Single-port laparoscopic posterior sectionectomy using suture traction and an in situ dorsal approach: a case report

Single-port laparoscopic posterior sectionectomy using suture traction and an in situ dorsal approach: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Single-port laparoscopic posterior sectionectomy using suture traction and an in situ dorsal approach: a case report Rixin Zhang, Chongwei Yang, Chaowen Xiao, Ling Zhu, Xinhua Wu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9169961/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Single-port laparoscopic right posterior sectionectomy remains technically challenging due to inadequate exposure and significant instrument interference. Few effective technical solutions have been reported to address these core barriers, making this case noteworthy for its novel integrated surgical strategy. Case presentation A 77-year-old man was diagnosed with a 5.4-cm hepatocellular carcinoma in the right posterior hepatic section. He underwent single-port laparoscopic right posterior sectionectomy, with an auxiliary 5-mm subcostal port used for enhanced safety and maneuverability. Two key techniques were incorporated to address technical challenges. The first was percutaneous suture traction on the right anterior hepatic section, which optimized surgical field exposure and reduced instrument clash. The second was an in situ dorsal approach, with parenchymal transection performed before ligament division to adapt to the single-port caudodorsal view. The procedure lasted 270 minutes with an estimated blood loss of 100 mL. No transfusion was required. The patient had an uncomplicated postoperative recovery and was discharged on postoperative day 11. Tumor markers normalized during follow-up. Conclusions Suture traction combined with an in situ dorsal approach facilitates single-port posterior sectionectomy by addressing the core problems of exposure and triangulation. This integrated strategy appears feasible and effective for this complex resection. Single-port laparoscopy Posterior sectionectomy Suture traction In situ Dorsal approach Minimal-access surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Single-port laparoscopic liver resection (SPLLR) has emerged as a refined minimal-access surgical modality, offering superior cosmetic outcomes and reduced postoperative morbidity compared with conventional multiport laparoscopic liver resection. However, its application remains largely confined to simple resections such as left lateral sectionectomy or anterolateral segmentectomy, due to the inherent limitations of single-port access including loss of instrument triangulation, severe instrument interference, and inadequate surgical field exposure[ 1 ]. Laparoscopic right posterior sectionectomy (LRPS) is widely recognized as one of the most technically challenging procedures even in multiport settings, owing to the deep location and and the complexity of vascular structures[ 2 – 4 ]. These challenges are further exacerbated in single-port laparoscopy, rendering SPLLR for the right posterior section exceedingly rare in clinical practice and published literature[ 5 , 6 ]. To overcome these challenges while maintaining surgical safety and efficacy, we developed an integrated surgical strategy combining percutaneous suture traction and an in situ dorsal approach for single-port LRPS. This article details the technique and reports its successful initial application. Materials and Methods Patient A 77-year-old man with a body mass index of 25.4 kg/m² presented with a liver mass. The patient had a long history of chronic hepatitis B virus infection, managed with regular antiviral therapy, and no prior abdominal surgical history. Imaging revealed a 5.4-cm tumor in the right posterior section (Figure 1), with no evidence of vascular invasion or distant metastasis. Preoperative alpha-fetoprotein (AFP) was 28.82 ng/mL and protein induced by vitamin K absence-II (PIVKA-II) was 6604.70 mAU/mL. Liver function was Child-Pugh A. A multidisciplinary team discussion concluded the patient was a suitable candidate for curative surgical resection, and single-port LRPS with an auxiliary 5-mm port was selected as the surgical plan. The study was approved by the Institutional Ethics Committee (WHZXKYL2025-220), and written informed consent was obtained from the patient. Surgical Technique Positioning and Port Placement: The patient was placed supine with 30° right elevation. The surgeon stood on the patient’s right side, with two assistants on the left. A 3-cm vertical incision was made at the right upper edge of the umbilicus and a single-port laparoscopic device (IIIA-4E-70×150; SURGAID, China) was inserted to establish access. To ensure surgical safety during the initial implementation of this novel technique, an additional 5-mm trocar was placed at the right subcostal margin for assistance. The port placement is shown in Figure 2. Carbon dioxide pneumoperitoneum was maintained at 12–14 mmHg throughout the procedure. Suture Traction: A straight needle with 3-0 prolene suture was inserted percutaneously below the xiphoid. The suture was passed through the parenchyma of the right anterior section. Dynamic traction on the externalized suture ends effectively retracted the right anterior section superiorly and to the left, creating a stable and broad exposure of the plane between the anterior and posterior sections (Figure 3). In Situ Dorsal Approach for tumor resection: The right hepatic ligaments were kept intact initially. The caudate lobe was dissected first to expose the dorsal side of the right posterior Glissonean pedicle, which was then isolated at Rouviere’s sulcus and divided using clips. Intraoperative indocyanine green fluorescence imaging confirmed the perfusion boundary. Parenchymal transection was initiated from the caudal and dorsal side using an extended-length ultrasonic dissector (HARH45; Ethicon, USA). Owing to the tumor's extension beyond the posterior section, the transection plane was dynamically defined using the fluorescence guidance combined with intraoperative ultrasound visualization of the right hepatic vein (RHV). Given the tumor’s distance from the RHV, we preserved the portion of the caudate lobe adjacent to the vena cava after exposing the RHV trunk, rather than fully exposing the inferior vena cava and the RHV root. The right perihepatic ligaments were divided after completing the parenchymal transection (Figure 3). Specimen Extraction: The specimen was placed in a bag and extracted en bloc through the slightly extended supraumbilical incision. A drainage tube was placed through the 5-mm auxiliary port site (Figure 4). The detailed surgical procedure is demonstrated in the supplementary video. Results The procedure was completed successfully without conversion to open surgery. Operative time was 270 minutes. Estimated blood loss was 100 mL, with no transfusion required. The postoperative course was uneventful, with no complications. The patient was discharged on postoperative day 11. Final pathology confirmed a poorly differentiated hepatocellular carcinoma with clear margins. Postoperative liver function showed transient elevation, which gradually returned to normal during follow-up (Fig. 5 a). Serum AFP and PIVKA-II levels normalized within one month (Fig. 5 b). Discussion Single-port LPRS is a highly complex minimal-access procedure, with inadequate surgical field exposure and compromised instrument triangulation as its core technical challenges. These hurdles stem from the deep anatomical location of the right posterior hepatic section and the narrow operating space inherent to single-port laparoscopy, which limit instrument maneuverability and increase the risk of vascular injury. In this report, we successfully applied an integrated strategy to address these barriers, achieving favorable surgical and oncological outcomes. Percutaneous suture traction serves as a simple, cost-effective, and efficient exposure technique, acting as an “invisible assistant” in single-port laparoscopy. This approach aligns with the goal of liver traction techniques—optimizing surgical field exposure while minimizing iatrogenic injury[ 7 – 9 ]—yet offers unique advantages tailored to the constraints of single-port access. Our method allows for dynamic retraction without preliminary division of perihepatic ligaments, which aligns with the in situ dorsal approach and avoids unnecessary dissection in the confined single-port surgical field. Compared to the diaphragm-anchored “Pulley maneuver” described by Kim et al.[ 8 ], our percutaneous approach eliminates the need for intracorporeal suturing to the diaphragm, simplifying the procedure and reducing instrument manipulation within the single port. This is critical in single-port surgery, where even minor increases in instrument movement can exacerbate interference and prolong operative time. Another notable advantage is its dynamic adjustability, enabling real-time modification of traction force to improve deep hepatic parenchymal tension and adapt to evolving surgical field changes during parenchymal transection. Additionally, the technique utilizes only purse-string sutures combined with small patches cut from rubber drainage tubes as anchor points, eliminating the need for specialized materials such as barbed sutures[ 8 ] or Hem-o-lok clips[ 7 ]. This simplicity makes the technique economically efficient and widely accessible to institutions with basic laparoscopic equipment. The in situ dorsal approach serves as a rational and effective strategy for single-port laparoscopy. This method retains the procedural logic of our previously established multiport technique[ 10 ], confirming that prioritizing caudate lobe dissection and posterior pedicle isolation from the dorsal side remains safe and feasible even under the limitations of single-port access[ 11 ]. A key advantage of this method is that parenchymal transection initiated from the dorsal side leverages the thinner hepatic parenchyma in this region to facilitate rapid exposure of hepatic vein branches, providing critical anatomical guidance. This characteristic proves especially valuable in the constrained single-port surgical field where tactile feedback remains limited. Notably, the in situ principle is central to its efficacy. By avoiding early division of the right perihepatic ligaments, the anatomical position of the right hepatic lobe is preserved. This not only maintains unobstructed venous return through the RHV to minimize congestion-related bleeding but also aligns with oncologic "no-touch" principles. It thereby reduces the risk of tumor cell dissemination caused by intraoperative manipulation and mobilization of the liver[ 12 ]. Additionally, this method avoids the technically demanding task of early diaphragmatic dissection, which is particularly challenging through a single port due to limited instrument triangulation and operating space. It should be noted that the use of an auxiliary 5-mm port, while deviating from pure single-port dogma, proved invaluable for safety and efficiency during our initial experience[ 13 ]. It provided rapid access for Pringle maneuver application, efficient suction, and instrumental assistance without adding significant trauma. This "single-port plus one" approach offers a practical balance, combining the goal of minimizing scarring with the essential requirements of patient safety and procedural control in such a complex resection. In addition, the incision was deliberately placed at a supraumbilical and slightly right-sided position, deviating from the conventional umbilical site. This decision was based on two practical considerations. First, our multiport experience indicated that a port shifted superiorly and to the right provides a more direct axis and improved exposure for the deep posterior section. Second, given the limited availability of dedicated extra-length single-port instruments such as clip appliers and suction devices, a higher incision facilitated the use of available standard-length instruments. The use of an extended-length ultrasonic dissector further compensated for reach limitations to the posterosuperior segments, ensuring adequate maneuverability and force application. This report has several limitations that should be acknowledged. First, it is based on a single-case design with a relatively short follow-up duration of 4 months. Larger-scale clinical series and extended follow-up are therefore needed to further validate the technique’s reproducibility and long-term oncological efficacy. Additionally, although the "single-port plus one" auxiliary port strategy enhances procedural safety, it deviates from the definition of pure single-port laparoscopy. Conclusion The combination of percutaneous suture traction and an in situ dorsal approach offers a feasible and effective strategy for performing single-port LRPS. This method effectively addresses the critical challenges of exposure and instrument maneuverability in deep liver resection under limited port access, providing a pathway to extend the benefits of minimal-access surgery to more complex hepatic resections. Abbreviations AFP Alpha-fetoprotein ALT Alanine aminotransferase CT Computed tomography HCC Hepatocellular carcinoma IRHV Inferior right hepatic vein IVC Inferior vena cava LRPS Laparoscopic right posterior sectionectomy PIVKA-II Protein induced by vitamin K absence-II PP Posterior Glissonean pedicle RHV Right hepatic vein SPLLR Single-port laparoscopic liver resection TB Total bilirubin Declarations Acknowledgements The authors would like to thank the surgical team and nursing staff of the Department of Hepatobiliary Surgery, The Central Hospital of Wuhan, for their technical support and clinical care during the procedure. We also gratefully acknowledge the patient for his informed consent and participation in this study. Authors' contributions RIZ and CWY made contributions to the conceptualization, design, methodology, and writing of the original draft. CWX took part in the investigation and data curation. LZ undertook project administration, validation and resource provision. XHW participated in investigation and validation. FZW and GY performed visualization and formal statistical analysis, respectively. YYL contributed to visualization, funding acquisition, as well as the manuscript’s review and editing. PXW was responsible for project administration and supervision, and also took part in the manuscript’s review and editing. All authors read and approved the final manuscript. Funding The authors received no specific funding for this work. Data availability All data generated or analysed during this study are included in this published article and its supplementary information files. Ethics approval and consent to participate This study was approved by the Institutional Ethics Committee of The Central Hospital of Wuhan (Approval No.: WHZXKYL2025-220). Written informed consent was obtained from the patient for all study procedures and the use of the surgical technique. Consent for publication Written, informed consent for publication was obtained from the patient in this study. Competing interests The authors declare no competing interests. References Tsai KY, Chen HA, Wang WY, Huang MT. Long-Term and Short-Term Surgical Outcomes of Single-Incision Laparoscopic Hepatectomy On Anterolateral Liver Segments. SURG ENDOSC. 2020;34(7):2969–79. https://doi.org/10.1007/s00464-019-07080-7 . Rhu J, Kim SJ, Choi GS, Kim JM, Joh J, Kwon CHD. Laparoscopic Versus Open Right Posterior Sectionectomy for Hepatocellular Carcinoma in a High-Volume Center: A Propensity Score Matched Analysis. WORLD J SURG. 2018;42(9):2930–7. https://doi.org/10.1007/s00268-018-4531-z . Hasegawa Y, Wakabayashi G, Nitta H, Takahara T, Katagiri H, Umemura A, Makabe K, Sasaki A. A Novel Model for Prediction of Pure Laparoscopic Liver Resection Surgical Difficulty. SURG ENDOSC. 2017;31(12):5356–63. https://doi.org/10.1007/s00464-017-5616-8 . Ban D, Tanabe M, Ito H, A Novel Difficulty Scoring System for Laparoscopic Liver Resection. J, HEPATO-BIL-PAN, SCI. 2014; 21(10):745–753. https://doi.org/10.1002/jhbp.166 Han JH, You YK, Choi HJ, Hong TH, Kim DG. Clinical Advantages of Single Port Laparoscopic Hepatectomy. WORLD J GASTROENTERO. 2018;24(3):379–86. https://doi.org/10.3748/wjg.v24.i3.379 . Seo CH, Choi HJ, You YK. Long-Term Outcomes of Single-Port Laparoscopic Hepatectomy for Hepatocellular Carcinoma: A Retrospective Comparative Analysis. ANN SURG TREAT RES. 2024;106(6):354–60. https://doi.org/10.4174/astr.2024.106.6.354 . Yang X, Ruoman A, Wu J, Yan S, Zhou B. Modified Extracorporeal Traction with Wires: A Method for Steering the Liver for Laparoscopic Resection of Hepatic Tumors in Segment 7 (with Video). BMC SURG. 2025;25(1):178. https://doi.org/10.1186/s12893-025-02876-y . Kim JH, Cho SC. Novel Traction Method by Stratafix Symmetric (Pulley Maneuver) in Laparoscopic Hepatectomy. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract. 2023; 27(2):460–3. https://doi.org/10.1007/s11605-023-05584-1 de la Torre AN, Adibi J, Zubair Z. The Sling Technique for Laparoscopic Liver Mobilization. JSLS: Journal of the Society of Laparoendoscopic Surgeons. 2024; 28(2):e2011-e2024. https://doi.org/10.4293/JSLS.2024.00011 Yang C, Zhang R, Zhu L, Zheng X, Li K, Wang P. Caudodorsal Approach Combined with in Situ Split for Laparoscopic Right Posterior Sectionectomy. Surg Endosc. 2023;37(2):1334–41. https://doi.org/10.1007/s00464-022-09657-1 . Homma Y, Honda G, Kurata M, Ome Y, Doi M, Yamamoto J. Pure Laparoscopic Right Posterior Sectionectomy Using the Caudate Lobe-First Approach. SURG ENDOSC. 2019;33(11):3851–7. https://doi.org/10.1007/s00464-019-06877-w . Agrawal S, Belghiti J. Oncologic Resection for Malignant Tumors of the Liver. ANN SURG. 2011;253(4):656–65. https://doi.org/10.1097/SLA.0b013e3181fc08ca . Katagiri H, Nitta H, Takahara T, et al. Standardized Single-Incision Plus One-Port Laparoscopic Left Lateral Sectionectomy: A Safe Alternative to the Conventional Procedure. Langenbeck's archives Surg. 2022;407(3):1277–84. https://doi.org/10.1007/s00423-021-02340-4 . Additional Declarations No competing interests reported. Supplementary Files VedioSILRPS.mp4 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9169961","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":634168528,"identity":"f1102e64-170c-4aa4-a059-46dc61b8c348","order_by":0,"name":"Rixin Zhang","email":"","orcid":"","institution":"The Central Hospital of Wuhan","correspondingAuthor":false,"prefix":"","firstName":"Rixin","middleName":"","lastName":"Zhang","suffix":""},{"id":634168529,"identity":"edfa2958-4ec9-4c6a-b45a-1c33808579fe","order_by":1,"name":"Chongwei Yang","email":"","orcid":"","institution":"The Central Hospital of Wuhan","correspondingAuthor":false,"prefix":"","firstName":"Chongwei","middleName":"","lastName":"Yang","suffix":""},{"id":634168530,"identity":"2dd1003f-1267-4164-a765-b8c7c57355ed","order_by":2,"name":"Chaowen Xiao","email":"","orcid":"","institution":"The Central Hospital of Wuhan","correspondingAuthor":false,"prefix":"","firstName":"Chaowen","middleName":"","lastName":"Xiao","suffix":""},{"id":634168531,"identity":"80291938-3908-4e5c-892d-66ba6ab9f2e2","order_by":3,"name":"Ling Zhu","email":"","orcid":"","institution":"The Central Hospital of Wuhan","correspondingAuthor":false,"prefix":"","firstName":"Ling","middleName":"","lastName":"Zhu","suffix":""},{"id":634168532,"identity":"2442421c-e10f-422e-9d1a-d2313c01a893","order_by":4,"name":"Xinhua Wu","email":"","orcid":"","institution":"The Central Hospital of Wuhan","correspondingAuthor":false,"prefix":"","firstName":"Xinhua","middleName":"","lastName":"Wu","suffix":""},{"id":634168533,"identity":"faede63b-0b29-4ef9-82de-8748192f0bc8","order_by":5,"name":"Fangze Weng","email":"","orcid":"","institution":"The Central Hospital of Wuhan","correspondingAuthor":false,"prefix":"","firstName":"Fangze","middleName":"","lastName":"Weng","suffix":""},{"id":634168534,"identity":"8150f99a-0339-47ec-be32-b638302891fa","order_by":6,"name":"Gen Yu","email":"","orcid":"","institution":"The Central Hospital of Wuhan","correspondingAuthor":false,"prefix":"","firstName":"Gen","middleName":"","lastName":"Yu","suffix":""},{"id":634168535,"identity":"a0da9cb5-108f-45ae-9b18-a23dac2063a0","order_by":7,"name":"Yuanyuan Li","email":"","orcid":"","institution":"The Central Hospital of Wuhan","correspondingAuthor":false,"prefix":"","firstName":"Yuanyuan","middleName":"","lastName":"Li","suffix":""},{"id":634168536,"identity":"fa4be1b0-9c38-48f9-9233-0a17d4c9186a","order_by":8,"name":"Pi-Xiao Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYPACGwYDEMVDgpY00rUcJkGLwfGzh18Xtp1P3C6RwPjgbRuDvDlBLWfy0qxnnLmduHNGArPh3DYGw50NBLSYHcgxM+apuJ274UYCmzRvG0OCwQFCWs6/AWoxOAfSwv6bOC03cowf81QcANvCTJQW+xtvzJhnnEmu33DmYbPknHMShhsIaZHszzH+XNhmZ2xwPPnghzdlNvIEbQECNmkIzdgAJCQIqwcC5s9EKRsFo2AUjIKRCwDsE0KHITnvUQAAAABJRU5ErkJggg==","orcid":"","institution":"The Central Hospital of Wuhan","correspondingAuthor":true,"prefix":"","firstName":"Pi-Xiao","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2026-03-19 13:23:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9169961/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9169961/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108979869,"identity":"3d01b488-5a8e-46df-83c1-b925ff3f180d","added_by":"auto","created_at":"2026-05-11 12:02:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":583212,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative imaging. (a) Portal venous and (b) equilibrium phase CT scans, with three-dimensional reconstructions shown in (c) anterior and (d) posterior views. RHV, right hepatic vein; PP, posterior pedicle; AP, anterior pedicle; G6, Glissonean pedicle of segment 6; G7, Glissonean pedicle of segment 7; IRHV, inferior right hepatic vein.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9169961/v1/c42517a1b9453c7c1b4151f4.png"},{"id":108978766,"identity":"56f06284-d464-41cf-b7a7-7a4b52011934","added_by":"auto","created_at":"2026-05-11 11:48:24","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":218782,"visible":true,"origin":"","legend":"\u003cp\u003ePatient positioning and port placement.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9169961/v1/e4d705dfd515737d893300c0.jpeg"},{"id":108978705,"identity":"d664e026-3ae4-46c1-a5a5-3f3f36d82915","added_by":"auto","created_at":"2026-05-11 11:47:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3248041,"visible":true,"origin":"","legend":"\u003cp\u003eKey intraoperative steps and suture traction technique. (a) Dissection of the caudate lobe to expose the dorsal side of the posterior pedicle. (b) Isolation of the posterior pedicle at Rouviere’s sulcus. (c) A straight needle with suture was passed percutaneously through the liver parenchyma and retrieved externally via the single-port device. (d) The externalized suture ends were tied to a pre-cut patch, which was then introduced intra‑abdominally to serve as a parenchymal anchor. (e) Exposure of V6 by parenchymal transection on the caudodorsal side under suture traction. (f) Exposure of the RHV trunk along its peripheral branches. (g) Division of the IRHV and transection of the remaining parenchyma in S7. (h) Division of the right perihepatic ligaments. CP, caudate process; IVC, inferior vena cava; PP, posterior pedicle; V5, segment 5 vein; V6, segment 6 vein; RHV, right hepatic vein; AP, anterior pedicle; S6, segment 6; IRHV, inferior right hepatic vein; S7, segment 7.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9169961/v1/22187b33953cf1906e52e1e4.png"},{"id":108978706,"identity":"2c6fab55-bfd3-40ba-bbd9-e25c93627cb3","added_by":"auto","created_at":"2026-05-11 11:47:42","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":246880,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative wound and drainage.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9169961/v1/c730e18f29bed2ff9d6916d7.jpeg"},{"id":108978733,"identity":"16048eb3-10ef-4714-a4f1-ed8bd98eef70","added_by":"auto","created_at":"2026-05-11 11:48:13","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":125212,"visible":true,"origin":"","legend":"\u003cp\u003ePerioperative trends of liver function (a) and tumor markers (b). ALT, alanine aminotransferase; TB, total bilirubin. AFP, alpha-fetoprotein; PIVKA-II, protein induced by vitamin K absence-II.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-9169961/v1/bdd5b11e4f414937bb34c435.png"},{"id":109337534,"identity":"a002d603-fe38-4070-ad32-657ea0ce3c84","added_by":"auto","created_at":"2026-05-15 17:39:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5620232,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9169961/v1/5e0dd80c-efa8-4e5e-a783-b1dcbd2e2973.pdf"},{"id":108978713,"identity":"4d16290e-f99d-4624-8e16-3b0296b31364","added_by":"auto","created_at":"2026-05-11 11:47:55","extension":"mp4","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":272586850,"visible":true,"origin":"","legend":"","description":"","filename":"VedioSILRPS.mp4","url":"https://assets-eu.researchsquare.com/files/rs-9169961/v1/9a08c1d78cff481b274bda80.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Single-port laparoscopic posterior sectionectomy using suture traction and an in situ dorsal approach: a case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSingle-port laparoscopic liver resection (SPLLR) has emerged as a refined minimal-access surgical modality, offering superior cosmetic outcomes and reduced postoperative morbidity compared with conventional multiport laparoscopic liver resection. However, its application remains largely confined to simple resections such as left lateral sectionectomy or anterolateral segmentectomy, due to the inherent limitations of single-port access including loss of instrument triangulation, severe instrument interference, and inadequate surgical field exposure[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Laparoscopic right posterior sectionectomy (LRPS) is widely recognized as one of the most technically challenging procedures even in multiport settings, owing to the deep location and and the complexity of vascular structures[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These challenges are further exacerbated in single-port laparoscopy, rendering SPLLR for the right posterior section exceedingly rare in clinical practice and published literature[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. To overcome these challenges while maintaining surgical safety and efficacy, we developed an integrated surgical strategy combining percutaneous suture traction and an in situ dorsal approach for single-port LRPS. This article details the technique and reports its successful initial application.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003ePatient\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A 77-year-old man with a body mass index of 25.4 kg/m\u0026sup2; presented with a liver mass. The patient had a long history of chronic hepatitis B virus infection, managed with regular antiviral therapy, and no prior abdominal surgical history. Imaging revealed a 5.4-cm tumor in the right posterior section (Figure 1), with no evidence of vascular invasion or distant metastasis. Preoperative alpha-fetoprotein (AFP) was 28.82 ng/mL and protein induced by vitamin K absence-II (PIVKA-II) was 6604.70 mAU/mL. Liver function was Child-Pugh A. A multidisciplinary team discussion concluded the patient was a suitable candidate for curative surgical resection, and single-port LRPS with an auxiliary 5-mm port was selected as the surgical plan. The study was approved by the Institutional Ethics Committee (WHZXKYL2025-220), and written informed consent was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003ePositioning and Port Placement:\u0026nbsp;The patient was placed supine with 30\u0026deg; right elevation. The surgeon stood on the patient\u0026rsquo;s right side, with two assistants on the left. A 3-cm vertical incision was made at the right upper edge of the umbilicus and a single-port laparoscopic device (IIIA-4E-70\u0026times;150; SURGAID, China) was inserted to establish access. To ensure surgical safety during the initial implementation of this novel technique, an additional 5-mm trocar was placed at the right subcostal margin for assistance. The port placement is shown in Figure 2.\u0026nbsp;Carbon dioxide pneumoperitoneum was maintained at 12\u0026ndash;14 mmHg throughout the procedure.\u003c/li\u003e\n \u003cli\u003eSuture Traction:\u0026nbsp;A straight needle with 3-0 prolene suture was inserted percutaneously below the xiphoid. The suture was passed through the parenchyma of the right anterior section. Dynamic traction on the externalized suture ends effectively retracted the right anterior section superiorly and to the left, creating a stable and broad exposure of the plane between the anterior and posterior sections (Figure 3).\u003c/li\u003e\n \u003cli\u003eIn Situ Dorsal Approach for tumor resection:\u0026nbsp;The right hepatic ligaments were kept intact initially. The caudate lobe was dissected first to expose the dorsal side of the right posterior Glissonean pedicle, which was then isolated at Rouviere\u0026rsquo;s sulcus and divided using clips. Intraoperative indocyanine green fluorescence imaging confirmed the perfusion boundary. Parenchymal transection was initiated from the caudal and dorsal side using an extended-length ultrasonic dissector\u0026nbsp;(HARH45; Ethicon, USA). Owing to the tumor\u0026apos;s extension beyond the posterior section, the transection plane was dynamically defined using the fluorescence guidance combined with intraoperative ultrasound visualization of the right hepatic vein (RHV). Given the tumor\u0026rsquo;s distance from the RHV, we preserved the portion of the caudate lobe adjacent to the vena cava after exposing the RHV trunk, rather than fully exposing the inferior vena cava and the RHV root. The right perihepatic ligaments were divided after completing the parenchymal transection (Figure 3).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSpecimen Extraction: The specimen was placed in a bag and extracted en bloc through the slightly extended supraumbilical incision. A drainage tube was placed through the 5-mm auxiliary port site (Figure 4). The detailed surgical procedure is demonstrated in the supplementary video.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Results","content":"\u003cp\u003eThe procedure was completed successfully without conversion to open surgery. Operative time was 270 minutes. Estimated blood loss was 100 mL, with no transfusion required. The postoperative course was uneventful, with no complications. The patient was discharged on postoperative day 11. Final pathology confirmed a poorly differentiated hepatocellular carcinoma with clear margins. Postoperative liver function showed transient elevation, which gradually returned to normal during follow-up (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003ea). Serum AFP and PIVKA-II levels normalized within one month (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eb).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSingle-port LPRS is a highly complex minimal-access procedure, with inadequate surgical field exposure and compromised instrument triangulation as its core technical challenges. These hurdles stem from the deep anatomical location of the right posterior hepatic section and the narrow operating space inherent to single-port laparoscopy, which limit instrument maneuverability and increase the risk of vascular injury. In this report, we successfully applied an integrated strategy to address these barriers, achieving favorable surgical and oncological outcomes.\u003c/p\u003e \u003cp\u003ePercutaneous suture traction serves as a simple, cost-effective, and efficient exposure technique, acting as an \u0026ldquo;invisible assistant\u0026rdquo; in single-port laparoscopy. This approach aligns with the goal of liver traction techniques\u0026mdash;optimizing surgical field exposure while minimizing iatrogenic injury[\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u0026mdash;yet offers unique advantages tailored to the constraints of single-port access. Our method allows for dynamic retraction without preliminary division of perihepatic ligaments, which aligns with the in situ dorsal approach and avoids unnecessary dissection in the confined single-port surgical field. Compared to the diaphragm-anchored \u0026ldquo;Pulley maneuver\u0026rdquo; described by Kim et al.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], our percutaneous approach eliminates the need for intracorporeal suturing to the diaphragm, simplifying the procedure and reducing instrument manipulation within the single port. This is critical in single-port surgery, where even minor increases in instrument movement can exacerbate interference and prolong operative time. Another notable advantage is its dynamic adjustability, enabling real-time modification of traction force to improve deep hepatic parenchymal tension and adapt to evolving surgical field changes during parenchymal transection. Additionally, the technique utilizes only purse-string sutures combined with small patches cut from rubber drainage tubes as anchor points, eliminating the need for specialized materials such as barbed sutures[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] or Hem-o-lok clips[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This simplicity makes the technique economically efficient and widely accessible to institutions with basic laparoscopic equipment.\u003c/p\u003e \u003cp\u003eThe in situ dorsal approach serves as a rational and effective strategy for single-port laparoscopy. This method retains the procedural logic of our previously established multiport technique[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], confirming that prioritizing caudate lobe dissection and posterior pedicle isolation from the dorsal side remains safe and feasible even under the limitations of single-port access[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A key advantage of this method is that parenchymal transection initiated from the dorsal side leverages the thinner hepatic parenchyma in this region to facilitate rapid exposure of hepatic vein branches, providing critical anatomical guidance. This characteristic proves especially valuable in the constrained single-port surgical field where tactile feedback remains limited. Notably, the in situ principle is central to its efficacy. By avoiding early division of the right perihepatic ligaments, the anatomical position of the right hepatic lobe is preserved. This not only maintains unobstructed venous return through the RHV to minimize congestion-related bleeding but also aligns with oncologic \"no-touch\" principles. It thereby reduces the risk of tumor cell dissemination caused by intraoperative manipulation and mobilization of the liver[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Additionally, this method avoids the technically demanding task of early diaphragmatic dissection, which is particularly challenging through a single port due to limited instrument triangulation and operating space.\u003c/p\u003e \u003cp\u003eIt should be noted that the use of an auxiliary 5-mm port, while deviating from pure single-port dogma, proved invaluable for safety and efficiency during our initial experience[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It provided rapid access for Pringle maneuver application, efficient suction, and instrumental assistance without adding significant trauma. This \"single-port plus one\" approach offers a practical balance, combining the goal of minimizing scarring with the essential requirements of patient safety and procedural control in such a complex resection.\u003c/p\u003e \u003cp\u003eIn addition, the incision was deliberately placed at a supraumbilical and slightly right-sided position, deviating from the conventional umbilical site. This decision was based on two practical considerations. First, our multiport experience indicated that a port shifted superiorly and to the right provides a more direct axis and improved exposure for the deep posterior section. Second, given the limited availability of dedicated extra-length single-port instruments such as clip appliers and suction devices, a higher incision facilitated the use of available standard-length instruments. The use of an extended-length ultrasonic dissector further compensated for reach limitations to the posterosuperior segments, ensuring adequate maneuverability and force application.\u003c/p\u003e \u003cp\u003eThis report has several limitations that should be acknowledged. First, it is based on a single-case design with a relatively short follow-up duration of 4 months. Larger-scale clinical series and extended follow-up are therefore needed to further validate the technique\u0026rsquo;s reproducibility and long-term oncological efficacy. Additionally, although the \"single-port plus one\" auxiliary port strategy enhances procedural safety, it deviates from the definition of pure single-port laparoscopy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe combination of percutaneous suture traction and an in situ dorsal approach offers a feasible and effective strategy for performing single-port LRPS. This method effectively addresses the critical challenges of exposure and instrument maneuverability in deep liver resection under limited port access, providing a pathway to extend the benefits of minimal-access surgery to more complex hepatic resections.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAFP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAlpha-fetoprotein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAlanine aminotransferase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHepatocellular carcinoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIRHV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInferior right hepatic vein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIVC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInferior vena cava\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLRPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLaparoscopic right posterior sectionectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePIVKA-II\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProtein induced by vitamin K absence-II\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePosterior Glissonean pedicle\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRHV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRight hepatic vein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPLLR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSingle-port laparoscopic liver resection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTotal bilirubin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the surgical team and nursing staff of the Department of Hepatobiliary Surgery, The Central Hospital of Wuhan, for their technical support and clinical care during the procedure. We also gratefully acknowledge the patient for his informed consent and participation in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRIZ and CWY made contributions to the conceptualization, design, methodology, and writing of the original draft. CWX took part in the investigation and data curation. LZ undertook project administration, validation and resource provision. XHW participated in investigation and validation. FZW and GY performed visualization and formal statistical analysis, respectively. YYL contributed to visualization, funding acquisition, as well as the manuscript\u0026rsquo;s review and editing. PXW was responsible for project administration and supervision, and also took part in the manuscript\u0026rsquo;s review and editing.\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Ethics Committee of The Central Hospital of Wuhan (Approval No.: WHZXKYL2025-220). Written informed consent was obtained from the patient for all study procedures and the use of the surgical technique.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten, informed consent for publication was obtained from the patient in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTsai KY, Chen HA, Wang WY, Huang MT. Long-Term and Short-Term Surgical Outcomes of Single-Incision Laparoscopic Hepatectomy On Anterolateral Liver Segments. 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JSLS: Journal of the Society of Laparoendoscopic Surgeons. 2024; 28(2):e2011-e2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4293/JSLS.2024.00011\u003c/span\u003e\u003cspan address=\"10.4293/JSLS.2024.00011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang C, Zhang R, Zhu L, Zheng X, Li K, Wang P. Caudodorsal Approach Combined with in Situ Split for Laparoscopic Right Posterior Sectionectomy. Surg Endosc. 2023;37(2):1334\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00464-022-09657-1\u003c/span\u003e\u003cspan address=\"10.1007/s00464-022-09657-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHomma Y, Honda G, Kurata M, Ome Y, Doi M, Yamamoto J. Pure Laparoscopic Right Posterior Sectionectomy Using the Caudate Lobe-First Approach. SURG ENDOSC. 2019;33(11):3851\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00464-019-06877-w\u003c/span\u003e\u003cspan address=\"10.1007/s00464-019-06877-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgrawal S, Belghiti J. Oncologic Resection for Malignant Tumors of the Liver. ANN SURG. 2011;253(4):656\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/SLA.0b013e3181fc08ca\u003c/span\u003e\u003cspan address=\"10.1097/SLA.0b013e3181fc08ca\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatagiri H, Nitta H, Takahara T, et al. Standardized Single-Incision Plus One-Port Laparoscopic Left Lateral Sectionectomy: A Safe Alternative to the Conventional Procedure. Langenbeck's archives Surg. 2022;407(3):1277\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00423-021-02340-4\u003c/span\u003e\u003cspan address=\"10.1007/s00423-021-02340-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Single-port laparoscopy, Posterior sectionectomy, Suture traction, In situ, Dorsal approach, Minimal-access surgery","lastPublishedDoi":"10.21203/rs.3.rs-9169961/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9169961/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle-port laparoscopic right posterior sectionectomy remains technically challenging due to inadequate exposure and significant instrument interference. Few effective technical solutions have been reported to address these core barriers, making this case noteworthy for its novel integrated surgical strategy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 77-year-old man was diagnosed with a 5.4-cm hepatocellular carcinoma in the right posterior hepatic section. He underwent single-port laparoscopic right posterior sectionectomy, with an auxiliary 5-mm subcostal port used for enhanced safety and maneuverability. Two key techniques were incorporated to address technical challenges. The first was percutaneous suture traction on the right anterior hepatic section, which optimized surgical field exposure and reduced instrument clash. The second was an in situ dorsal approach, with parenchymal transection performed before ligament division to adapt to the single-port caudodorsal view. The procedure lasted 270 minutes with an estimated blood loss of 100 mL. No transfusion was required. The patient had an uncomplicated postoperative recovery and was discharged on postoperative day 11. Tumor markers normalized during follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSuture traction combined with an in situ dorsal approach facilitates single-port posterior sectionectomy by addressing the core problems of exposure and triangulation. This integrated strategy appears feasible and effective for this complex resection.\u003c/p\u003e","manuscriptTitle":"Single-port laparoscopic posterior sectionectomy using suture traction and an in situ dorsal approach: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-09 00:19:04","doi":"10.21203/rs.3.rs-9169961/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"10dbf38f-6d01-4f0b-9b21-bb8668615013","owner":[],"postedDate":"May 9th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-15T17:28:39+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"90690702226140139256933079827773661271","date":"2026-05-04T03:48:40+00:00","index":45,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T20:14:44+00:00","index":44,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T17:14:17+00:00","index":43,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T17:39:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-09 00:19:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9169961","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9169961","identity":"rs-9169961","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}