Functional anatomical hepatectomy guided by indocyanine green fluorescence imaging in patients with localized cholestasis:Report of four cases

BACKGROUND Liver cancer is a malignant tumor with a high incidence.At present,the most effective treatment is laparoscopic hepatectomy(LH).Indocyanine green fluorescence imaging(ICG-FI)has become an important tool in LH,and the most common fluorescent types of tumors are total fluorescence,partial fluorescence,and rim fluorescence.CASE SUMMARY We presented four cases of LH guided by ICG-FI in which we also observed the fourth special fluorescent type.When the tumor or intrahepatic stone compresses the adjacent bile duct to cause local cholestasis,the liver segment or subsegment with obstructed bile drainage will show strong fluorescence.Complete removal of the lesion together with the fluorescent liver parenchyma may help reduce the risk of tumor or stone recurrence.CONCLUSION This type of partial fluorescence can indicate local biliary compression,and the resection method is related to bile drainage,which may be called functional anatomical hepatectomy and ensures radical resection of the lesion.

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

Objective:Laparoscopic anatomical hepatectomy has been proven to be achievable for segmentectomy,subsegmentectomy and multi-segmentectomy.The extraglissonian approach in the context of selective hepatic inflow ocdlusion has been skilled under laparoscopy.This study aims to examine the suitability of the technique stated above for laparoscopic anatomical hepatectomy.Methods:This retrospective study analyzed the dinical data of 114 patients diagnosed with hepatocel-lular 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.Results:The 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 hospi-tal stay were 229.0±85.0 min,133.0±112.0 mL,and 5.4±1.7 d,res pectively.Notably,no intraoperative blood transfusions were necessary,and no postoperative complications were observed.Conclusion:The extraglissonian hepatic inflow occlusion technique exhibits a notable advantage in terms of a high success rate,effectively guiding the selection process during laparoscopic parenchymal tran-section.Moreover,this technique has demonstrated safety,reproducibility,and significant potential for broader clinical adoption.

Anatomic resection of liver segments 6-8 for hepatocellular carcinoma

AIM: To report the devised anatomic liver resection of segments 6, 7 and 8 to improve the resection rate for patients with right liver tumors.

3D laparoscopic anatomical hepatectomy guided by 2D real-time indocyanine green fluorescence imaging for hepatocellular carcinoma

Laparoscopic anatomical hepatectomy(LAH)for patients with hepatocellular carcinoma(HCC)has been advocated by many surgeons in the hope of producing better oncological outcomes.Two recent techniques,3D laparoscopic system and 2D real-time indocyanine green fluorescence imaging(r-ICG)guidance,are benefit for improving the operative precision of LAH in different aspects.However,these two techniques cannot be applied concomitantly because of the technical limitation.Although a new modern laparoscopic system with both 3D and indocyanine green(ICG)imaging mode has been designed,it has not been listed in many countries including China.Thus,we design a new procedure to perform the 3D LAH with 2D r-ICG guidance for HCCs with conventional laparoscopic systems.In this procedure,both 3D and 2D laparoscopic systems were used.A total of 11 patients with HCC received 3D laparoscopic right posterior sectionectomy(LRPS)with 2D r-ICG guidance.The right posterior Glissonian pedicle was clamped under the 3D vision.Then ICG solution was then intravenously administrated.The liver parenchyma was transected under the 3D vision and guided by 2D ICG vision simultaneously.There was no severe complications(Clavien-Dindo≥III)and operation related death.The 90-day mortality was also nil.By using this procedure,the advantages of two techniques,3D laparoscopic system and 2D r-ICG guidance,were combined so that LAH could be performed with more precision.However,it should be validated in more studies.

Anatomical hepatectomy for achieving textbook outcome for perihilar cholangiocarcinoma treated with curative-intent resection: A multicenter study

Background and aim:The textbook outcome(TO)is a comprehensive measure that is superior to individual measures for analysis of surgical quality of care.Anatomical hepatectomy(AH)is beneficial in terms of short-term outcomes in patients undergoing resection.This study was performed to investigate the association between AH and achieving the TO for patients with perihilar cholangiocarcinoma(pCCA)treated with curative-intent resection.Methods:This study involved patients who underwent curative-intent resection for newly diagnosed pCCA from January 2013 to January 2018 at three hospitals in China.All patients were divided into two groups according to the type of hepatectomy:the AH group and non-AH group.The incidence and distribution of achieving the TO were compared between the two groups.Univariable and multivariable logistic regression analyses were used to identify independently predictive factors associated with achieving the TO in patients with pCCA.Results:In total,333 patients were enrolled[AH group,225(67.6%);non-AH group,108(32.4%)].The incidence of achieving the TO in all patients was 24.3%,and the incidence was significantly higher in the AH than non-AH group(30.7%vs.11.1%,respectively).Multivariable analysis revealed that AH,total bilirubin concentration of<34μmol/L,maximum tumor size of<3 cm,no macrovascular invasion,and no lymph node metastasis were independently associated with a higher incidence of achieving the TO.Conclusions:The TO was achieved in approximately one-fourth of patients with pCCA who underwent curative-intent resection.The use of AH was more conducive to achieving the TO in patients with pCCA.

The evolution of anatomical hepatectomy:Past,present,and future

The liver contains a complex structure of blood vessels and bile ducts,and the vascular structure is highly variable.The anatomical segmentation of the liver is still controversial,and the Couinaud segmentation method based on the portal vein is more widely used in clinical practice.The treatment of liver tumors and other lesions is closely related to the liver anatomy.The mechanism of liver tumor invasion and metastasis is complex,and it is currently believed that tumor invasion mainly spreads along the portal vein.Anatomic liver resection is an important surgical method for liver diseases,especially liver tumors.This article reviews the vascular structure of the liver,the development of anatomical hepatectomy,blood flow control,surgical planning,intraoperative navigation,minimally invasive surgery,and precise hepatectomy.Anatomic liver resection is a part of precision liver surgery,which is becoming increasingly more precise in terms of surgical evaluation,surgical planning,and surgical operation.New technologies will facilitate precision surgery with less trauma and greater benefits for patients.With the development and advancement of technology,image-based surgical planning and intraoperative surgical navigation will become more widely used in precision liver surgery.