Laparoscopic Anatomical Right Anterior Sectionectomy with a Hepatic Pedicle-first Approach: Technical Details and Representative Case Illustration

Laparoscopic anatomical right anterior sectionectomy remains technically demanding due to intricate hepatic anatomy and the need to preserve segmental portal inflow and outflow during resection. Key challenges include intraoperative hemostasis, prevention of bile leakage, and lack of standardized approaches across segments. The hepatic pedicle-first technique offers a promising solution to simplify the procedure and reduce risks. This article presents a clinical case to illustrate our institutional approach, which involves lowering the hepatic portal plate along Laennec's capsule, then extra-capsularly dissecting and ligating the right anterior pedicle (AP) to create an ischemic demarcation in its drainage territory. The left transection plane follows preoperative planning with precise ligation of the middle hepatic vein (MHV) branches. For tumors near the dorsal of the right anterior section, intraoperative ultrasonography refines the right transection along the right hepatic vein (RHV) plane, exposing the entire RHV to ensure a wide margin. The innovations for this approach include: (1) Laennec's capsule and "portal" theory-guided resection, simplifying steps and reducing cancer spread via excision of the tumor-bearing portal territory; (2) intraoperative ultrasonography for dynamic transection plane adjustment, ensuring precision and margin adequacy. This case presentation demonstrates the potential of the approach to enhance safety and efficacy in laparoscopic right anterior sectionectomy and highlights its feasibility as a reproducible framework for complex hepatic surgeries.