Hepatic grooves:An observational study at laparoscopic surgery

BACKGROUND In traditional descriptions,the upper surface of the liver is smooth and convex,but deep depressions are variants that are present in 5%-40%of patients.We sought to determine the relationship between surface depressions and the diaphragm.AIM To use exploratory laparoscopy to determine the relationship between surface depressions and the diaphragm.METHODS An observational study was performed in all patients undergoing laparoscopic upper gastro-intestinal operations between January 1,2023 and January 20,2024.A thirty-degree laparoscope was used to inspect the liver and diaphragm.When surface depressions were present,we recorded patient demographics,presence of diaphragmatic bands,rib protrusions and/or any other source of compression during inspection.RESULTS Of 394 patients,343 had normal surface anatomy,and 51(12.9%)had prominent surface depressions on the liver.There was no significant relationship between the presence of surface depressions and gender nor the presence of rib projections.However,there was significant association between the presence of surface depressions and diaphragmatic muscular bands(P<0.001).CONCLUSION With these data,the diaphragmatic-band theory has gained increased importance over other theories for surface depressions.Further studies are warranted using cross sectional imaging to confirm relationships with intersectional planes as well as beta-catenin assays in the affected liver parenchyma.

Simultaneous portal and hepatic vein embolization is better than portal embolization or ALPPS for hypertrophy of future liver remnant before major hepatectomy: A systematic review and network meta-analysis

Background:Post-hepatectomy liver failure(PHLF)is the Achilles’heel of hepatic resection for colorectal liver metastases.The most commonly used procedure to generate hypertrophy of the functional liver remnant(FLR)is portal vein embolization(PVE),which does not always lead to successful hypertrophy.Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)has been proposed to overcome the limitations of PVE.Liver venous deprivation(LVD),a technique that includes simultaneous portal and hepatic vein embolization,has also been proposed as an alternative to ALPPS.The present study aimed to conduct a systematic review as the first network meta-analysis to compare the efficacy,effectiveness,and safety of the three regenerative techniques.Data sources:A systematic search for literature was conducted using the electronic databases Embase,PubMed(MEDLINE),Google Scholar and Cochrane.Results:The time to operation was significantly shorter in the ALPPS cohort than in the PVE and LVD cohorts by 27 and 22 days,respectively.Intraoperative parameters of blood loss and the Pringle maneuver demonstrated non-significant differences between the PVE and LVD cohorts.There was evidence of a significantly higher FLR hypertrophy rate in the ALPPS cohort when compared to the PVE cohort,but non-significant differences were observed when compared to the LVD cohort.Notably,the LVD cohort demonstrated a significantly better FLR/body weight(BW)ratio compared to both the ALPPS and PVE cohorts.Both the PVE and LVD cohorts demonstrated significantly lower major morbidity rates compared to the ALPPS cohort.The LVD cohort also demonstrated a significantly lower 90-day mortality rate compared to both the PVE and ALPPS cohorts.Conclusions:LVD in adequately selected patients may induce adequate and profound FLR hypertrophy before major hepatectomy.Present evidence demonstrated significantly lower major morbidity and mortality rates in the LVD cohort than in the ALPPS and PVE cohorts.

Effect of an Airbag-selective Portal Vein Blood Arrester on the Liver after Hepatectomy:A New Technique for Selective Clamping of the Portal Vein

Objective:A novel technique was explored using an airbag-selective portal vein blood arrester that circumvents the need for an intraoperative assessment of anatomical variations in patients with complex intrahepatic space-occupying lesions.Methods:Rabbits undergoing hepatectomy were randomly assigned to 4 groups:intermittent portal triad clamping(PTC),intermittent portal vein clamping(PVC),intermittent portal vein blocker with an airbag-selective portal vein blood arrester(APC),and without portal blood occlusion(control).Hepatic ischemia and reperfusion injury were assessed by measuring the 7-day survival rate,blood loss,liver function,hepatic pathology,hepatic inflammatory cytokine infiltration,hepatic malondialdehyde levels,and proliferating cell nuclear antigen levels.Results:Liver damage was substantially reduced in the APC and PVC groups.The APC animals exhibited transaminase levels similar to or less oxidative stress damage and inflammatory hepatocellular injury compared to those exhibited by the PVC animals.Bleeding was significantly higher in the control group than in the other groups.The APC group had less bleeding than the PVC group because of the avoidance of portal vein skeletonization during hepatectomy.Thus,more operative time was saved in the APC group than in the PVC group.Moreover,the total 7-day survival rate in the APC group was higher than that in the PTC group.Conclusion:Airbag-selective portal vein blood arresters may help protect against hepatic ischemia and reperfusion injury in rabbits undergoing partial hepatectomy.This technique may also help prevent liver damage in patients requiring hepatectomy.

Computed tomography perfusion in differentiating portal hypertension: A correlation study with hepatic venous pressure gradient

BACKGROUND Hepatic venous pressure gradient(HVPG)is the gold standard for diagnosis of portal hypertension(PH),invasiveness and potential risks in the process of measurement limited its widespread use.AIM To investigate the correlation of computed tomography(CT)perfusion parameters with HVPG in PH,and quantitatively assess the blood supply changes in liver and spleen parenchyma before and after transjugular intrahepatic portosystemic shunt(TIPS).METHODS Twenty-four PH related gastrointestinal bleeding patients were recruited in this study,and all patients were performed perfusion CT before and after TIPS surgery within 2 wk.Quantitative parameters of CT perfusion,including liver blood volume(LBV),liver blood flow(LBF),hepatic arterial fraction(HAF),spleen blood volume(SBV)and spleen blood flow(SBF),were measured and compared before and after TIPS,and the quantitative parameters between clinically significant PH(CSPH)and non-CSPH(NCSPH)group were also compared.Then the correlation of CT perfusion parameters with HVPG were analyzed,with statistical significance as P<0.05.RESULTS For all 24 PH patients after TIPS,CT perfusion parameters demonstrated decreased LBV, increased HAF, SBV and SBF, with no statistical difference in LBF. Compared withNCSPH, CSPH showed higher HAF, with no difference in other CT perfusion parameters. HAFbefore TIPS showed positive correlation with HVPG (r = 0.530, P = 0.008), while no correlation wasfound in other CT perfusion parameters with HVPG and Child-Pugh scores.CONCLUSIONHAF, an index of CT perfusion, was positive correlation with HVPG, and higher in CSPH thanNCSPH before TIPS. While increased HAF, SBF and SBV, and decreased LBV, were found afterTIPS, which accommodates a potential non-invasive imaging tool for evaluation of PH.

Clinical studies on inferior right hepatic veins

BACKGROUND: Many small veins are called accessory, short hepatic veins in addition to the right, middle and left hepatic veins. The size of these veins varied from a pinhole to 1 cm; the size of inferior right hepatic veins (IRHVs) is thicker than that of short hepatic veins or more than 1 cm. occasionally. Adults have a higher incidence rate of the IRHV. DATA SOURCES: A literature search of the PubMed database was conducted and research articles were reviewed. RESULTS: The size of IRHVs is related to the size of the right hepatic vein, i.e. the larger the diameter of the right hepatic vein, the smaller the diameter of the IRHVs, and vice versa. The IRHVs are divided into superior, medial and inferior groups, separately named the superior, medial and inferior right hepatic veins according to the position of the IRHV entering the inferior vena cava. The superior right hepatic vein mainly drains the superior part of segment VII, and the medial right hepatic vein drains the middle part of segment VII. A thicker IRHV mainly drains segment VI and the inferior part of segment VII and a thinner IRHV drains the inferior part of segment V. CONCLUSIONS: The clinical significance of these studies on IRHVs is varied: (1) Hepatic caudate lobe resection could be introduced after study on the veins of that lobe. (2) It is very important to identify the draining region of the IRHV for guiding hepatic segmentectomy. The postero-inferior area of the right lobe can be preserved along with the hypertrophic IRHV even if the entire main right hepatic vein is resected during segmentectomy of VII and VIII with right hepatic vein resection for patients with primary liver cancer. (3) The ligation of the major hepatic vein for the treatment of juxtahepatic vein injury is recommended because of severe hemorrhagic shock and difficulty in exposure. (4) It is very helpful to decide therapeutic modalities for Budd-Chiari syndrome.

Early control of short hepatic portal veins in isolated or combined hepatic caudate lobectomy

BACKGROUND:Caudate lobectomy has long been considered technically difficult.This study aimed to elaborate the significance of early control of short hepatic portal veins(SHPVs) in isolated hepatic caudate lobectomy or in hepatic caudate lobectomy combined with major partial hepatectomy,and to describe the anatomical characteristics of SHPVs.METHODS:The data of 117 patients who underwent either isolated or combined caudate lobectomy by the same team of surgeons from 2005 to 2009 were retrospectively analyzed.From 2005 to 2007(group A,n=55),we carried out early control of short hepatic veins(SHVs) only;from 2008 to 2009(group B,n=62),we carried out early control of both SHVs and SHPVs.The two groups were compared to evaluate which surgical procedure was better.A detailed anatomical study was then carried out on the last 25 consecutive patients in group B to study the number and distribution of SHPVs during surgery.RESULTS:Patients in group B had less intra-operative blood loss,less impairment of liver function,shorter postoperative hospital stay,fewer postoperative complications and required less blood transfusion(P<0.05).The number of SHPVs in the 25 patients was 183,with 7.3±2.7 per patient.The diameters of SHPVs were 1 to 4 mm.On average,3.4 SHPVs/patient came from the left portal vein,2.2 from the bifurcation,1.4 from the right portal vein,and 0.3 from the main portal vein.On average,3.3 SHPVs/patient supplied segment I of the liver,0.4 for segment II,2.1 for segment IV,1.4 for segment V and 0.1 for segment VI.CONCLUSION:Early control of SHPVs in isolated or combined hepatic caudate lobectomy may be a useful method to decrease surgical risk and improve postoperative recovery.

Hepatic veins anatomy and piggy-back liver transplantation

BACKGROUND:The piggy-back caval anastomosis technique is widely used in orthotopic liver transplantation although it carries an increased risk of complications,including outflow obstruction and Budd-Chiari syndrome.The aim of this study is to clarify the anatomy and variations of hepatic veins(HVs) draining into the inferior vena cava(IVC),and to classify the surgical techniques of piggy-back liver transplantation(PBLT) based on the anatomy of HVs which can reduce the occurrence of complications.METHODS:PBLT was performed in 248 consecutive cases at our hospital from January 2004 to August 2011.The anatomy of recipients’ HVs was determined when removing the native diseased livers.Both anatomy of HVs and short HVs draining into the IVC were recorded.These data were collected and analyzed.RESULTS:We classified anatomic variations of HVs in the 248 livers into five types according to the way of drainage into the IVC:type I(trunk type of left and middle HVs),142(57.3%) patients;type II(trunk type of right and middle HVs),54(21.8%);type III(trunk type of left,middle and right HVs),14(5.6%);type IV(non-trunk type of left,middle and right HVs),of which,type IVa,16(6.5%),in the same horizontal plane;type IVb,18(7.3%),in different horizontal planes;and type V(segment type),4(1.6%).The patients whose HVs anatomy belonged to types I,II and III underwent classical piggy-back liver transplantation.Type IVa patients had classical PBLT via HV venoplasty prior to piggy-back anastomosis,while type IVb patients and type V patients could only have modified PBLT.CONCLUSION:This study demonstrates that HVs can be classified according to the anatomy of their drainage into the IVC and we can use this classification to choose the best operative approach to PBLT.

Efficacy of 5-Fluorouracil and High-Concentration Cisplatin Suspended in Lipiodol by Short-Term Hepatic Arterial Infusion Chemotherapy for Advanced Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis

Background: Since advanced hepatocellular carcinoma (HCC) is potentially fatal, and patients’ quality of life (QOL) often deteriorates during their treatment, improving the prognosis and QOL of patients given chemotherapy is very important. In addition, cost-effective treatments are highly desirable when chemotherapy must be given repeatedly. The aim of this study was to evaluate the efficacy and usefulness of 5-fluorouracil (5-FU) and high-concentration cisplatin by short-term hepatic arterial infusion chemotherapy (3-day FPL) in advanced HCC patients. Methods: Thirty patients with unresectable advanced HCC were enrolled. The patients underwent hepatic arterial infusion chemotherapy via the implanted port system with 5-FU on days 1 - 3 and a fine-powder formulation of cisplatin in suspended pre-warmed lipiodol on day 2 every 4 to 10 weeks. Tumor response was assessed one month later with CT. Results: All patients had evidence of portal vein invasion (Vp2-4). Four patients achieved a complete response (CR), 8 patients achieved a partial response (PR), and 7 patients had stable disease (SD). The median progression-free survival (PFS) and overall survival (OS) were 198 days and 452 days, respectively. The OS was significantly longer in the successful disease control group (CR, PR, and SD) than in the progressive disease group (P < 0.005). Conclusions: Three-day FPL was effective and tolerable in advanced HCC patients due to its shorter time of administration than conventional FP therapy. Therefore, repetitive 3-day FPL appears useful and contributes to improving the prognosis and QOL of patients with advanced HCC. In addition, this protocol is a cost-effective treatment.

Is right lobe liver graft without main right hepatic vein suitable for living donor liver transplantation?

BACKGROUND Since the first living donor liver transplantation(LDLT)was performed by Raia and colleagues in December 1988,LDLT has become the gold standard treatment in countries where cadaveric organ donation is not sufficient.Adequate hepatic venous outflow reconstruction in LDLT is essential to prevent graft congestion and its complications including graft loss.However,this can be complex and technically demanding especially in the presence of complex variations and congenital anomalies in the graft hepatic veins.CASE SUMMARY Herein,we aimed to present two cases who underwent successful right lobe LDLT using a right lobe liver graft with rudimentary or congenital absence of the right hepatic vein and describe the utility of a common large opening drainage model in such complex cases.CONCLUSION Thanks to this venous reconstruction model,none of the patients developed postoperative complications related to venous drainage.Our experience with venous drainage reconstruction models shows that congenital variations in the hepatic venous structure of living liver donors are not absolute contraindications for LDLT.

Surgical relevance of anatomic variations of the right hepatic vein

BACKGROUND Variations in the anatomy of hepatic veins are of interest to transplant surgeons,interventional radiologists,and other medical practitioners who treat liver diseases.The drainage patterns of the right hepatic veins(RHVs)are particularly relevant to transplantation services.AIM The aim was to identify variations of the patterns of venous drainage from the right side of the liver.To the best of our knowledge,there have been no reports on RHV variations in in a Caribbean population.METHODS Two radiologists independently reviewed 230 contrast-enhanced computed tomography scans performed in 1 year at a hepatobiliary referral center.Venous outflow patterns were observed and RHV variants were described as:(1)Tributaries of the RHV;(2)Variations at the hepatocaval junction(HCJ);and(3)Accessory RHVs.RESULTS A total of 118 scans met the inclusion criteria.Only 39%of the scans found conventional anatomy of the main hepatic veins.Accessory RHVs were present 49.2%and included a well-defined inferior RHV draining segment VI(45%)and a middle RHV(4%).At the HCJ,83 of the 118(70.3%)had a superior RHV that received no tributaries within 1 cm of the junction(Nakamura and Tsuzuki type I).In 35 individuals(29.7%)there was a short superior RHV with at least one variant tributary.According to the Nakamura and Tsuzuki classification,there were 24 type II variants(20.3%),six type III variants(5.1%)and,five type IV variants(4.2%).CONCLUSION There was significant variation in RHV patterns in this population,each with important relevance to liver surgery.Interventional radiologists and hepatobiliary surgeons practicing in the Caribbean must be cognizant of these differences in order to minimize morbidity during invasive procedures.

Budd-Chiari syndrome: A case with a combination of hepatic vein and superior vena cava occlusion

We here report a recent, rare case of Budd-Chiari syndrome, associated with a combination of hepatic vein and superior vena cava occlusion. A young female, who had been ingood health, was admitted to our hospital because of massive ascites. The patient had used no oral contraceptives. Tests for coagulation disorders, hematological disorders, and antiphospholipid syndrome were all negative. BuddChiari syndrome was diagnosed by radiographic examination. The patient was suffering from a combination of hepatic vein and superior vena cava occlusion. In particular, the venous flow returned from the liver mainly through a right accessory hepatic vein, and stenosis was recognized at the orifice of this collateral vein into the vena cava.Subsequently, the patient underwent percutaneous balloon dilatation therapy for this stenosis. After this treatment, the massive ascites was gradually reduced, and she was discharged from our hospital. It has now been one year since discharge, and the patient has been doing well. If deteriorating liver function or intractable ascites occur again, a liver transplantation may be anticipated. This is the first case report of Budd-Chiari syndrome associated with a superior vena cava occlusion.

Left hepatic vein: can be sutured and ligated blindly in left hepatectomy?

OBJECTIVE: To determine whether the anatomic characteristics of the left hepatic vein, middle hepatic vein and common trunk could influence the operation procedures of left hepatectomy. METHOD: Fifteen fresh human liver specimens were dissected and their anatomic characteristics were recorded. RESULTS: The left hepatic vein and middle hepatic vein formed the common trunk of 1.2±0.4 cm in length in the 15 liver specimens. The angle between the left hepatic vein and middle hepatic vein was 91±18.3°. CONCLUSION: The left hepatic vein should not be sutured and ligated blindly in left hepatectomy because there might be a potential damage to the middle hepatic vein.

Linear endoscopic ultrasound evaluation of hepatic veins

Liver resection surgery can be associated with significant perioperative mortality and morbidity. Extensive knowledge of the vascular anatomy is essential for successful, uncomplicated liver surgeries. Various imaging techniques like multidetector computed tomographic and magnetic resonance angiography are used to provide information about hepatic vasculature. Linear endoscopic ultrasound(EUS) can offer a detailed evaluation of hepatic veins, help in assessment of liver segments and can offer a possible route for EUS guided vascular endotherapy involving hepatic veins. A standard technique for visualization of hepatic veins by linear EUS has not been described. This review paper describes the normal EUS anatomy of hepatic veins and a standard technique for visualization of hepatic veins from four stations. With practice an imaging of all the hepatic veins is possible from four stations. The imaging from fundus of stomach is the easiest and most convenient method of imaging of hepatic veins. EUS of hepatic vein and the tributaries is an operator dependent technique and in expert hands may give a mapping comparable to computed tomographic and magnetic resonance imaging. EUS of hepatic veins can help in identification of individual sectors and segments of liver. EUS guided interventions involving hepatic veins may require approach from different stations.

Clinical value of ^(18)F-FDG PET/CT in evaluation of hepatic vein,inferior vena cava and right atrium tumor thrombi in hepatocellular carcinoma:Initial results

In this paper,eleven consecutive hepatocellular carcinoma(HCC) patients with an embolus in the hepatic vein(HV),inferior vena cava(IVC)and right atrium(RA) were studied with 18F-FDG PET/CT and contrast enhanced CT.When correlated with final diagnosis,18F-FDG PET/CT and contrast enhanced CT was positive in 11 patients(100%),7 patients(63.6%),respectively.The accuracy of PET/CT and contrast-enhanced CT were 100%,63.6%.Three cases with secondary blood thrombi in the distant IVC,which were confirmed by PET/CT,cannot be identified by contrast enhanced CT.The average survival was 3 months(range,1-12mo).The 12 months survival rate was 9.1%.Our results suggest that highly metabolic tumor thrombus in the HV,IVC and RA may be depicted on 18F-FDG PET/CT in HCC patients.It may discriminate between malignant and secondary benign blood thrombi.

Complete resection of the hepatic veins: The role of right inferior vein

To the editor:In the recent years liver surgery has been dramatically improved because of technical and technological innovations,perioperative and intraoperative intensive care,better knowledge of liver physiology and early recognition and treatment of postoperative complications.Last but not least,liver anatomy,though not

Hepatic veins as a site of clot formation following liver resection

Pulmonary embolism occurs more frequently after hepatectomy than previously thought but is infrequently associated with peripheral deep vein thrombosis. In this paper, we report 2 cases of postoperative hepatic vein thrombosis after liver resection. Both patients had undergone major hepatectomy of a non-cirrhotic liver largely exposing the middle hepatic vein. Clots were incidentally found in the middle hepatic vein 4 and 17 d after surgery despite routine systemic thrombo-prophylaxis with low molecular weight heparin. Coagulation of the transition plan in a context of mutation of the prothrombin gene and inflammation induced biloma were the likely predisposing conditions. Clots disappeared following curative anticoagulation. We conclude that thrombosis of hepatic veins may occur after liver resection and is a potential source of pulmonary embolism.

Clinical anatomy of hepatic vessels by computed tomography angiography:A minireview

The liver has a complex vascular anatomy with a unique dual blood supply.Clinical conditions of the liver vary widely and include disorders originating in the vascular and biliary systems as well as the parenchyma.In most vascular disorders,the effects on the liver are generally subclinical because of its abundant blood supply.However,early diagnosis of such vascular diseases can significantly reduce patient morbidity and mortality.Because imaging findings of vascular disease are not always readily apparent,diagnosis can be difficult.Computed tomography angiography is an excellent imaging modality for visualizing the vascular anatomy of patients for treatment planning.In this review article,we focus on the vascular anatomy of the liver and the imaging findings in some acute hepatic vascular diseases.

Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt to reduce hepatic encephalopathy

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS) is currently used for the treatment of complications of portal hypertension. The incidence of hepatic encephalopathy(HE) remains a problem in TIPS placement. It has been reported that the right branch mainly receives superior mesenteric venous blood while the left branch mainly receives blood from the splenic vein. We hypothesized that targeted puncture of the left portal vein would divert the non-nutritive blood from the splenic vein into the TIPS shunt; therefore, targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE.AIM To evaluate the influence of targeted puncture of left branch of portal vein in TIPS on HE.METHODS A retrospective analysis of 1244 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2000 to January 2013 was performed. Patients were divided into group A(targeting left branch of portal vein, n = 937) and group B(targeting right branch of portal vein, n = 307). TIPS-related HE and clinical outcomes were analyzed.RESULTS The symptoms of ascites and variceal bleeding disappeared within a short time.By the endpoint of follow-up, recurrent bleeding and ascites did not differ significantly between groups A and B(P = 0.278, P = 0.561, respectively).Incidence of HE differed significantly between groups A and B at 1 mo(14.94% vs36.80%, χ~2 = 4.839, P = 0.028), 3 mo(12.48% vs 34.20%, χ~2 = 5.054, P = 0.025), 6 mo(10.03% vs 32.24%, χ~2 = 6.560, P = 0.010), 9 mo(9.17% vs 31.27%, χ~2 = 5.357, P =0.021), and 12 mo(8.21% vs 28.01, χ~2 = 3.848, P = 0.051). There were no significant differences between groups A and B at 3 years(6.61% vs 7.16%, χ~2 = 1.204, P =0.272) and 5 years(5.01% vs 6.18%, χ~2 = 0.072, P = 0.562). The total survival rate did not differ between groups A and B(χ~2 = 0.226, P = 0.634, log-rank test).CONCLUSION Targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE but has no direct influence on prognosis of portalhypertension-related complications.

Precise hepatectomy guided by the middle hepatic vein

The middle hepatic vein (MHV) lies in the midplane of the liver. The classical teaching of right or left hepatectomy is transection of liver I cm to the right or left wall of the MHV in order to avoid bleeding. However, guidance of liver transection is lost if the course of the MHV is not known. By exposing the MHV early in the phase of liver transection and following its course to the inferior vena cava, a precise liver transection plane could be obtained. Such technique has the potential of achieving adequate tumor-free resection margin, avoiding damage to intrahepatic portal pedicles, preserving venous drainage and functional liver tissue, and less postoperative infection.

Glissonian approach combined with major hepatic vein first for laparoscopic anatomic hepatectomy

Background: Laparoscopic anatomic hepatectomy remains challenging because of the complex interior structures of the liver. Our novel strategy includes the Glissonian approach and the major hepatic vein first, which serves to define the external and internal landmarks for laparoscopic anatomic hepatectomy.Methods: Eleven cases underwent laparoscopic anatomic hepatectomy, including three right hepatectomies, three left hepatectomies, three right posterior hepatectomies, and two mesohepatectomies. The Glissonian approach was used to transect the hepatic pedicles as external demarcation. The major hepatic vein near the hepatic portal was exposed and served as the internal landmark for parenchymal transection. The liver parenchyma below and above the major hepatic vein was transected along the major hepatic vein. Fifty-nine subjects were used to compare the distance between the major hepatic vein and secondary Glisson pedicles among different liver diseases.Results: The average operative time was 327 min with an estimated blood loss of 554.55 m L. Only two patients received three units of packed red blood cells. The others recovered normally and were discharged on postoperative day 7. The distance between right posterior Glissonian pedicle and right hepatic vein was shorter in the patients with cirrhosis than that without cirrhosis, and this distance was even shorter in patients with hepatocellular carcinoma.Conclusion: The Glissonian approach with the major hepatic vein first is easy and feasible for laparoscopic anatomic hepatectomy, especially in patients with hepatocellular carcinoma and cirrhosis.