Laparoscopic anatomical hepatectomy with ICG fluorescence staining by lap-ultrasound and 3D visualization guided portal branch puncture approach

Abstract

Introduction: Anatomical hepatic resection could improve survival and limit complications from hepatectomy in HCC. The segment identification techniques used in open surgery are blue dye staining and Glissonean pedicle approach. However, it is difficult to reproduce these techniques laparoscopically and is impossible to identify the intersegmental plane during division of the liver parenchyma. Herein, we developed laparoscopic ultrasound and 3D visualization guided portal branch puncture technique to injection ICG fluorescence dye to the visualization of segments or subsegments during pure laparoscopic anatomical hepatectomy. Method: Preoperative 3D reconstruction of the tumor and vessels, and simulation of the perfusion area of portal branches were performed.The portal branches were identified by lap US and punctured with the 22-gauge PTCD needle through the abdominal wall under lap US and 3D visualization image guide. 5mL ICG dye (0.0125 mg/ml) was injected into the portal branches of target segment or subsegments without clamping inflow. Liver parenchyma was transected along the fluorescence boundary by harmonic and CUSA. Result: The success rate of puncture was 100% if the diameter of PV was larger than 2mm. The target segments or subsegments started to fluoresce immediately after the injection of the ICG. The intersegmental plane could be identified clearly during division of the liver parenchyma. The hepatic veins and the origin of the Glissonean pedicles of target segment were present on the border of fluorescence. This technique made lap anatomical S8,S7 and subsegmentectomy much easy. Conclusion: Laparoscopic anatomical hepatectomy with ICG fluorescence staining by lap ultrasound and 3D visualization guided portal branch puncture approach is feasible and safe. This novel technique enhanced the accuracy of pure laparoscopic anatomical hepatectomy and has great value in posterosuperior segmentectomy and subsegmentectomy.