Modified Glissonean pedicle transection vs. hilar dissection in laparoscopic left hemihepatectomy for hepatolithiasis: a propensity score analysis (with video).

BACKGROUND

Laparoscopic anatomical liver resection for hepatolithiasis is frequently complicated by dense hilar adhesions. Traditional hilar dissection (LHDA) is associated with biliary and vascular injury, whereas the standard Glissonean approach can be compromised by stapler failure when impacted stones are present. This study assessed the safety and efficacy of a two-step laparoscopic modified Glissonean approach (LMGA) for left-sided hepatolithiasis.

METHODS

This retrospective cohort study evaluated 215 consecutive patients who underwent laparoscopic anatomical left hemihepatectomy for hepatolithiasis between October 2018 and September 2025 (149 LHDA vs. 66 LMGA). Propensity score matching (1:1) yielded 48 well-balanced pairs. Perioperative outcomes, early liver function, stone clearance, and recurrence-free survival (RFS) were compared.

RESULTS

After matching, baseline characteristics were similar between groups. The LMGA group had a shorter median operative time than the LHDA group (275 vs. 315 min, P = 0.035) and lower AST levels on postoperative day 3 (40.75 vs. 69.95 U/L, P < 0.001). Blood loss, conversion rates, and morbidity were comparable. The residual stone rate was numerically lower with LMGA, though the difference did not reach statistical significance (2.1 vs. 14.6%, P = 0.065). RFS did not differ significantly between groups (log-rank P = 0.66). In univariable Cox analysis, Child-Pugh class B, elevated preoperative bilirubin, high AST, and longer operative time were associated with shorter RFS, whereas the surgical approach was not.

CONCLUSIONS

The "incise‑verify‑transect" LMGA strategy offers a safe and efficient approach to laparoscopic left hemihepatectomy. Direct-vision clearance of impacted stones helps to reduce stapler-related risks, shorten operative time, and promote earlier functional recovery, without increasing perioperative morbidity.