Patient: Female, 70-year-old Final Diagnosis: Hepatocellular carcinoma with extrahepatic portal vein obstruction Symptoms: — Medication: — Clinical Procedure: Preoperative simulation and intraoperative navigation technique Specialty: Surgery Objective: Background: Case Report: Conclusions: Unusual setting of medical care Extrahepatic portal vein obstruction (EHPVO) is one of the most important diseases that causes pre-hepatic portal hypertension, and EHPVO sometimes develops cavernous transformation to maintain hepatopetal flow. In this report, we describe the first case of hepatocellular carcinoma (HCC) with EHPVO having underwent pure laparoscopic left hepatectomy with middle hepatic vein (MHV) resection. A 70-year-old woman with a diagnosis of mixed-type HCC or cholangiocarcinoma located in segment 4b was referred to our hospital, and computed tomography revealed EHPVO with cavernous transformation. We suc-cessfully performed pure laparoscopic left hepatectomy with MHV resection by using the individual hilar ap-proach, frequent intraoperative sonography, and indocyanine green imaging. In this case, the routine Glissonian approach was impossible due to cavernous transformation growth and the absence of a portal vein. Therefore, frequent confirmation of intrahepatic flow was crucial to avoid intraoperative complications. The patient was discharged with no complications on postoperative day 7. A histopathological examination revealed that the moderately differentiated HCC formed a pseudoglandular pattern and cord-like structures, thereby defined as type II according to Edmondson’s classification. Currently, difficulty scoring systems for laparoscopic liver resection (LLR) usually contain the procedure and location of the hepatic tumor, but they do not contain the variety of anatomical abnormality due to its rarity. However, the false recognition of hilar vessels and biliary ducts in patients with an anatomical abnormality, in-cluding EHPVO, leads to severe injury; therefore, anatomical variety and abnormality are also important fac-tors increasing the difficulty of LLR.
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