Arantius' Ligament Approach to Middle Hepatic Vein in Laparoscopic Extended Medial Segmentectomy (with Video).

Under laparoscopy-specific caudal and lateral view, Aranitius’ ligament could be the landmark for the root of the venous trunks in the left hepatic lobe.1–3 We performed laparoscopic hepatic extended medial segmentectomy including the middle hepatic vein (MHV) using the Arantius’ approach. An 86-year-old man was referred to our hospital for hepatocellular carcinoma, 4.5 cm in size, located in the medial hepatic segment (Video 1). After pneumoperitoneum and placement of four working ports, the Arantius’ ligament was exposed, isolated, and divided. The liver parenchyma underneath the Arantius’ ligament was opened to widely expose the root of the MHV, umbilical fissure vein (UFV), and left hepatic vein (LHV). After dividing the Glissonean branches for segment 4 (G4), the parenchymal tissue between MHV and LHV was divided. The trunk of the MHV was fully exposed and was divided using the endo-stapling device. Parenchymal resection was further proceeded along the dorsal side of the MHV, and the planned hepatectomy was completed. The operation time was 337 min, and the estimated blood loss was 400 g. His postoperative course was uneventful, and he was discharged on postoperative day 10. The significance of Arantius’ ligament approach is short-cut exposure of the MHV as the anatomical landmark during the initial process of the surgery under laparoscopy-specific caudal and lateral view, and is a reasonable technique in extended medial segmentectomy including the MHV.