Laparoscopic hepatectomy based on diseased bile duct tree territory guided by double landmarks for hepatolithiasis: A case report

Figure 1 Schematic diagram of enhanced magnetic resonance imaging, and 3D reconstruction results before surgery. A-C: Coronal and axial magnetic resonance imaging views showing the distribution of the lesion; D: Axial magnetic resonance image revealing dilated bile ducts; E: Magnetic resonance cholangiopancreatography clearly delineates the affected bile ducts and pancreatic ducts; F: 3D reconstruction model demonstrating the spatial relationships of intrahepatic vasculature from multiple perspectives, with volumetric analysis of the future liver remnant.

Figure 2 Schematic diagram of the pathological results of the lesions after surgery. A: Gross images of the surgery specimen; B and C: Light microscopic images of the surgery specimen with the following results: Chronic inflammation of the intrahepatic bile ducts with lithiasis, focal low-grade intraepithelial neoplasia of the glandular epithelium, and clustered proliferation of peripheral small bile ducts; chronic inflammation of the extrahepatic bile ducts with acute suppurative inflammation and cystic dilatation, accompanied by focal epithelial atypia.

Figure 3 Intraoperative images during the operation. A: Adhesiolysis and mobilization of the extrahepatic bile duct; B: Cystic dilatation of the extrahepatic bile duct was identified. Choledochotomy was performed, followed by choledochoscopic exploration, stone extraction, and assessment of the duodenal papilla; C: Resection of the dilated bile duct; D: Intermittent occlusion of the right anterior pedicle; E: Hepatic transection guided by the pathological bile ducts and hepatic veins; F: Opening of the hilar bile ducts with complete stone clearance; G: Repeat choledochoscopic exploration of the right anterior sectoral bile ducts; H: Hepaticojejunostomy performed.

Figure 4 Schematic diagram of the trends in liver function-related indices during follow-up of the disease course. TBIL: Total bilirubin; DBIL: Direct bilirubin; IBIL: Indirect bilirubin; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; GGT: Gamma-glutamyl transferase; POD 1: Postoperative day 1; POD 3: Postoperative day 3; POD 7: Postoperative day 7; POY 1: Postoperative year 1; POY 2: Postoperative year 2.

Figure 5 Diagram of the lesion bile duct. A: Dilated bile ducts and stones, which are often close to the iconic hepatic veins; B: Hepatectomy was performed along the double markers of diseased bile duct and hepatic vein. MHV: Middle hepatic vein; LHV: Left hepatic vein; RHV: Right hepatic vein.

Figure 6 Bile duct tree distribution. A: Diseased bile duct tree territory, B: Resection of the diseased bile duct tree.