First dissect the left Glisson’s pedicle. Dissect the first porta hepatis, and expose the confluence of the left and right hepatic ducts and the bifurcation of the proper hepatic artery. Dissect along the left hepatic artery until its left medial branch is exposed, and suture and divide this branch. Be careful to protect the left hepatic duct, as it is accompanied by the trunk of the left hepatic artery in the inferior aspect of the ligamentum teres hepatis. Beneath the divided left medial branch of the left hepatic artery is the left medial branch of the left hepatic duct, which should be divided and sutured; alternatively, this branch can be divided during the transection of the parenchyma. The left hepatic artery and the left hepatic duct are gently lifted to expose the left portal branch which lies beneath theses structures, and dissection should be continued anteriorly to expose the left medial branch of the portal vein, which should be carefully clamped and sutured. This completes the dissection process for the left Glisson’s pedicle; a similar process should be performed on the right Glisson’s pedicle. At the bifurcation of the proper hepatic artery, the common hepatic duct should be pulled to the left to provide a better exposure as the right hepatic artery is commonly found the behind common hepatic duct. The right hepatic artery is dissected along the right portal vein fissure to expose the right anterior and posterior branches of the right hepatic artery, and its right anterior branch points to the gallbladder bed while the right posterior branch points to the bottom right almost vertically [20]. The right anterior branch of the hepatic artery is sutured and divided, and then the right anterior branch of the right hepatic duct, which is commonly found next to the hepatic artery, should be divided and sutured carefully. The division of the right bile duct can also be carried out during transection of the parenchyma. In the end, the liver parenchyma is transected, along with the relevant canals. Now that the central liver is basically devascularized, the dividing line between the central liver and the left lateral lobe, as well as the dividing line between the central liver and the right posterior lobe, can be seen on the surface. The transection line is marked using an electronic knife, and the liver parenchyma is transected using CUSA, a water jet dissector, a LigaSure, or a hemostat. During this process, relatively large relevant canals should be divided and sutured, ligated, or clipped, using titanium clips.

There is no need to dissect the Glisson’s pedicle when dissecting the hepatic pedicle.

A lack of precision creates a certain risk of subsidiary injury, especially for individuals with complicated anatomical variation of canals entering the liver.

First dissect the gallbladder, and then find the hepatic pedicle of the right anterior lobe at the intersection of the longitudinal axis of the gallbladder and the lower limb of the liver parenchyma. Bluntly dissect the lateral parenchyma to within 0.5 cm of this intersection, and then use straight hemostatic forceps to take a suture from the back of the hepatic pedicle of the right anterior lobe and ligate the pedicle. The dividing line between the right anterior and posterior lobes can be seen on the parenchyma surface. After ligating and dividing the Glisson’s pedicles from the right to the round ligament one by one, the left dividing line can be exposed. The key technical point is to avoid opening the Glisson’s pedicle; rather, bluntly dissect between the pedicle and the parenchyma. Now several portal branches of the left medial lobe are ligated and divided, while the arteries are not involved. The left ischemic line can be seen after all portal branches of the left medial lobe are ligated. Finally, transect the liver parenchyma [11].

There is a high incidence of complications such as uncontrolled hemorrhage and bile duct damage because of the special anatomy of the central liver and anatomical variants of the intrahepatic vessels.

Anatomical structures are magnified with the laparoscope; thus, regional structures are seen more clearly than in an open procedure. The dissections of the hepatic artery, the portal vein, and the hepatic vein are performed one by one and can be managed by careful dissection using instruments.

Set up pneumoperitoneum in a routine fashion, insert the instruments, and tilt the operating table l5–30° to the left as required. The surgeon stands between the patient’s legs, assistants stand by either side of the surgeon, and the instrument nurse stands by the patient’s right foot. Five or six ports are created (Fig. 14.2). Normally, the observing port is located 1 cm beneath the umbilicus. The main port is located 2–4 cm beneath the xiphoid when resecting the left aspect of the central liver and dissecting the left lobe’s Glisson’s pedicle, 4–6 cm beneath the xiphoid when resecting the right aspect of the central liver and dissecting the right lobe’s Glisson’s pedicle. Two or three ancillary ports are located at the intersections of the right costal margin with the midclavicular line and anterior axillary line. Pretreatment blocking is set up routinely at the porta hepatis, and the transection area is marked according to preoperative imaging, intraoperative exploration, and anatomical markers of the liver. First dissect the porta hepatis. Dissect the hepatoduodenal ligament, and mobilize the common bile duct, the left and right hepatic ducts, the proper hepatic artery and its two branches, and the portal trunk and its two branches, respectively. Clip and divide the left hepatic artery, the left branch of portal vein, and the left medial branch of the left hepatic duct, respectively. Suture and divide the right hepatic artery, the right branch of the portal vein, and the right anterior branch of the right hepatic duct, respectively, in the same way. Then transect the liver parenchyma, which is commonly performed using a laparoscopic ultrasonic scalpel. Finally, handle the transection and relevant canals using the same method as in an open procedure.