Reappraisal of the Arantius Ligament Hanging Maneuver: From Open to Laparoscopic Caudate Lobectomy

We read with great interest the recent article by Okuda et al., entitled “The Usefulness of the Arantius Ligament Hanging Maneuver in Laparoscopic Caudate Lobectomy for a Tumor in the Paracaval Portion” 1. The authors clearly demonstrated the feasibility and safety of using the Arantius ligament as a hanging route during laparoscopic resection of the paracaval portion of the caudate lobe. We previously reported the usefulness of a modified hanging maneuver employing the same route in open isolated caudate lobectomy, showing that the Arantius ligament hanging maneuver provides a reliable and precise anatomical plane for liver hanging and orientation during paracaval dissection, particularly in cases involving large tumors or hypertrophy of the Spiegel lobe 2. Caudate lobectomy from the right side can be divided into five major steps: (1) dissection on the right side of the inferior vena cava (IVC), including the right IVC ligament and plural accessory hepatic vein (short hepatic veins); (2) separation of the caudate process and paracaval portion from the posterior segment; (3) dissection of the Glissonean pedicle of the caudate lobe; (4) parenchymal transection from the ventral region, including the anterior segment, the dorsal surface of the middle hepatic vein, and the medial segment; and (5) dissection on the left side of the IVC, including the proper hepatic vein and the left IVC ligament 3, 4. In our experience, this technique facilitates safe hepatic parenchymal transection between the paracaval portion and the ventral region, where the risk of bleeding is high. Moreover, by using the hanging maneuver, the surgeon's left hand is no longer required to maintain exposure of the operative field, allowing both hands to perform meticulous dissection. We believe that this principle is equally applicable in the laparoscopic setting. The present report extends meaningfully this concept to minimally-invasive liver surgery. The Arantius ligament, serving as a natural anatomical guide, appears to be universally useful. The authors' clear demonstration of the direction of traction of the guiding tape at each surgical step is both informative and valuable. Another technical aspect that may warrant further discussion is the control of traction tension during laparoscopic manipulation, given the limited tactile feedback inherent to this approach. This issue is particularly relevant when dealing with small vessels in a confined operative field, where achieving hemostasis can be technically demanding. We commend the authors for their valuable contribution to the advancement of minimally-invasive hepatobiliary surgery and look forward to future comparative studies that may clarify whether this maneuver can also reduce operative time or intraoperative blood loss in the laparoscopic setting. Taiji Tohyama: conceptualization, validation, original draft, and writing – review and editing. Yoshimi Fujimoto: review and editing. Takayoshi Murakami: review and editing. The authors have nothing to report. The authors declare no conflicts of interest. This article is linked to Okuda et al. papers. To view this article, visit https://doi.org/10.1002/jhbp.70081. The authors have nothing to report.