Anterior approach with liver hanging maneuver vs conventional approach in major hepatic resections: can 3D visualization technology affect complex surgical maneuvers?

Abstract

The anterior approach (AA) with liver hanging maneuver (LHM) has been proposed as an alternative to the conventional approach (CA) for major hepatectomies. Despite its potential advantages, LHM remains underutilized, partly due to concerns about vascular injury and tumor rupture. Three-dimensional visualization technology (3DVT) may improve anatomical comprehension and inform preoperative decision-making in selecting surgical strategies. We retrospectively analyzed 20 patients undergoing major hepatic resections (right/left hepatectomy and right posterior sectionectomy) between 2019 and 2024. Four expert hepatobiliary surgeons (HPB) and four postgraduate surgical trainees (PGY5) independently assessed surgical strategy based on 2D imaging, followed by reevaluation with 3D reconstructions. Patient-specific 3D structures were generated using an AI-assisted segmentation pipeline and systematically revised by physician specialists, a board-certified abdominal radiologist and two hepatobiliary surgeons. Intra-rater concordance was evaluated using Cohen's Kappa. Primary endpoint was the rate and directionality of surgical plan modifications due to 3DVT. Secondary endpoints included perioperative outcomes and segmentation performance metrics. 3DVT prompted significant changes in surgical planning, particularly in assessing LHM feasibility. Trainees exhibited a higher proportion of positive shifts in decision-making (No → Yes: 17.6%) compared to experts (10.8%), whereas experts more frequently reversed previously affirmative decisions (Yes → No: 9.5%). In select raters, negative Kappa values indicated systematic reassessment driven by 3D data. No significant differences in intraoperative blood loss, operative time, transfusion rate, complications, or mortality were observed between AA + LHM and CA cohorts. 3D segmentation achieved high concordance with manual ground truth (median Dice similarity coefficient for liver parenchyma: 0.98). 3DVT exerts a quantifiable influence on preoperative strategy, particularly for complex hepatic resections. It facilitates surgical planning among trainees and enhances precision among experienced surgeons. Integration of 3DVT may support safer adoption of technically demanding maneuvers such as LHM, especially in minimally invasive settings.