Objective To explore the efficacy of contrast-enhanced ultrasound (CEUS) combined with mixed reality (MR) in laparoscopic anatomical hepatectomy. Methods The clinical data of 45 patients with primary liver cancer who underwent laparoscopic anatomical hepatectomy in Luoyang Central Hospital Affiliated to Zhengzhou University from January 2019 to June 2022 were retrospectively analyzed. All patients underwent abdominal thin-layer enhanced CT scan before operation, then collected data to build a three-dimensional visualization model of the liver. According to the auxiliary method of intraoperative imaging, the patients were divided into observation group (n=25, CEUS combined with MR technology was used to provide precise navigation for surgery) and the control group (n=20, routine anatomical hepatectomy was performed, and CEUS and MR technology were not used during surgery). The postoperative follow-up was to January 2023. The size of the lesion, the time of operation, the time of selective hepatic blood flow blockade, the amount of intraoperative bleeding, the intraoperative and postoperative complications, the rate of R0 resection, the length of hospital stay, the postoperative liver function [alanine aminotransferase (ALT), aspartate aminotransferase(AST), creatinine level], and the survival time were recorded and compared between two groups. Results The remaining 42 patients were successfully operated under laparoscopy except for 3 patients in control group who were converted to laparotomy. There was no statistically significant difference in lesion size between the two groups [(5.6±1.1) cm vs. (5.4±1.3) cm, P>0.05]. The observation group had significantly shorter intraoperative selective hepatic blood flow blockade time and surgical time compared to control group [(27.1±6.8) min vs. (46.9±4.3) min, P<0.001; (135.4±4.3) min vs. (199.3±5.8) min, P<0.001]. The intraoperative blood loss and transfusion volume of observation group were significantly lower than those in control group [(102.7±10.1) ml vs. (259.4±16.9) ml, P<0.001; (120.7±9.6) ml vs. (247.4±12.3) ml, P<0.001], the levels of ALT and AST were significantly lower than those in control group 24 h after operation [(96.7±23.7) U/L vs. (185.3±38.5) U/L, P<0.001; (91.4±30.9) U/L vs. (198.1±42.6) U/L, P<0.001]. One patient in the observation group developed postoperative pulmonary infection (1/25, 4.0%), and recovered after conservative treatment. In the control group, 3 patients (3/20, 15.0%) underwent massive intraoperative hemorrhage, resulting in conversion to laparotomy, 2 patients (2/20, 10.0%) experienced postoperative pulmonary infection, and 2 patients (2/20, 10.0%) experienced gastric emptying dysfunction, all patients recovered after conservative treatment. Neither patient in the two groups experienced abdominal bleeding, biliary fistula and other complications after operation. The incidence of complications in the observation group was lower than that in control group, and the difference was statistically significant (P=0.021). There was no statistically significant difference in postoperative creatinine levels, R0 resection rate, and postoperative hospital stay between the two groups [(57.4±18.2) μmol/L vs. (58.1±17.6) μmol/L, P>0.05; 100.0%(25/25) vs. 90.0%(18/20), P>0.05; (8.4±2.2) d vs. (8.9±1.9) d, P>0.05]; The median survival time of observation group was longer than that of control group, but the difference was not statistically significant [18.5(9.2, 24.5) months vs. 18.0 (8.7, 23.0) months, P>0.05]. Conclusion The combination of CEUS and MR technology is safe and effective in laparoscopic anatomical hepatectomy, which can shorten the operation time, reduce intraoperative bleeding, completely remove the tumor, and improve the treatment effect, and has good clinical application value.