Laparoscopic right posterior sectionectomy for HCC in cirrhotic liver: ICG for tumor enhancement and negative counter-staining of the transection plane

Abstract

Background: The importance of anatomical reactions in liver cancer surgery is well known since the first description by Makuuchi in 1985, but its technical difficulty is equally known because of the absence of a clear demarcation of the hepatic segments during parenchymal transection. Takasaki et al. proposed a new concept of anatomical resection in which the Glissonean pedicles can be transected extrahepatically to identify the boundaries of the intersegmental planes. Based on these concepts, intraoperative Indocyanine-Green (ICG) fluorescence can be used to obtain a positive or negative staining of the segments to be resected. Methods: A 54-year-old male patient with well-compensated HCV-related cirrhosis underwent right posterior sectionectomy for a large HCC. 96h before surgery he was injected with 0.5 mg / kg of ICG to achieve intraoperative tumor enhancement. Surgical procedure starts with the preparation of the Pringle maneuver and the mobilization of the right liver. Then, to perform a formal anatomical resection with the so called Glissonean approach, we started the parenchymal dissection at the level of the De Rouvière sulcus, which allows to identify and isolate the portal branch of the right lateral posterior sector. This is then ligated with hemolocks and sectioned. Then 0,05 mg/kg of ICG were intravenously administrated. Results: A negative counter-staining of the transection plane for the right posterior sectionectomy was visualized. The sharp contrast between the dark area (segment 6-7) and the area highlighted in fluorescent green guided the parenchymal transection, allowing to obtain a true anatomical resection. Furthermore, a final check of the transection line was performed, and it turned out to be wrong in the lower portion, where the parenchymotomy was initially carried out without the use of indocyanine green fluorescence guidance. In this way, a re-assessing and a correction of the section line was carried out. Conclusions: The quality of the surgical act has greatly benefited from the use of ICG fluorescence, allowing to obtain a better visualization of the cancerous lesion, best resection margins, better quality specimen. The use of ICG can facilitate a technically complex procedure, through a visual immediacy that gives a real-time feedback on the goodness of the procedure, even allowing to correct a wrong transection plance and making the surgery more didactic.