Precise anatomical laparoscopic liver resection using staining technique of portal inflow territory

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Introduction: Staining technique in order to remove portal inflow territory are performed in conventional anatomical liver resection. Due to magnified caudal view, Laparoscopic liver resection (LLR)can provide better exposure on hepatic hilum than open surgery. Therefore, isolation and transection of Glissonean vessels which ramify close to hepatic hilum can be performed. However, for vessels which ramify far from hilum, it could be difficult to isolate them in hilum prior to parenchymal transection. We describe our application of staining technique in LLR, depending on the variation of portal ramification. Method: Until January 2019, we performed 14 cases of anatomical LLRs using dye staining technique. Negative staining (NS) using near-infrared fluorescence scope were made by systemic administration of Indocyanine green (ICG) after ischemia by selective inflow occlusion. Positive staining (PS) using dye injection is made by direct needle puncture into portal vein under guidance of laparoscopic ultrasonography. Result: All LLRs were successfully performed anatomically. In NS, selective inflow occlusion can be standardized for Glissonean vessels which ramify close to hepatic hilum. ICG near-infrared fluorescence scope can help to detect the ischemic area even in patients with liver cirrhosis or post-adhesiolysis, in which have unclear demarcation under usual white light of endoscope. Although, PS have been considered technically difficult under the pneumoperitoneum, we experienced successful application of PS for vessels which ramify far from hilum, using our original modification tool under guidance of laparoscopic ultrasonography. Conclusion: Staining technique of portal inflow territory could contribute to perform precise anatomical laparoscopic liver resection.