Trans-Arterial Indocyanine Green Staining for Precise Anatomical Hepatectomy of Liver Segments VII and VIII

Summary

Laparoscopic anatomical hepatectomy has gained global recognition in liver surgery. However, delineating tumor boundaries in liver segments VII and VIII presents distinct technical challenges. This protocol utilizes trans-arterial indocyanine green (ICG) staining to accurately identify liver subsegments, facilitating complete tumor resection while preserving functional liver volume.

Abstract

Anatomical hepatectomy for resectable hepatocellular carcinoma (HCC) is performed with precision using the Glissonean system, ultrasound imaging, and indocyanine green (ICG) fluorescence staining to define liver segments, enhancing surgical radicality and preserving liver volume. However, laparoscopic clamping and ultrasound-guided ICG staining for deep-seated tumors in liver segments VII and VIII pose challenges due to the depth of the Glissonean ducts and other technical limitations. This study aimed to overcome these obstacles by exploring a protocol using trans-arterial ICG staining, a technique specifically tailored for complex anatomical hepatectomy of liver segments VII and VIII. In this method, an interventionalist accessed the right femoral artery and advanced to the celiac trunk for arteriography, followed by strategic placement of a microcatheter into the tumor's blood supply vessel to facilitate surgical resection. During the operation, ICG was injected through the microcatheter to fluorescently label the tumor's liver segment, enabling precise anatomical resection under fluorescence guidance. This trans-arterial ICG staining approach allows for the accurate identification of tumor subsegments, facilitates complete resection, and optimizes liver function preservation, ultimately improving oncological outcomes without increasing surgical complication rates.

Introduction

Hepatocellular carcinoma (HCC) is the most prevalent malignant tumor of the digestive system, ranking fourth in incidence in China and first globally. HCC accounts for an estimated 50% of annual new cases and deaths worldwide¹. Laparoscopic anatomical hepatectomy is one of the primary radical treatments for patients with early-stage HCC^2,3. According to the Glissonean system, the liver's intricate architecture allows for precise division into eight distinct segments, each with its own blood supply, bile duct, and vascular drainage. This anatomical segmentation is based on Glisson

Protocol

This study protocol adhered to the ethical guidelines established by the relevant committee on human experimentation and conformed to institutional and national standards, as well as the principles outlined in the 1964 Declaration of Helsinki and its subsequent amendments. Ethical approval for this study was granted by the Institutional Review Board of the Ethics Committee of Guangdong Provincial People's Hospital. Informed consent was obtained from the patient included in this study, who provided written consent for the publication of anonymized information. The indications and contraindications for synchronous interventions align broadly with those for laparosco

Results

Preoperative three-dimensional (3D) liver reconstruction and hepatic arteriography of the patient revealed that the tumor was primarily vascularized by branches A7 and A8 of the hepatic artery (Figure 1). An embolization coil was used to occlude branch A7, and a microcatheter was placed in branch A8 for the intraoperative injection of indocyanine green (ICG) (Figure 2).

Following transcatheter hepatic artery embolization, ICG was inje...

Discussion

The upper posterior regions of the liver, specifically segments VII and VIII, present significant challenges in anatomical demarcation. As a result, precisely identifying and resecting these segments are complex yet critical aspects of hepatic surgery^18,19. The trans-arterial indocyanine green (ICG) staining approach during anatomical hepatectomy provides distinct advantages in managing tumors in these segments.

Tumors in segments VII ...

Materials

Name	Company	Catalog Number	Comments
B-scan ultrasonography	BK Medical	Pro Focus 2202
Curved Cutter Stapler	ETHICON	ECH45C
FloNavi Endoscopic Fluorescence Imaging System	OptoMedic Group	FloNavi 2100
Microcatheter	Hengrui Pharmaceuticals Co., Ltd.	C2215045