Introduction : The caudal approach is the main conceptual change in laparoscopic liver resection. The middle hepatic vein (MHV) is the landmark of the midplane of hemihepatectomy. In the caudal approach, it is difficult to expose the MHV from the peripheral branch toward the main root because of variations in branching patterns. Here, we presents ventral approach to the MHV during laparoscopic hemihepatectomy.

Methods : In the ventral approach, the liver was transected from the ventral side to the dorsal side, via a flexible laparoscope, as in open liver resection. The key characteristic of the ventral approach is the early opening of the cranial part, which guides the accurate transection and maintains an open cutting plane. After achieving a wide surgical plane, the MHV is exposed from the main root toward the peripheral branch. The liver parenchymal transection plane is easily modified according to the planning of preservation or resection of the MHV.

Results : From March 2016 to September 2017, this technique was performed on 14 patients. Of these patients, five underwent right hepatectomy, six underwent left hepatectomy, and three underwent extended left hepatectomy that included the MHV. The median operative time was 263 min (range 180-350 min), and the median blood loss was 150 mL (range 80-260 mL). The median postoperative hospital stay was 8 days (range 5-14 days). There was no postoperative morbidity or mortality.

Conclusions : Our ventral approach to the exposure of the MHV from main root toward peripheral branch may be an effective and feasible technique during laparoscopic hemihepatectomy.