Hepatic vein-oriented double cone-unit laparoscopic hepatic resection

Purpose: To achieve a negative margin when removing tumors adjacent to the hepatic vein, it is important to resect the two tertiary Glissonean pedicles that straddle the hepatic vein. The smallest unit that achieves anatomical resection of small tumors adjacent to the vein is a double cone unit (DCU). Patients and methods: We here report four patients who underwent laparoscopic DCU resection of hepatic tumors among 127 who had undergone laparoscopic hepatectomy at the Jikei Medical University Hospital from 2020 through 2021. DCU resection was considered when computed tomography imaging showed the hepatic vein was near the tumor and the tumor was relatively small (< 50 mm). After reaching the target Glissonean pedicles, bulldog clamps were used to clamp the hepatic vein, after which indocyanine green was injected via peripheral veins. A few minutes later, the tumor-bearing portal territory could be identified as regions lacking fluorescence under near-infrared imaging. The target hepatic vein, which runs between these two territories, was dissected where it crosses from the first to the second territory. Results The median operative time in these four patients was 308 minutes, and the median blood loss 302 g. The average tumor size was 31.3 mm and the average surgical margin 0.6 mm. Conclusion The smallest unit for achieving anatomical hepatectomy of small tumors adjacent to the hepatic vein may be DCU resection.