Laparoscopic left-sided hepatectomy guided by dilated bile ducts as anatomical landmarks for hepatolithiasis: a single-center preliminary study

Introduction

Hepatolithiasis is a prevalent condition in East and Southeast Asia, posing ongoing therapeutic challenges (1,2). It can lead to recurrent cholangitis, hepatic abscesses, biliary bleeding, strictures, and an increased risk of cholangiocarcinoma (3). Although endoscopic and percutaneous techniques (e.g., choledochoscopy, lithotripsy) have advanced stone retrieval, complete clearance is difficult due to multiple complex stones, altered biliary anatomy, strictures, and segmental variations (4,5). Residual stones are common, necessitating repeated procedures.

Hepatectomy is considered the gold-standard treatment for localized hepatolithiasis because it simultaneously removes stones, strictured ducts, and any atrophic liver tissue at risk for malignancy (1,6,7). The primary goals include complete stone clearance, excision of damaged and strictured bile ducts, and removal of inflamed or atrophic liver tissue with a high risk of malignancy (8). Anatomically, the left hepatic duct is longer, narrower, and has a sharper angulation compared to the common hepatic duct, leading to poorer bile drainage than the right hepatic duct. Consequently, hepatolithiasis predominantly affects the left lobe, with left-sided hepatolithiasis accounting for over 90% of cases (1).

Conventional left hepatectomy follows anatomical landmarks based on portal branches and hepatic veins. However, factors such as changes in bile fluid dynamics, stone compression and chronic inflammation associated with hepatolithiasis lead to portal vein and hepatic artery stenosis and occlusion in some diseased areas, resulting in dilated bile ducts (DBDs) and hepatic veins becoming significant characteristic anatomical structures. Unfortunately, DBD often extend beyond the margin of the parenchymal resection, which can lead to incomplete stone removal—especially in hospitals that lack access to flexible choledochoscopy. This retention of DBD increases the risk of stone recurrence and potential malignant transformation. Additionally, during the transection of the DBD, there is a risk of bile leakage and stone spillage into the abdominal cavity, raising the likelihood of postoperative infections. Finally, suturing over inflamed and DBDs can further heighten the risk of postoperative bile leakage.

To tackle these problems, we proposed a modified laparoscopic left-sided hepatectomy with the concept that the resection margin is based on the DBD, so that we can ensure resection on the DBD, particularly in cases with significant anatomical distortion, rather than depending only on the portal veins and hepatic vein as in conventional anatomical hepatectomy. In this study, we described the technical characteristics of the modified laparoscopic left-sided hepatectoMy guided by dIlated bile ducTs as aNatomical lAnmarks for hepatolithiasis, and to evaluate the outcomes of this method, we called this the MITNA approach. We present this article in accordance with the STROCSS reporting checklist (9) (available at https://tgh.amegroups.com/article/view/10.21037/tgh-25-111/rc).

Methods

Study design and participants

We conducted a prospective observational study of 32 consecutive patients with left-sided hepatolithiasis who underwent laparoscopic left-sided hepatectomy at the Department of Hepatopancreatobiliary Surgery, 108 Military Central Hospital, between January 2023 and January 2025. All patients were classified as Child-Pugh class A and demonstrated adequate hepatic reserve on preoperative assessment. For patients planned for left hemihepatectomy (LHH), contrast-enhanced computed tomography (CT) volumetry was performed to estimate the future liver remnant, and resection was considered appropriate only when the future liver remnant exceeded 40% of total liver volume, in accordance with contemporary hepatobiliary surgical guidelines (10). Patients were classified preoperatively according to the criteria proposed by Huang et al., using magnetic resonance cholangiopancreatography (MRCP) (11). Type I disease was limited to segments 2–s3, type II extended into segment 4 or toward the hepatic hilum, and type IV included bilateral involvement. All procedures were performed by one experienced surgeon. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of the 108 Military Central Hospital (No. 384/BB-BV), and all patients provided written informed consent. A local prospective analysis plan defined the primary endpoint as final stone clearance at 6 months and secondary endpoints including operative metrics and complication rates. The study was not registered in a public trial registry (observational, single-center cohort).

Operative technique

All procedures followed a standardized laparoscopic protocol under general anesthesia. Patients were positioned supine with legs apart (French position). A 10-mm trocar for the laparoscope was placed via a supraumbilical incision. Additional working trocars (usually 4–5 total) were positioned in the epigastrium and bilateral subcostal areas (Figure 1). In patients with coexisting gallbladder stones, laparoscopic cholecystectomy was performed before liver transection.

Figure 1 Trocars’ positions and the incision for specimen extraction.

Preoperative MRCP defined the extent of the DBD. We defined DBD as intrahepatic ductal diameter ≥4 mm (or ≥1.5× contralateral duct) on MRCP with imaging evidence of intraductal disease; this threshold was chosen on the basis of published normative MRCP/ultrasound values and radiology guidance on intrahepatic duct dilatation (12,13).

For patients with type I left-side hepatolithiasis, we performed left lateral hepatectomy (LLH) with the transection line shifted to the right of the falciform ligament (Figure 2). This oriented the cut along the inflamed left hepatic ducts rather than transecting through them. In conventional LLH, the line is placed left of the falciform ligament (14). In hepatolithiasis, following the usual left line would cut through the dilated ducts, leaving residual disease. By moving rightward, we ensured the line followed the dilated duct complex and removed it en bloc with the specimen. Glissonean pedicles to segments 2–3 were transected at the umbilical fissure level after parenchymal division while portal vein and artery for segment 4 were preserved.

Figure 2 Transection lines for left lateral hepatectomy. (A) The conventional line (red line) is placed left of the falciform ligament, often crossing the dilated left duct. The modified line (blue line) is shifted to the right, aligning with dilated bile ducts. (B) This ensures complete removal of the pathological duct.

For patients whose dilated ducts extended into segment 4 or approached the hilum, a LHH was indicated. In these cases, the transection plane was planned between the DBD and the middle hepatic vein (MHV). In type II patients, inflamed ducts in segment 4 run closely to the MHV, increasing the risk of intraoperative bleeding. In line with Huang’s strategy (11), we prioritized careful skeletonization of the MHV to ensure safe exposure of the ductal structures and en bloc resection (Figure 3). Occasionally, the MHV was nearly fully exposed (Figure 4). The left Glissonean pedicle was controlled and divided at its root.

Figure 3 Anatomical space between dilated bile ducts and MHV. (A) Preoperative MRI showed narrow space between the dilated bile duct and MHV. (B) The illustration of left-sided hepatolithiasis in this patient; this is type II Huang’s classification—the most likely to cause intraoperative bleeding. (C) Intraoperative laparoscopic view after initial dissection, with the MHV skeletonized away from the dilated left duct. B2, bile duct of segment 2; B3, bile duct of segment 3; LHB, left hepatic bile duct; LHV, left hepatic vein; LMHB, left medial hepatic bile duct; MHV, middle hepatic vein; MRI, magnetic resonance imaging; RAHB, right anterior hepatic bile duct; RHV, right hepatic vein; RPHB, right posterior hepatic bile duct.

Figure 4 Resection surface following left hemihepatectomy. In this case, the inferior margin of the middle hepatic vein is virtually excavated into segment 8, indicating that the dilated left bile duct (not visible) extended beneath it.

We used an ultrasonic scalpel or Cavitron ultrasonic surgical aspirator for parenchymal transection, following the planned line. Intermittent Pringle maneuver was used as needed for bleeding control. Small intrahepatic vessels and ducts were clipped. Glissonean pedicles and the left hepatic vein were divided with endoscopic linear staplers. After liver resection, intraoperative choledochoscopy via choledochotomy was performed in cases with suspected residual common bile duct stones, followed by T-tube placement if needed. The specimen was retrieved in a bag through a 4–6 cm incision. A closed-suction drain was placed on the cut surface.

Postoperative management and follow-up

Standard postoperative care included early mobilization and imaging as indicated. Drain output was monitored for bile leakage. The T-tube (if placed) was managed per protocol, and cholangiography was performed to confirm ductal clearance before removal. All patients were followed clinically and with imaging or endoscopy as needed to detect any residual or recurrent stones.

Stone clearance was defined as the complete removal of all intrahepatic and extrahepatic stones confirmed by postoperative imaging (ultrasound, CT, or MRCP) or choledochoscopy. Residual stones were defined as stones detected within 6 months postoperatively via imaging or endoscopy. Recurrence was defined as new stone formation identified more than 6 months postoperatively (15,16).

Statistical analysis

Continuous variables are reported as mean ± standard deviation. Categorical data are reported as counts and percentages. Comparisons between LLH and LHH groups were made using Chi-squared tests for categorical variables and Student’s t-test for continuous variables. A P value <0.05 was considered statistically significant. Analyses were performed using SPSS version 27.0 (IBM Corp., Armonk, NY, USA).

Results

Patients’ characteristics

A total of 32 consecutive patients undergoing laparoscopic left-sided hepatectomy for hepatolithiasis between January 2023 and January 2025 were included. Table 1 summarizes the baseline characteristics. The mean patient age was 54.8±9.9 years; 75.0% were female. Five patients (15.6%) had prior biliary surgery (e.g., cholecystectomy or bile duct exploration). Twenty-eight patients (87.5%) had impacted stones in segments 2-3. Ten patients (31.3%) had stones in the common bile duct, and four (12.5%) had gallbladder stones. According to the Huang’s classification (11), 22 patients (68.8%) were type I, 9 (28.1%) type II, and 1 (3.1%) type IV (Table 1). Comorbidities included hypertension (31.3%) and diabetes (18.8%).

Surgical outcomes

Surgical outcomes are summarized in Table 2. The mean operative time was 140.7±46.8 minutes, with an estimated blood loss of 111.5±70.8 mL. Adhesions requiring lysis were noted in 9 patients (28.1%). Associated procedures included cholecystectomy (in 6 patients, 18.8%) and laparoscopic common bile duct exploration (7 patients, 21.9%).

Postoperative complications occurred in 4 patients (12.5%). These included one case of intra-abdominal fluid collection requiring drainage (Clavien-Dindo grade IIIa) (17), one case of mild intra-abdominal bleeding managed conservatively (grade I), and two cases of minor bile leakage (grade I), which resolved with drainage and antibiotic treatment. There were no deaths or major morbidity. The mean postoperative hospital stay was 7.7±2.5 days. All of the postoperative pathology results show chronic fibrous inflammation of the bile ducts.

At a mean follow-up of 9.50±4.08 months (range, 3–21 months), one patient (3.1%) was found to have residual stones. This patient underwent choledochoscopic removal of retained stones via a T-tube tract. After this, all patients (100%) achieved complete stone clearance. No patients developed stone recurrence or biliary malignancy during follow-up.

Compare of LLH vs. LHH outcomes

Table 3 compares characteristics and outcomes between the LLH and LHH groups. All patients classified as type I per Huang underwent LLH; patients with type II or IV disease underwent LHH, reflecting the anatomical demands of ductal extension into segment 4 or the contralateral lobe (11). Otherwise, age, sex, and prior surgery rates were similar (P>0.05). The LLH group tended to have shorter operative times and less blood loss than LHH (mean 134.50 vs. 156.25 min and 97.89 vs. 143.75 mL, respectively), but these differences did not reach statistical significance. Complication rates and lengths of stay were comparable. Residual stones occurred in 1 LHH patients (10.0%), but again this difference was not significant (P=0.646). Overall, shifting the transection line based on the DBD did not compromise safety or efficiency in either group, and all patients in both groups ultimately had full stone clearance.

Discussion

This study demonstrates that a modified laparoscopic left-sided hepatectomy, guided by the anatomy of the DBD (and MHV), is a feasible and promising strategy for complex left-sided hepatolithiasis. Our technique addresses key challenges of hepatolithiasis surgery: maximizing stone clearance while minimizing parenchymal sacrifice. Only one patient had residual stone (3.1%) in our series. This is notably lower than the typically reported rates (10–17%) for conventional approaches (14,18). This patient had type IV left-side hepatolithiasis (11), so that we indicated LHH and after that he underwent choledochoscopy via a T-tube tract to removal of retained stones in the right hepatic ducts. Moreover, operative times and blood loss in our series (mean 140.7 min and 111.5 mL) were at least comparable to prior studies of laparoscopic left hepatectomy (14,18), despite the technically demanding disease. We observed no increase in morbidity; our 12.5% minor complication rate was modest, and no severe or fatal events occurred.

Our findings align with the known benefits of minimally invasive hepatectomy for hepatolithiasis. Previous work has established laparoscopic left hepatectomy as safe and effective in experienced surgeons (14,18). According to Peng et al. [2017], laparoscopic left hepatectomy for hepatolithiasis is a safe and effective procedure for selected patients, offering advantages over open surgery in terms of reduced blood loss, lower transfusion rates, fewer complications, and faster recovery (6,14). Similarly, Wang et al. [2021] further emphasized that laparoscopic left hepatectomy is associated with reduced bleeding, smaller incisions, lower complication rates, shorter hospital stays, and quicker postoperative recovery (18). In our series, the patients’ baseline characteristics were similar to those in other hepatolithiasis cohorts (19), reinforcing the generalizability of our approach.

Hepatectomy for hepatolithiasis differs significantly from resection for hepatocellular carcinoma. In oncologic hepatectomy, anatomical resection is essential, requiring prior control of the hepatic pedicle to manage the transection margin. However, a unique aspect of hepatolithiasis is the distortion of intrahepatic anatomy. Chronic stone obstruction causes parenchymal atrophy, vascular changes, and extensive ductal dilation (8). These changes can obscure normal landmark planes. Our analysis of the pathoanatomy suggests that the dilated ducts effectively redefine the segmental boundaries; thus, following DBD path is essentially performing an “anatomical” resection tailored to the pathology. Liao et al. (20,21) have previously advocated anatomical liver resection guided by the dilated ducts and veins, showing that this reduces residual stones and recurrence. Our method complements theirs by implementing this concept laparoscopically and systematically.

Specifically, shifting the transection line in LLH to the right of the falciform ligament prevented inadvertent transection of the left hepatic duct. In many hepatolithiasis patients, bile ducts of the segment 2 and 3 is markedly dilated and tortuous. In conventional LLH, this duct frequently lies across or medial to the standard line. By moving the cut plane rightward (Figure 2), we ensured the entire dilated duct system was excised with the specimen. This maneuver avoids the need to suture inflamed ducts in the remnant liver, reducing leak risk and stone spillage. This modified hepatectomy, oriented by the pathology, preserved uninvolved tissue by sparing more lateral parenchyma than a standard LLH would require.

For LHH cases, our strategy exploited the otherwise narrow space between the DBD and the MHV (Figure 3). Preoperative imaging frequently reveals this gap due to inflammatory adhesions. In cases classified as type II left-side hepatolithiasis—those most likely to cause intraoperative bleeding (11), it is crucial for surgeons to meticulously skeletonize the MHV alongside the DBD (Figure 4) to allow for the complete removal of the dilated duct in segment 4. Compared with the MHV-guided approach described by Liao et al. [2021] (21), our MITNA technique differs in both rationale and extent of dissection. In conventional left anatomical hepatectomy, orientation according to the MHV typically requires exposure only at the transection plane to identify its position. Liao’s MHV-guided method is effective for cases with localized bile duct dilatation confined to the left liver. However, in many of our patients the DBDs extended beyond the normal anatomical boundaries, sometimes crossing into the opposite parenchyma and spreading above and below the MHV plane. In such circumstances, the MHV plane alone does not define the true boundary of disease. The key surgical objective is to remove all pathologically DBDs completely; therefore, the surgeon must trace the dilated ducts to their full extent. As a result, the MHV is almost completely exposed on all three sides—lateral, anterior, and posterior—rather than only on the transection surface, as in Liao’s study.

This bile duct-guided technique has several practical implications. First, it can be applied without specialized equipment. Flexible choledochoscopy may not be available in all centers; by orienting transection to the dilated duct tract (which is evident on CT/magnetic resonance imaging), surgeons can maximize stone clearance intraoperatively. Second, the method may simplify decision-making. Instead of rigidly adhering to anatomical templates, surgeons can adapt the resection plane based on the individual disease pattern. In our experience, only 18.9% of patients required a formal hemihepatectomy, lower than reported rates, because many cases could be managed with LLH by simply modifying the transection plane. Less parenchyma removed means better postoperative liver function. Third, this strategy offers a conceptual shift: in hepatolithiasis, “dilated bile ducts” becomes a key landmark akin to a vessel. Training should emphasize identifying and tracing the dilated ducts intraoperatively.

Our outcomes support these advantages. The average operative time and blood loss in our series compare favorably to prior large series. For instance, Peng et al. (14) reported mean time 206 min and blood loss 216 mL in laparoscopic left hepatectomy, higher than our experience. Their cohort included many extended hepatectomies, which may explain longer operations. Our lower transfusion and complication rates may reflect both the laparoscopic approach and our focus on tailored transection. Postoperative bile leak and other complications were managed conservatively and matched or improved on other reports (14,18). Length of stay (7.7 days) was similar to the 7.7 days reported by Peng (14), despite our complex cases.

Notably, five patients in our series had multiple prior hepatobiliary surgeries, leading to dense adhesions. Even in these cases, our laparoscopic approach with careful adhesiolysis (from left to right, top to bottom, using the DBD for orientation) was successful (Figure 5). This suggests that, with meticulous technique, a history of surgery is not a contraindication to this approach. Similarly, Gao et al. [2016] and Fan et al. demonstrated that hepatectomy remains feasible in such patients with meticulous preoperative planning (22,23).

Figure 5 Laparoscopic left hemihepatectomy in a patient with prior surgery. (A) Preoperative MRI showing left intrahepatic stones (arrows). (B) Resected liver specimen containing stones. (C) Strategy for adhesiolysis: dissect from left to right, superior to inferior, and from easier to more difficult areas, following the course of the inflamed ducts. MRI, magnetic resonance imaging.

Residual stones were in one patient with additional stones in the right posterior duct, outside the primary resection area. This highlights the importance of thorough evaluation for contralateral ductal stones. Importantly, multidisciplinary care ensured this stone was cleared endoscopically, achieving final 100% clearance. Üstüner et al. (24) similarly noted that multidisciplinary follow-up is crucial to address any early residual stones or recurrences.

Our study has several limitations, including its single-center design and the relatively short mean follow-up of 9.5 months. Given that late recurrences are common in hepatolithiasis, our follow-up period may not be long enough to capture them. Furthermore, the preliminary nature of this work limited our sample size. Despite these constraints, the initial results are promising based on our definition of recurrence. While a prospective randomized trial would be valuable, it would be ethically challenging to conduct given the clear rationale for our technique. We believe these findings support the consideration of this approach as a new standard for left-sided hepatolithiasis surgery.

Conclusions

Laparoscopic left-sided hepatectomy guided by DBDs as anatomical landmarks (MITNA approach) is a feasible and promising approach for left-sided hepatolithiasis, and warrants further validation in larger, multicenter studies. By aligning the resection plane with the dilated ducts, this method achieves excellent stone clearance while preserving healthy liver tissue.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROCSS reporting checklist. Available at https://tgh.amegroups.com/article/view/10.21037/tgh-25-111/rc

Data Sharing Statement: Available at https://tgh.amegroups.com/article/view/10.21037/tgh-25-111/dss

Peer Review File: Available at https://tgh.amegroups.com/article/view/10.21037/tgh-25-111/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tgh.amegroups.com/article/view/10.21037/tgh-25-111/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of 108 Military Central Hospital (No. 384/BB-BV), and written informed consent was obtained from all patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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