Open Parenchyma-Preserving Enucleation of Giant Hepatic Hemangiomas: A Systematic Cavitron Ultrasonic Surgical Aspirator (CUSA)-Guided Pringle-Free Technique

Giant hepatic hemangiomas, particularly those involving central hepatic segments (IV, V, and VIII), present unique surgical challenges due to their proximity to major hepatic veins and first-order portal structures. While laparoscopic approaches have been described, detailed guidance for open enucleation across a range of lesion locations and complexities remains limited. This technical report describes a systematic open parenchyma-preserving enucleation technique and presents a retrospective consecutive case series of six patients who underwent the described procedure over an eight-year period at a tertiary hepatobiliary center (American University of Beirut Medical Center, AUBMC). Patient demographics, tumor characteristics, operative details, and postoperative outcomes were retrospectively extracted from medical records following a structured chart review. All patients were followed clinically postoperatively, with no evidence of recurrence or late complications during the available follow-up period. Six patients (5 female, 1 male), with ages ranging from 26 to 50 years, underwent open enucleation using a uniform Cavitron Ultrasonic Surgical Aspirator (CUSA)-guided pseudocapsular technique without inflow occlusion (Pringle maneuver). Tumor locations included purely central segments (n=2), mixed central and peripheral segments (n=3), and a complex suprahepatic lesion with inferior vena cava (IVC) involvement (n=1). Preoperative tumor sizes ranged from 7 to 12.9 cm. Documented estimated blood loss ranged from 150 to 500 mL; five of six cases required no transfusion. One case involving direct IVC adherence required primary suture repair and intraoperative transfusion (3 units; Clavien-Dindo grade III). One patient experienced urinary retention (Clavien-Dindo grade I). No conversions to formal hepatectomy, bile leaks, postoperative liver failure, or mortality occurred. Length of hospital stay ranged from 5 to 10 days. All pathology specimens confirmed cavernous hemangioma. The described CUSA-guided pseudocapsular enucleation technique without the Pringle maneuver is feasible and safe for giant hepatic hemangiomas across central, peripheral, and complex tumor locations. This technical report provides detailed operative guidance applicable across central and peripheral tumor locations, with particular attention to centrally located lesions where proximity to major hepatic veins and portal structures demands structured operative planning and heightened technical vigilance.