# Laparoscopic left hepatectomy for a patient with an absence of portal bifurcation using real-time imaging: a case report

## TL;DR

A rare case of portal vein anomaly was successfully managed with laparoscopic surgery using real-time imaging.

## Contribution

Demonstrates successful laparoscopic left hepatectomy in a patient with absent portal bifurcation using real-time ICG fluorescence imaging.

## Key findings

- Real-time indocyanine green fluorescence imaging helped confirm liver anatomy during surgery.
- Absence of portal bifurcation was diagnosed preoperatively using 3D CT imaging.
- Laparoscopic left hepatectomy was safely performed despite the rare anatomical anomaly.

## Abstract

Absence of portal bifurcation is an extremely rare anomaly that should be recognized preoperatively, especially prior to a major hepatectomy.

A 45-year-old woman presented with abdominal pain, and abdominal computed tomography (CT) revealed dilatation of both the common bile duct (CBD) and intrahepatic bile duct (IHBD). Endoscopic retrograde cholangiopancreatography (ERCP) showed CBD and IHBD stones (B2 and B4). The CBD stones were removed, but the IHBD stones could not be, yet there was no evidence of malignancy at the site of IHBD stenosis. Enhanced CT revealed a dilated IHBD, while three-dimensional CT images showed the left portal vein running through the ventral side of the middle hepatic vein, which was diagnosed as the absence of portal vein bifurcation (APB). Laparoscopic left hepatectomy was successfully performed using real-time indocyanine green (ICG) fluorescence imaging.

Surgeons should be aware of the possibility of APB, a rare portal vein anomaly, before performing major hepatectomy. Real-time ICG fluorescence imaging may be helpful to ensure the precise anatomy of the liver during laparoscopic surgery.