Laparoscopic Anatomical Portal Territory Hepatectomy with Cirrhosis by Takasaki's Approach and Indocyanine Green Fluorescence Navigation (with Video).

Abstract

Anatomical liver resection has shown advantages in the treatment of hepatocellular carcinoma (HCC).1 Pure laparoscopic hepatectomy for some deep lesions remains challenging, especially for anatomical resection.2 Because of many kinds of hepatic venous variations, resection along the hepatic vein may not be a "real" anatomical resection. We used a three-dimensional visualization technique to construct a portal territory model which represented the patient-specific anatomy. During the operation, the territory was visualized by indocyanine green (ICG) navigation. A 48-year-old man was admitted to our institution with a single hepatic mass of 4.5cm in segment 7. The patient suffered hepatitis B related cirrhosis and portal hypertension. A resection plan was put forward by 3-D visualization technique in advance (Fig.1a). The patient was placed in a supine position with pillows underneath the upper right semi-lateral body. The position of the trocar is shown in Fig.1b. After removal of the gallbladder and overhang of the G6, the G7 was dissected and ligated by Takasaki's Glissonean pedicle approach (Fig.1c).3 The ischemic line appeared and was consistent with the demarcation line of portal territory (Fig.1d). A parenchyma transection was performed along the boundary of the unstained side of the ICG fluorescence. Fig.1 Some important images from the video. a The trocar position of this laparoscopic surgery. Operator-1 or -2: the first and the second trocar for the operator; assistant: the trocar for the assistant; operator/assistant: the trocar can be used by operator and assistant interchangeably; scope: the trocar for the laparoscope. b The transection plan constructed by preoperative 3-D visualization technique. The blue area was the tumor-bearing portal territory and targeted part of the liver that should be removed. c The intrahepatic anterior and posterior Glissonean pedicle of G6 and G7. G6: glissonean pedicle of segment 6; G7: glissonean pedicle of segment 7. d The ischemic line, the demarcation line of portal territory staining by ICG and the target territory constructed by 3-D visualization technique before the operation RESULT: The operation time was 205min, the estimated blood loss was 150ml. With no postoperative complications, the patient was discharged on the fourth day. Hepatocellular carcinoma was confirmed in histopathology. The resection margin was free of tumor involvement. A preoperative 3-D visualization technique combined with intraoperative ICG fluorescence navigation could facilitate a precise and safe laparoscopic anatomical hepatectomy.