Middle hepatic vein compression in left-sided hepatolithiasis: Clinical classification, surgical challenges, and feasibility of laparoscopic resection via Laennec's approach

Middle hepatic vein (MHV) compression represents a complex subtype in left-sided hepatolithiasis that has not yet been sufficiently investigated. The clinical value of the Laennec's capsule-based approach in this context needs clarification. For comparative analysis, we established two additional groups based on the proximity between the dilated Glissonian pedicles/bile ducts and the middle hepatic vein (MHV): the MHV proximity group and the non-MHV-involvement group. A retrospective analysis was conducted on 107 patients who underwent hepatectomy for left-sided hepatolithiasis (January 2016–September 2021). Additionally, tissue specimens from seven patients with left-sided hepatolithiasis (March 2023–December 2024) were collected for a study on Laennec's capsule. MHV compression occurred in 25.2 % (27/107) cases, mostly (70.4 %) due to compressed mid-MHV by dilated Segment 4 pedicles. The MHV compression group demonstrated significantly higher rates of grade II postoperative complications (59.3 %) than both the non-MHV involvement group (13.4 %, p < 0.001) and the MHV proximity group (7.69 %, p = 0.0018). Multivariate analysis identified MHV compression (OR 3.199, 95 % CI 1.160–8.825; p = 0.025) and previous biliary surgery (OR 5.916, 95 % CI 2.307–15.171; p < 0.001) as independent factors associated with surgeons' preference for open over laparoscopic approaches. Subsequent pathological examination confirmed the preserved integrity of Laennec's capsule surrounding hepatic veins, dilated Glissonean pedicles, and regions where Glissonean pedicles compressed hepatic veins. MHV compression in left-sided hepatolithiasis presents a significant surgical challenge. The Laennec's approach remains anatomically viable, and laparoscopic resection is feasible in experienced centers with appropriate patient selection.