Right Liver Hanging Maneuver for Laparoscopic Resection of Segment 6 Hepatocellular Carcinoma

Introduction

The traditional liver hanging maneuver (LHM), was originally introduced by Belghiti et al¹ in 2001. The basic steps are creating a retrohepatic tunnel (RT) in front of the inferior vena cava (IVC) without detaching the right lobe of the liver and then pass a tape through this tunnel to provide upward traction. LHM was initially employed in technically demanding right hepatectomy for massive hepatic tumors and in liver transplantation.^2,3 This approach can substantially reduce intraoperative blood loss, shorten hepatic hilum occlusion time, and decrease the incidence of postoperative liver dysfunction and complications. In subsequent years, several modifications of the LHM have been proposed by different surgeons. The core advantage of these methods is to improve intraoperative visualization and operative accessibility by hanging the liver. However, its clinical adoption remains limited, and application scope is limited.^4,5

Currently, laparoscopic techniques have become the predominant modality for partial hepatectomy. Nevertheless, the laparoscopic liver resection (LLR) of situated in the right posterior hepatic lobe continues to present multiple technical difficulties, particularly regarding sufficient exposure of the targeted hepatic segments and effective control of venous hemorrhage during hepatic traction and rotation. Repeated or excessive rotation may elevate the risk of hematogenous tumor dissemination. In patients with concomitant liver cirrhosis or additional risk factors, they should undertake limited hepatic segmentectomy, shorten operative duration, minimize intraoperative blood loss.

Based on these considerations, the right liver hanging maneuver (RLHM) was employed during laparoscopic resection of a segment 6 hepatocellular carcinoma (HCC) located in the right posterior sector. Initially, dissection of the ligaments surrounding the right hemiliver was performed to establish the RT. RT is the area between right side of the inferior vena cava and the save tumor margins. The tumor margins were delineated using intraoperative ultrasound (IOUS). The traction tape was positioned to RT, corresponding anatomically to the peri-bare area. During hepatic parenchymal transection, tension applied to the suspension tape enhanced laparoscopic visualization, expanded the operative workspace, and obviated the need for repeated hepatic manipulation. The traction force also guided a perpendicular transection plane and provided moderate compression to the hepatic venous system, thereby reducing the transection surface area and intraoperative hemorrhage from the cut surface. Owing to RLHM method has achieved favorable short-term outcomes. We summarized the surgical procedures and explained its clinical significance.

Case Presentation

Patient 1

A 56-year-old male with a 17-year history of hepatitis B virus (HBV) infection was admitted for skin jaundice. On admission, the Child–Pugh classification was grade B with a score of 9 and contrast-enhanced computed tomography (CT) revealed an approximately 3 cm lesion in segment 6, highly suggestive of HCC, prompting hospital admission (Figure 1A and B). After seven days of medical management, the preoperative C–P classification improved to grade B with a score of 7. The patient had an approximately 20-year history of tobacco and alcohol use, which has increased the risk of anesthesia. The laboratory test results during the perioperative period are shown in Table 1.

Table 1 Pre-Operative Lab Test Results of These Two Patients

Figure 1 Representative preoperative imaging, intraoperative photographs, and postoperative histopathology for patient 1. (A) Contrast-enhanced CT reveals a 3.1*2.7 cm lesion, which shows hypovascular during the arterial phase, portal venous phase and delayed phase. This figure shows the arterial-phase axial section. (B) Portal-venous-phase coronal contrast-enhanced CT. The red marked line denotes the approximate position of the suspension band. (C) The right abdominal wall received one 10 mm trocar (the green dot on the left side of figure) and one 12 mm trocar (the yellow dot on the left side), the left abdominal wall accommodated one 10 mm trocar (the yellow dot on the right of figure) and one 5 mm trocar (the green dot on the right side), the sub-umbilical trocar port (the right dot) to insert the 3D laparoscope. (D) By uniting the superior and inferior dissection planes, the posterior hepatic tunnel is fully developed to accommodate the pre-placed suspension band (the area near the red marking line, and the left side is right margin of the inferior hepatic IVC). (E) A 16-French Foley catheter was employed as the suspension band. (F) Suspension band traction of the detached liver parenchyma, Hemlock clamp to occlude the thick tube. (G) The resected gross specimen displayed malignant features. (H) High magnification of pathological tissue sections.

Main Surgical Steps

After induction of general anesthesia, the patient was positioned in the lithotomy posture, and intra-abdominal pressure was maintained at 12 mmHg. Five trocars were inserted into the upper abdomen (Figure 1C), followed by adjustment of the patient to the left lateral decubitus position. The round, falciform, right coronary, and right triangular ligaments were sequentially divided. The right hemiliver was mobilized toward the right margin of the IVC. The bare area was dissected, and the RT was subsequently established (Figure 1D). A suspension tape was pre-positioned in this tunnel (Figure 1E). IOUS was performed to localize the lesion, and safety boundary was marked using an electrocautery hook. Under low central venous pressure anesthesia, hepatic inflow occlusion was achieved through the Pringle maneuver. The suspension tape was tracted, and hepatic parenchymal transection was carried out using an ultrasonic scalpel in combination with bipolar electrocoagulation. Finally, the tumor was successfully and completely removed (Figure 1F and G). The operating duration was 135 minutes. Hepatic inflow was occluded twice intraoperatively, each for 15 minutes with a 5-minute reperfusion interval. Estimated blood loss was approximately 80 mL, and neither blood transfusion nor blood products were required. Postoperative recovery proceeded uneventfully, and the patient was discharged on postoperative day 6. The resection margin was negative, and histopathological examination verified HCC (Figure 1H).

Patient 2

A 72-year-old male with a 20-year history of HBV-related liver cirrhosis presented with progressive abdominal distension, fatigue, and weight loss. Contrast-enhanced CT revealed a 7×5 cm lesion in segment 6, highly suggestive of HCC (Figure 2A and B). The patient had a 20-year history of hypertension and diabetes mellitus, as well as a 10-year history of coronary heart disease, with cardiac function classified as New York Heart Association class II. Hepatic function was graded as C–P class A with a score of 5. Preoperative laboratory findings are summarized in Table 1.

Figure 2 Representative preoperative imaging, intraoperative photographs, and postoperative histopathology for patient 2. (A) Contrast-enhanced CT demonstrates a 6.9*5.0 cm heterogeneously enhancing lesion with arterial hyperenhancement (indicated by red arrow) and washout on delayed-phase imaging. This figure shows the arterial-phase axial section. (B) The red marked line denotes the approximate position of the suspension band. (C) The red arrow points to the tumor. Adhesions occured between the tumor and the peritoneum; the deformed liver attached to the diaphragm. (D) Suspension band. (E) The resected gross specimen displayed malignant features. (F) High magnification of pathological tissue section.

Main Surgical Steps

The anesthesia method, patient positioning, and trocar placement were consistent with those used in patient 1. Laparoscopic exploration revealed dense adhesions between the tumor and adjacent tissues (Figure 2C). An ultrasonic scalpel was employed to dissect both adhesions and hepatic ligaments. The right hepatic lobe appeared atrophic and deformed due to long-standing cirrhosis, with the entire liver displaced upward and posteriorly, lying in close proximity to the diaphragm, and an exophytic lesion was identified in hepatic segment S6. IOUS was performed to localize the lesion, and safe margin was marked using an electrocautery hook. A suspension tape and a hepatic hilar occlusion tape were pre-positioned (Figure 2D). Intraoperatively, hepatic hilar clamping was performed twice, each lasting 15 minutes with a 5-minute interval. Complete tumor resection was achieved (Figure 2E), with an operative duration of 120 minutes and an estimated blood loss of approximately 100 mL. Postoperative recovery was uneventful, and the patient was discharged on postoperative day 6. Pathological examination confirmed HCC (Figure 2F).

Discussion

Compared with open liver resection, LLR confers several well-established short-term benefits, while yielding comparable long-term outcomes.⁶ So it has been increasingly implemented in the management of HCC.⁷ However, most patients with HCC present with concomitant liver cirrhosis.^6,8,9 Factors such as abdominal adhesions, advanced age, chronic comorbidities, liver cirrhosis, tumors exceeding 3 cm, and localization within the right posterior section are classified as moderate-to-high difficulty resections.^10,11 For these patients, decrease operation time or limited hepatectomy is generally recommended, as these approaches significantly decrease the incidence of severe postoperative complications,^12–14 Couinaud segment VI lies deep within the hepatic parenchyma, adjacent to the right adrenal gland. Patients with chronic cirrhosis frequently develop perihepatic adhesions due to previous spontaneous peritonitis. The hepatic venous branches in the right posterior sector are characteristically short and thin-walled, and excessive or repeated manipulation of the right hepatic lobe may result in IVC distortion, abrupt reduction in venous return, or hepatic vein rupture. These anatomical constraints elevate the risks of intraoperative hemorrhage and CO₂ gas embolism.¹⁵ Based on these risk factors, our team has decided to apply RLHM in the laparoscopic resection surgery for HCC patients with liver cirrhosis located in segment 6. Collectively, short-term prognosis indicates that the technique offers distinct advantages and is both safe and feasible. Since the LHM technique was originally proposed, LHM has undergone continuous improvements and has been applied to various parts. We reviewed these reports and made a summary in Table 2.^16–19

Table 2 Summary and Comparison of Right Posterior Lobe Using LHM Techniques

From the above comparison, the main differences between RLHM and previous modified LHMs are as follows: RLHM is a flexible, individualized, and non-dependent on a certain fixed anatomical landmark suspension method. Compared with these reports, the short-term surgical prognosis of our study is relatively optimistic. The specific advantages are summarized as follows: 1. Both operative time and intraoperative blood loss in anatomical resection (AR) are higher than in non-anatomical resection (NAR).^20–22 When operative exposure is adequate, extensive mobilization is not obligatory, thereby reducing intraoperative risk. 2. With the central concept of procedural simplification and risk reduction. This suspension approach individualizes the positioning of the traction tape according to tumor location. It avoids the need for the suspension strap to be fixed at a specific anatomical site, such as Lu’s sulcus. Reducing the limitations caused by anatomical variations. 3. In cirrhotic livers, the parenchyma exhibits increased stiffness and rotational deformation. The RLHM technique enables the transformation of deeply situated posterior lesions into anteriorly exposed ones through traction, thereby facilitating operative manipulation. Traction, combined with appropriate camera angulation, minimizes blind areas, allows direct visualization of the origin of the right hepatic vein, and increases the distance from the IVC.4. Laparoscopic procedures are inherently prone to spatial disorientation. Liver elevation allows vertical visualization and guides an optimal minimal transection plane. The combination of traction force effectively limits blood loss and reduces the incidence of postoperative refractory ascites.²³

We have also identified some points that require attention. First, because the suspension strap has a relatively large range of movements, the position of the suspension strap needs to be adjusted appropriately. Second, the suspended force should be controlled to ensure that surgical field is adequate without causing excessive force. Attention must be directed toward traction-related complications associated with the suspension tape, including hepatic capsule tears or vascular injury resulting from excessive traction. The suspense direction is recommended to be vertical or away from the tumor side. Ensure a safe surgical margin while not hindering the surgeon.

Conclusion

The RLHM may be applicable to liver cirrhosis, lesions of no more than 5 cm in the S6 segment, patients with poor surgical tolerance and require shortened operation time. It may not be appropriate to patients whose conditions are unsuitable for laparoscopy, dense adhesions in the retrohepatic region may hinder successful tunnel establishment.

The limitation of this study lies in the small sample size. The lack of a control group, and the absence of long-term follow-up. Multi-center and large series is required to conduct a further assessment of this technique.