Cranioventral Approach for Bleeding Control and Operative Outcomes in Laparoscopic Hemihepatectomy: A Single-Surgeon Comparative Study.

BACKGROUND: This study aimed to evaluate the clinical advantages of the cranioventral (CVA) approach compared with the caudodorsal approach (CDA) in laparoscopic hemihepatectomy. Specifically, we assessed whether early cranial access to the middle hepatic vein (MHV) improves perioperative outcomes, such as intraoperative blood loss and operative efficiency, by addressing the challenges of parenchymal transection and preservation of anatomic orientation. METHODS: This retrospective analysis included 23 patients who underwent laparoscopic hemihepatectomy performed by a single surgeon between April 2016 and October 2021. Perioperative outcomes, including operative time, blood loss, Pringle time, and complications, were compared between the caudodorsal (CDA) (early; n=13) and cranioventral (CVA) (later; n=10) groups. Independent factors associated with high intraoperative blood loss (>240 mL) were investigated using exploratory multivariable Firth penalized logistic regression analysis. RESULTS: The baseline patient characteristics were generally comparable between the 2 groups. Compared with CDA, CVA resulted in significantly less blood loss (82.5 vs. 315 mL, P=0.001), shorter operative time (370 vs. 436 min, P=0.026), and shorter Pringle time (109 vs. 147 min, P=0.047). No 90-day mortality or severe complications occurred in either group. High intraoperative blood loss (>240 mL) occurred in 11 of the 23 patients (47.8%). In the exploratory multivariable Firth penalized logistic regression analysis, left hepatectomy (OR: 0.066, 95% CI: 0.004-0.525, P=0.008) and CVA (OR: 0.114, 95% CI: 0.008-0.860, P=0.034) were independently associated with lower odds of high intraoperative blood loss. CONCLUSION: The CVA was associated with reduced intraoperative blood loss and improved operative efficiency during laparoscopic hemihepatectomy. Improved visualization of the MHV from the cranial side may facilitate stable parenchymal transection and better bleeding control. Further validation in larger multicenter studies is warranted.