Anatomical Hepatectomy Research Articles

Laparoscopic anatomical hepatectomy using negative staining method with Indocyanine Green fluorescence in treatment of Hepatocellular carcinoma: a single center experiences in Viet Nam

Laparoscopic anatomical hepatectomy using negative staining method with Indocyanine Green fluorescence in treatment of Hepatocellular carcinoma: a single center experiences in Viet Nam

Preliminary result of anatomical hepatectomy on recurrence based on preoperative circulating tumor cell status in hepatocellular carcinoma-update to august 2023

Preliminary result of anatomical hepatectomy on recurrence based on preoperative circulating tumor cell status in hepatocellular carcinoma-update to august 2023

Laennec approach for anatomic hepatectomy assisted with laparoscopy or robot: a multi-centers cohort study in China

Laennec approach for anatomic hepatectomy assisted with laparoscopy or robot: a multi-centers cohort study in China

Feasibility of novel intraoperative navigation for anatomical liver resection using real-time virtual sonography combined with indocyanine green fluorescent imaging technology.

To analyze the feasibility and clinical effect of novel intraoperative navigation of real-time virtual sonography (RVS) combined with indocyanine green (ICG) fluorescent imaging technology in anatomical liver resection (ALR) for hepatocellular carcinoma. The clinical data of 41 patients who underwent ALR using RVS intraoperative navigation combined with ICG fluorescent imaging technology in the Department of Hepatobiliary Surgery of Peking University International Hospital from January 2020 to May 2022 were retrospectively analyzed. RVS was applied to guide the surgical plane through fusing real-time intraoperative ultrasound images with corresponding preoperative CT or MRI images. Operation methods, operation time, intraoperative blood loss, operative margin, hospital stay and postoperative complications were analyzed. The 1-year overall survival rate and tumor-free survival rate of patients were followed up by outpatient review or telephone calls. ALR surgery was performed on each of 41 patients. There were no deaths during perioperative period and postoperative complications occurred in 7 cases (17.1%). The postoperative pathological examinations demonstrated all cases of hepatocellular carcinoma and negative operative margins. The 41 patients were followed up for 12 to 20 months, with a median follow-up time of 14 months. The overall survival rate 1 year after surgery was 100.0% (41/41), 3 patients (7.3%) experienced tumor recurrence, and the tumor-free survival rate of 1 year after surgery was 92.7% (38/41). In conclusion, novel intraoperative navigation of RVS combined with ICG fluorescent imaging technology is safe and feasible in anatomical segmental hepatectomy of hepatocellular carcinoma.

Parenchymal-sparing anatomical hepatectomy based on portal ramification of the right anterior section: A prospective multicenter experience with short-term outcomes.

Parenchymal-sparing anatomical hepatectomy (Ps-AH) based on portal ramification of the right anterior section (RAS) is a new technique to avoid unnecessarily transecting too much liver parenchyma, especially in cases of major anatomical hepatectomy. We prospectively assessed 26 patients with primary hepatic malignancies having undergone major Ps-AH based on portal ramification of the RAS from August 2018 to August 2022 (48 months). The perioperative indications, clinical data, intra-operative index, pathological postoperative specimens, postoperative complications, and follow-up results were retrospectively evaluated. Among the 26 patients analyzed, there was just one case that had intrahepatic cholangiocarcinoma The preoperative level of α-Fetoprotein was 25.2 ng/mL. All cases (100%) had Child-Pugh A liver function preoperatively. The ventral/dorsal RAS was preserved in 19 and 7 patients, respectively. The mean surgical margin was 6.2 mm. The mean surgical time was 228.5 minutes, while the mean blood loss was 255 mL. In pathology, 5 cases (19.2%) had microvascular invasion, and in the group of HCC patients, 92% of all cases had moderate or poor tumor differentiation. Six cases (23.1%) of postoperative complications were graded over III according to the Clavien-Dindo system, including in three patients resistant ascites or intra-abdominal abscess that required intervention. Parenchymal-sparing anatomical hepatectomy based on portal ramification of the RAS to achieve R0-resection was safe and effective, with favorable short-term outcomes. This technique can be used widely in clinical practice.

Is Precision Surgery Applicable to Colorectal Liver Metastases? A Systematic Review and Meta-analysis of Studies that Investigate the Association of Surgical Technique with Outcomes in the Context of Distinct Tumor Biology.

Although some data suggest that patients with mutRAS colorectal liver metastases (CRLM) may benefit from anatomic hepatectomy, this topic remains controversial. We performed a systematic review and meta-analysis to determine whether RAS mutation status was associated with prognosis relative to surgical technique [anatomic resection (AR) vs. nonanatomic resection (NAR)] among patients with CRLM. A systematic review and meta-analysis of studies were performed to investigate the association of AR versus NAR with overall and liver-specific disease-free survival (DFS and liver-specific DFS, respectively) in the context of RAS mutation status. Overall, 2018 patients (831 mutRAS vs. 1187 wtRAS) were included from five eligible studies. AR was associated with a 40% improvement in liver-specific DFS [hazard ratio (HR) = 0.6, 95% confidence interval (CI) 0.44-0.81, p = 0.01] and a 28% improvement in overall DFS (HR = 0.72, 95% CI 0.54-0.95, p = 0.02) among patients with mutRAS tumors; in contrast, AR was not associated with any improvement in liver-specific DFS or overall DFS among wtRAS patients. These differences may have been mediated by the 40% decreased incidence in R1 resection among patients with mutRAS tumors who underwent AR versus NAR [relative risk (RR): 0.6, 95% CI 0.40-0.91, p = 0.02]. In contrast, the probability of an R1 resection was not decreased among wtRAS patients who underwent AR versus NAR (RR: 0.93, 95% CI 0.69-1.25, p = 0.62). The data suggest that precision surgery may be relevant to CRLM. Specifically, rather than a parenchymal sparing dogma for all patients, AR may have a role in individuals with mutRAS tumors.

Transhepatic arterial approaches for ICG injection to guide laparoscopic anatomical hepatectomy: A case series study

Laparoscopic anatomical hepatectomy guided by near-infrared fluorescence imaging (NIR-FI) has been utilized extensively. However, it is difficult to resect "cone units" above the third branch of the Glissonean pedicle in the right posterior lobe using the laparoscopic positive or negative staining techniques. Therefore, we undertook a new laparoscopic segmentectomy based on the concept of "cone unit" assisted by interventional radiology combined with NIR-FI. Laparoscopic segmentectomy guided by NIR-FI via super-selective hepatic arteriography and trans-arterial injection of ICG was carried out on 13 patients with early-stage HCC between September 2020 and January 2022.11 of cases were successful, and relevant pathological characteristics and perioperative outcomes were retrospectively analyzed. Two cases failed NIR-FI out of which one case involved over-staining to the non-target segment, and in the other case, which was to undergo laparoscopic segment V resection, only the ventral segment was stained while the imaging of the dorsal segment failed. In the intraoperative conditions, the tumor safe margin was 1.1 (0.7-1.55) cm, the interventional operation time was 50 (45.5-60.5) minutes, the operation time was 280 (242.5-307.5) minutes, the blood loss was 100 (50-200) ml, the postoperative hospital stay was 5 (4.5-5.5) days. No cases converted to laparotomy, and no serious postoperative complications developed. NIR-FI through super-selective hepatic arteriography and trans-arterial injection of ICG can provide a clear and lasting navigation aid for laparoscopic segmentectomy, which may have positive implication for early-stage HCC with poor preoperative liver reserves.

Measuring intraoperative anesthetic parameters during hepatectomy with inferior vena cava clamping.

Uncontrollable bleeding remained problematic in anatomical hepatectomy exposing hepatic veins. Based on the inferior vena cava (IVC) anatomy, we attempted to analyze the hemodynamic and surgical effects of the combined IVC-partial clamp (PC) accompanied with the Trendelenburg position (TP). We prospectively assessed 26 consecutive patients who underwent anatomical hepatectomies exposing HV trunks between 2020 and 2023. Patients were divided into three groups: use of IVC-PC (group 1), no use of IVC-PC (group 2), and use of IVC-PC accompanied with TP (group 3). In 10 of 26 patients (38%), hepatic venous pressure was examined using transhepatic catheter insertion. IVC-PC was performed in 15 patients (58%). Operating time and procedures did not significantly differ between groups. A direct hemostatic effect on hepatic veins was evaluated in 60% and 70% of patients in groups 1 and 3, respectively. Group 1 showed significantly more unstable vital status and vasopressor use (p < 0.01). Blood or fluid transfusion and urinary output were similar between groups. Group 2 had a significantly lower baseline central venous pressure (CVP), while group 3 showed a significant increase in CVP in TP. CVP under IVC-PC seemed lower than under TP; however, not significantly. Hepatic venous pressure did not significantly differ between groups. Systolic arterial blood pressure significantly decreased via IVC-PC in group 1 and to a similar extent in group 3. Heart rate significantly increased during IVC-PC (p < 0.05). IVC-PC combined with the TP may be an alternative procedure to control intrahepatic venous bleeding during anatomical hepatectomy exposing hepatic venous trunks.

Chinese expert consensus on laparoscopic hepatic segmentectomy and subsegmentectomy navigated by augmented- and mixed-reality technology combined with indocyanine green fluorescence imaging

Abstract Augmented- and mixed-reality technologies have pioneered the realization of real-time fusion and interactive projection for laparoscopic surgeries. Indocyanine green fluorescence imaging technology has enabled anatomical, functional, and radical hepatectomy through tumor identification and localization of target hepatic segments, driving a transformative shift in the management of hepatic surgical diseases, moving away from traditional, empirical diagnostic and treatment approaches toward digital, intelligent ones. The Hepatic Surgery Group of the Surgery Branch of the Chinese Medical Association, Digital Medicine Branch of the Chinese Medical Association, Digital Intelligent Surgery Committee of the Chinese Society of Research Hospitals, and Liver Cancer Committee of the Chinese Medical Doctor Association organized the relevant experts in China to formulate this consensus. This consensus provides a comprehensive outline of the principles, advantages, processes, and key considerations associated with the application of augmented reality and mixed-reality technology combined with indocyanine green fluorescence imaging technology for hepatic segmental and subsegmental resection. The purpose is to streamline and standardize the application of these technologies.

The application of the extraglissonian approach for selective hepatic inflow occlusion during laparoscopic anatomical segmentectomy

ObjectiveLaparoscopic anatomical hepatectomy has been proven to be achievable for segmentectomy, subsegmentectomy and multi-segmentectomy. The extraglissonian approach in the context of selective hepatic inflow occlusion has been skilled under laparoscopy. This study aims to examine the suitability of the technique stated above for laparoscopic anatomical hepatectomy. MethodsThis retrospective study analyzed the clinical data of 114 patients diagnosed with hepatocellular carcinoma who underwent laparoscopic anatomical hepatectomy using the extraglissonian hepatic inflow occlusion technique at the Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital between September 2020 and December 2022. ResultsThe success rate of achieving the ischemic area using the described methods was determined to be 74.6%. Out of the 85 cases that underwent laparoscopic anatomical hepatectomy, 34 cases involved segmentectomy, 5 cases involved subsegmentectomy, and 46 cases involved multi-segmentectomy. The average duration of the operation, blood loss volume, and postoperative hospital stay were 229.0 ± 85.0 min, 133.0 ± 112.0 mL, and 5.4 ± 1.7 d, respectively. Notably, no intraoperative blood transfusions were necessary, and no postoperative complications were observed. ConclusionThe extraglissonian hepatic inflow occlusion technique exhibits a notable advantage in terms of a high success rate, effectively guiding the selection process during laparoscopic parenchymal transection. Moreover, this technique has demonstrated safety, reproducibility, and significant potential for broader clinical adoption.

Laparoscopic anatomical left hemihepatectomy guided by middle hepatic vein in the treatment of left hepatolithiasis with a history of upper abdominal surgery.

This study aimed to investigate the safety and efficacy of laparoscopic anatomical left hemihepatectomy guided by the middle hepatic vein (MHV) for the treatment of patients with hepatolithiasis who had a history of upper abdominal surgery. Retrospective data analysis was performed on patients who underwent laparoscopic left hepatectomy for hepatolithiasis and with previous upper abdominal surgery at the Second Affiliated Hospital of Nanchang University from January 2018 to April 2022. According to the different surgical approaches, patients were divided into laparoscopic anatomical left hepatectomy guided by the MHV group (MHV-AH group) and laparoscopic traditional anatomical left hepatectomy not guided by the MHV group (non-MHV-AH group). This study included 81 patients, with 37 and 44 patients in the MHV-AH and non-MHV-AH groups, respectively. There was no significant difference in the basic information between the two groups. Five cases were converted to laparotomy, and the remaining were successfully completed under laparoscopy. Compared to the non-MHV-AH group, the MHV-AH group had a slightly longer operation time (319.30min vs 273.93min, P = 0.032), lower bile leakage rate (5.4% vs 20.5%, P = 0.047), stone residual rate (2.7% vs 20.5%, P = 0.015), stone recurrence rate (5.4% vs 22.7%, P = 0.028), and cholangitis recurrence rate (2.7% vs 22.7%, P = 0.008).There were no significant differences in the results of other observation indices between the groups. Laparoscopic anatomical left hepatectomy guided by the MHV is safe and effective in the treatment of left hepatolithiasis with a history of upper abdominal surgery. It does not increase intraoperative bleeding and reduces the risk of postoperative bile leakage, residual stones, stone recurrence, and cholangitis recurrence.

A multicenter validation study for determining the condition of nonanatomical or minor anatomical hepatectomies satisfying technical difficulty of current high-level hepatectomy certificated by the Japanese Society of Hepato-Biliary-Pancreatic Surgery.

The current high-level hepatectomy (HLH) is certified by the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS), comprising only anatomical hepatectomies above Couinaud's segmentectomy. This multicenter study aimed to identify the conditions of non-HLH that satisfy equivalent technical difficulties to HLH. Between 2018 and 2021, 595 first open hepatectomies without biliary reconstruction (374 HLHs and 221 non-HLHs) were performed in the five institutions. Non-HLHs belonging to at least one of the three conditions; depth of hepatectomy ≥5 cm, number of resections ≥3 locations and at least one location with a depth of hepatectomy ≥3 cm, and hepatectomy involving the paracaval portion of the caudate lobe was proposed as the candidate for difficult non-HLH. The technical difficulty was estimated by the operative time and blood loss. Difficult non-HLHs were neither associated with shorter operative time (373 min vs. 354 min, p = .184) nor lesser blood loss than those with HLHs (503 mL vs. 436 mL, p = .126). Postoperative complications such as Clavien-Dindo classification grade III or more were not significant between the two groups (18.6% vs. 13.4%, p = 0212). Difficult non-HLHs were associated with no lesser technical difficulty than those with HLH.

Chinese expert consensus on laparoscopic hepatic segmentectomy and subsegmentectomy navigated by augmented and mixed reality technology combined with indocyanine green fluorescence(2023)

Augmented reality and mixed reality technologies have pioneered the realization of real-time fusion and interactive projection for laparoscopic surgery. Indocyanine green molecular imaging technology has realized anatomical, functional and radical hepatectomy through tumor identification and localization of target hepatic segmental extent, which has led to the transformation of hepatic surgical diseases from traditional empirical diagnostic and treatment modes to digital intelligent diagnostic and treatment modes. The Hepatic Surgery Group of the Surgery Branch of the Chinese Medical Association, the Digital Medicine Branch of the Chinese Medical Association, the Digital Intelligent Surgery Committee of the Chinese Society of Research Hospitals and the Liver Cancer Committee of the Chinese Medical Doctor Association have organized the relevant experts in China to formulate this consensus,which detailed advantages, process and key points of augmented reality and mixed reality technology combined with indocyanine green molecular imaging technology in hepatic segmental and subsegmental resection, to streamline and standardize the application of this technology for promotion.

Two-step artificial intelligence algorithm for liver segmentation automates anatomic virtual hepatectomy.

Anatomic virtual hepatectomy with precise liver segmentation for hemilivers, sectors, or Couinaud's segments using conventional three-dimensional simulation is not automated and artificial intelligence (AI)-based algorithms have not yet been applied. Computed tomography data of 174 living-donor candidates for liver transplantation (training data) were used for developing a new two-step AI algorithm to automate liver segmentation that was validated in another 51 donors (validation data). The Pure-AI (no human intervention) and ground truth (GT, full human intervention) data groups were compared. In the Pure-AI group, the median Dice coefficients of the right and left hemilivers were highly similar, 0.95 and 0.92, respectively; sectors, posterior to lateral: 0.86-0.92, and Couinaud's segments 1-8: 0.71-0.89. Labeling of the first-order branch as hemiliver, right or left portal vein perfectly matched; 92.8% of the second-order (sectors); 91.6% of third-order (segments) matched between the Pure-AI and GT data. The two-step AI algorithm for liver segmentation automates anatomic virtual hepatectomy. The AI-based algorithm correctly divided all hemilivers, and more than 90% of the sectors and segments.

Albumin-indocyanine green evaluation of future liver remnant predicts liver failure after anatomical hepatectomy for hepatocellular carcinoma: A dual-center retrospective study.

The albumin-indocyanine green evaluation (ALICE) score is a useful predictor of post-hepatectomy liver failure (PHLF); however, its usefulness in combination with future liver remnant (FLR), measured by 3-D volumetry, has not been investigated. This study aimed to investigate the relationship between the ALICE of the FLR (ALICE-FLR) score and severe PHLF. The clinical data of 215 patients who underwent anatomical hepatectomy for hepatocellular carcinoma without portal vein embolization at two institutes between January 2010 and December 2021 were analyzed retrospectively. PHLF occurrence and severity were determined according to the International Study Group of Liver Surgery's definition. Grades B and C PHLF were defined as severe PHLF. The ALICE-FLR, ALICE scores, and indocyanine green clearance of FLR (ICGK-FLR) were evaluated for severe PHLF prediction. Severe PHLF was observed in 40 patients (18.6%). The areas under the curve (AUCs) for the ALICE-FLR, ALICE scores, ICGK-FLR, and FLR were 0.76, 0.64, 0.73, and 0.69, respectively. The AUC of the ALICE-FLR score was significantly higher than that of the ALICE score. The ALICE-FLR score was identified as an independent predictor of severe PHLF (the odds ratio for every 0.01 increment in the ALICE-FLR score was 1.24; 95% confidence interval, 1.070-1.453; p = 0.004). Among patients with severe PHLF, the ALICE-FLR score was significantly higher in the grade C than in the grade B PHLF group. The combination of liver function models, including indocyanine green, albumin, and FLR is considered compatible for predicting severe PHLF.

Prevalence and clinical significance of the Sg6/Sg7 intersegmental veins based on re-evaluation of the Couinaud classification for the right posterior portal vein.

Although Segment 6(Sg6) and Segment 7(Sg7) are two independent units, there are currently no clear anatomical boundary markers between Sg6 and Sg7. This study aimed to identify intersegmental veins (ISV) in the intersegmental plane of Sg6 and Sg7, and evaluate the prevalence of ISV, and its clinical significance in anatomical hepatectomy. We analyzed data from 180 patients undergoing abdominal computed tomography (CT) examination, and simultaneously performed 3D reconstruction models of the liver for each patient. The right posterior portal vein was analyzed and re-typed. Furthermore, the existence of ISV was defined, and prevalence and confluence patterns of ISV were analyzed. The author attempted to apply ISV to laparoscopic S6/S7 segmentectomy. We sorted data from the right posterior portal vein and divided it into six types. The ISV could be identified in 82.2% (148/180) of the patients, which were derived from the right hepatic vein (RHV) (91.9%) and right posterior inferior vein (IRHV) (8.1%). Ten ISV-guided laparoscopic Sg6/Sg7 segmentectomy were successfully carried out, seven patients underwent Sg6 segmentectomy, and three patients underwent Sg7 segmentectomy. There was no perioperative mortality. The median operative time was 223min (range 181-260min). The median blood loss was 200ml (range 150-310ml). The R0 resection rate was 100%. The ISV may be a candidate vessel to distinguish the boundary of the right posterior sector; it is expected to be a landmark in the liver parenchyma of anatomical hepatectomy.

Exposure of the hepatic vein trunk via tracing of its branches: a useful surgical procedure for laparoscopic anatomical hepatectomy.

Although there are various advantages of laparoscopic liver resection (LLR) over open liver resection, some problems have been reported, such as disorientation and lack of control of bleeding during liver parenchymal dissection. In this study, we discuss a strategy to overcome the disorientation experienced during liver parenchymal dissection, especially in anatomical LLR. This procedure involves hepatic parenchymal dissection from the hepatic vein branch along its trunk to reveal an important landmark in anatomical LLR. Knowing which region of the liver is perfused into each hepatic vein in preoperative 3D simulation allows the tracing of the hepatic vein branch that naturally leads to the hepatic vein trunk. After that, hepatic resection can be easily completed by dissecting the line connected to the other landmarks, the Glisson branch, the root of the hepatic vein, and the liver demarcation line. In conclusion, this surgical procedure that traces the branch of the hepatic vein exposes the trunk, which makes it a very useful tool for limited laparoscopic anatomical hepatectomy.

Accessing from Gate 3 to Gate 1 for a safe anatomical full left hepatectomy.

Accessing from Gate 3 to Gate 1 for a safe anatomical full left hepatectomy.

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to the anatomical characteristics of the liver, with intraoperative hemorrhage being a primary concern. Intraoperative blood loss is the leading cause of conversion to open surgery; therefore, effective management of bleeding and hemostasis is crucial for a successful LAH. The two-surgeon technique is proposed as an alternative to the traditional single-surgeon approach, with potential benefits in reducing intraoperative bleeding during laparoscopic hepatectomy. However, there remains a lack of evidence to determine which mode of the two-surgeon technique yields superior patient outcomes. Besides, to our knowledge, the LAH technique, which involves the use of a cavitron ultrasonic surgical aspirator (CUSA) by the primary surgeon while an ultrasonic dissector by the second surgeon, has been rarely reported before. Herein, we present a modified, two-surgeon LAH technique, wherein one surgeon employs a CUSA while the other uses an ultrasonic dissector. This technique is combined with a simple extracorporeal Pringle maneuver and low central venous pressure (CVP) approach. In this modified technique, the primary and secondary surgeons utilize a laparoscopic CUSA and an ultrasonic dissectorconcurrently to achieve precise and expeditious hepatectomy. A simple extracorporeal Pringle maneuver, combined with the maintenance of low CVP, is employed to regulate the hepatic inflow and outflow in order to minimize intraoperative bleeding. This approach facilitates the attainment of a dry and clean operative field, which allows for the precise ligation and dissection of blood vessels and bile ducts. The modified LAH procedure is simpler and safer due to its effective control over bleeding as well as the seamless transition between the roles of primary and secondary surgeons. It holds great promise for future clinical applications.

Intrahepatic Glissonean Approach for Robotic Anatomical Liver Resection of Segment 7 Using the Saline-Linked Monopolar Cautery Scissors (SLiC-Scissors) Method: A Technical Case Report With Videos.

Anatomical hepatectomy of segment 7 (S7) is technically difficult due to its difficult accessibility. Here, we present our experience of robotic anatomical S7 subsectionectomy of the liver employing the saline-linked cauteryscissors (SLiC-Scissors) technique. After the right lobe was fully mobilized, dissection of the Glissonean pedicle and hepatic venous branch of S7, as well as the liver parenchymal transection, were safely performed using the SLiC-Scissors method. Despite its technological complexity, the intrahepatic Glissonean approach for robotic anatomical S7 subsectionectomy of the liver employing the SLiC scissors method is safe and efficient.