This work was supported by grants from the National Natural Science Foundation of China (No. 81702406) and the Natural Science Foundation of Guangdong Province of China (2016A030310207).

This protocol follows the guidelines of the human research ethics committee of Sun Yat-sen Memorial Hospital, Sun Yat-sen University. Written informed consent was obtained from the patients for performing this study.
1. Patient selection
<ol>
	<li>Select patients with a malignant tumor in the middle section of the liver, including patients with hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC).</li>
	<li>Ensure that these patients show no invasion of the portal or hepatic vein and no distant metastasis.</li>
</ol>
2. Patient preparation
NOTE: The patients were classified preoperatively as Child-Pugh A13.
<ol>
	<li>Administer antiviral drugs, such as entecavir or tenofovir (see Table of Materials), to the patients 1 week before the operation in case they are detected with hepatitis B. In our study,tThe ICG retention rate at 15 min was &#60;10%.</li>
	<li>Perform three-dimensional reconstruction in advance14. In our study, the future liver remnant (FLR) accounted for &#62;50% of the standard liver volume (SLV).</li>
</ol>
3. Surgical technique
<ol>
	<li>Preoperative preparation
	<ol>
		<li>Place the patient in a supine position, with the legs open and lying on the right side. Perform standard general anesthesia involving tracheal intubation and controlled ventilation. 
		NOTE: The dosage of anesthesia varies widely from patient to patient, determined mainly based on patient characteristics, age, and other medical conditions.</li>
		<li>Ensure that the surgeon stands on the right and the assistant on the left. Place the camera in the middle of the trocar sites and the camera holder in the middle.</li>
		<li>Place the trocar (see Table of Materials) as illustrated in Figure 1.</li>
		<li>Prepare fluorescent laparoscopic equipment and B-ultrasound with a laparoscopic probe (see Table of Materials).</li>
	</ol>
	</li>
	<li>Exploration phase
	<ol>
		<li>Perform abdominal cavity exploration from the epigastrium to the hypogastrium from left to right to reveal ascites, cirrhosis, and abdominal adhesions.</li>
		<li>Perform intraoperative ultrasound exploration of the liver. Evaluate the tumor size, location, relationship with surrounding blood vessels, and variations in the MHV and RHV. 
		NOTE: The tumor size is measured by intraoperative ultrasound. The relevant data are presented in Table 1.</li>
	</ol>
	</li>
	<li>Cholecystectomy and presetting of the hepatoduodenal ligament occlusion band
	<ol>
		<li>Anatomize Calot&#39;s triangle. Then, cut the cystic duct 5 mm from the common duct. Perform retrograde dissection of the gallbladder.</li>
		<li>Perform the hepatoduodenal ligament occlusion with a cotton string by using the Pringle maneuver15.</li>
		<li>Perform intermittent occlusion of the first porta hepatis by blocking for 15 min and opening for 5 min. Shorten the blocking time to 10 min for patients with obvious cirrhosis.</li>
	</ol>
	</li>
	<li>Resection of segments 4, 5, and 8
	<ol>
		<li>First, separate the liver parenchyma by resecting at 1 cm on the right side of the falciform ligament. Ligate and transect several branches of the segment 4 Glisson pedicle16 using clips.</li>
		<li>Second, separate the right anterior hepatic pedicle along the Laennec&#39;s capsule4. Ligate or occlude the right anterior hepatic pedicle.</li>
		<li>Administer a peripheral injection of 2 mL of 1:100 diluted ICG (see Table of Materials) for negative staining, to define the boundary between the right anterior section and the right posterior section (Figure 2).</li>
		<li>Dissect the liver parenchyma along the right fluorescent border. Transect the right anterior hepatic pedicle using a linear stapler after obtaining sufficient space.</li>
		<li>Separate the MHV at the root and transect it using a linear stapler.</li>
		<li>Under fluorescence tracing, reserve the trunk of the RHV, and transect the V5d and V8d branches of the RHV17. Finish resecting the specimens. 
		NOTE: ICG (25 mg ICG to 100 mL of sterile water) was diluted at a ratio of 1:100 for injection. Appropriate liver-cutting instruments, such as an ultrasonic scalpel, bipolar, cavitational ultrasonic surgical aspirator, etc., should be used, according to the surgeon&#39;s preference.</li>
	</ol>
	</li>
	<li>Resection of segments 5 and 8
	<ol>
		<li>Separate the right anterior hepatic pedicle along the Laennec&#39;s capsule.</li>
		<li>Perform a peripheral injection of 2 mL of 1:100 diluted ICG for negative staining to define the boundaries between the left, right anterior, and right posterior sections (Figure 3).</li>
		<li>First, process the left resection plane. Dissect the liver parenchyma along the left fluorescent border, preserve the trunk of the MHV, and transect the V5v and V8v branches of the MHV.</li>
		<li>Then, transect the right anterior hepatic pedicle using a linear stapler after obtaining sufficient space.</li>
		<li>Next, dissect the liver parenchyma along the right fluorescent border. Preserve the trunk of the RHV, and transect the V5d and V8d branches of the RHV. Finish resecting the specimen.</li>
	</ol>
	</li>
	<li>Hemostasis of residual liver after hepatectomy
	<ol>
		<li>Carefully check the residual liver and close the bleeding points one by one using bipolar electrocoagulation.</li>
	</ol>
	</li>
	<li>Specimen examination
	<ol>
		<li>After the surgery, visually confirm that the specimen margin is negative. Additionally, examine the specimens to confirm that the tumor capsule is complete and measure the distance from the tumor to the cutting edge.</li>
		<li>Immerse the specimens in formalin and send them to the pathology department. The operation is successful if the capsule is complete or the incision margin is &#62;1 cm.</li>
	</ol>
	</li>
</ol>

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Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Central+hepatectomy+for+centrally+located+malignant+liver+tumors:+A+systematic+review.">Central hepatectomy for centrally located malignant liver tumors: A systematic review.</a> World Journal of Hepatology. 6 (5), 347-357 (2014).</li><li>Takasaki, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Glissonean+pedicle+transection+method+for+hepatic+resection:+a+new+concept+of+liver+segmentation.">Glissonean pedicle transection method for hepatic resection: a new concept of liver segmentation.</a> Journal of Hepato-Biliary-Pancreatic Surgery. 5 (3), 286-291 (1998).</li><li>Torzilli, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound-guided+liver+resections+for+hepatocellular+carcinoma.">Ultrasound-guided liver resections for hepatocellular carcinoma.</a> Hepato-Gastroenterology. 49 (43), 21-27 (2002).</li><li>Takamoto, T., Makuuchi, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Precision+surgery+for+primary+liver+cancer.">Precision surgery for primary liver cancer.</a> Cancer Biology &amp; Medicine. 16 (3), 475-485 (2019).</li><li>Makuuchi, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+for+HCC--special+reference+to+anatomical+resection.">Surgical treatment for HCC--special reference to anatomical resection.</a> International Journal of Surgery. 11, 47-49 (2013).</li><li>Aoki, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Image-guided+liver+mapping+using+fluorescence+navigation+system+with+indocyanine+green+for+anatomical+hepatic+resection.">Image-guided liver mapping using fluorescence navigation system with indocyanine green for anatomical hepatic resection.</a> World Journal of Surgery. 32 (8), 1763-1767 (2008).</li><li>Felli, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+anatomical+liver+resection+for+malignancies+using+positive+or+negative+staining+technique+with+intraoperative+indocyanine+green-fluorescence+imaging.">Laparoscopic anatomical liver resection for malignancies using positive or negative staining technique with intraoperative indocyanine green-fluorescence imaging.</a> HPB. 23 (11), 1647-1655 (2021).</li><li>Ishizawa, T., Zuker, N. 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H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Notes+on+the+arrest+of+hepatic+hemorrhage+due+to+trauma.">Notes on the arrest of hepatic hemorrhage due to trauma.</a> Annals of Surgery. 48 (4), 541-549 (1908).</li><li>Yamamoto, M., Ariizumi, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Glissonean+pedicle+approach+in+liver+surgery.">Glissonean pedicle approach in liver surgery.</a> Annals of Gastroenterological Surgery. 2 (2), 124-128 (2018).</li><li>Cho, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Relation+between+hepatic+and+portal+veins+in+the+right+paramedian+sector:+proposal+for+anatomical+reclassification+of+the+liver.">Relation between hepatic and portal veins in the right paramedian sector: proposal for anatomical reclassification of the liver.</a> World Journal of Surgery. 28 (1), 8-12 (2004).</li><li>Shindoh, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complete+removal+of+the+tumor-bearing+portal+territory+decreases+local+tumor+recurrence+and+improves+disease-specific+survival+of+patients+with+hepatocellular+carcinoma.">Complete removal of the tumor-bearing portal territory decreases local tumor recurrence and improves disease-specific survival of patients with hepatocellular carcinoma.</a> Journal of Hepatology. 64 (3), 594-600 (2016).</li><li>Ishizawa, T., Saiura, A., Kokudo, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+application+of+indocyanine+green-fluorescence+imaging+during+hepatectomy.">Clinical application of indocyanine green-fluorescence imaging during hepatectomy.</a> Hepatobiliary Surgery and Nutrition. 5 (4), 322-328 (2016).</li><li>Nishino, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=What+is+a+precise+anatomic+resection+of+the+liver?+Proposal+of+a+new+evaluation+method+in+the+era+of+fluorescence+navigation+surgery.">What is a precise anatomic resection of the liver? Proposal of a new evaluation method in the era of fluorescence navigation surgery.</a> Journal of Hepato-Biliary-Pancreatic Sciences. 28 (6), 479-488 (2021).</li><li>Le Treut, Y. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+technique+and+outcomes+of+central+hepatectomy+by+the+Glissonian+suprahilar+approach.">The technique and outcomes of central hepatectomy by the Glissonian suprahilar approach.</a> European Journal of Surgical Oncology. 45 (12), 2369-2374 (2019).</li><li>Rotellar, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Standardized+laparoscopic+central+hepatectomy+based+on+hilar+caudal+view+and+root+approach+of+the+right+hepatic+vein.">Standardized laparoscopic central hepatectomy based on hilar caudal view and root approach of the right hepatic vein.</a> Journal of Hepato-Biliary-Pancreatic Sciences. 27 (1), 7-8 (2019).</li><li>Muttillo, E. 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The authors have nothing to disclose.

Anatomical hepatectomy is based on portal territory, and its therapeutic effect on liver cancer is still being explored. The theoretical basis for this is that the spread of liver cancer along the portal vein is the main reason for its recurrence and metastasis18. In the 20th century, Makuuchi first proposed anatomical hepatectomy from the initial open portal vein puncture with methylene blue staining, revealing the landmark hepatic veins, which has advanced to the current preoperative analysis of...

Central hepatectomy is the main surgical method used to treat liver malignancies located in segments 4, 5, and 81,2. Standard central hepatectomy requires the complete resection of these segments, which necessitates exposing the sagittal portion, middle hepatic vein (MHV), and right hepatic vein (RHV)3. Segments 4, 5, and 8 belong to the category of central hepatectomy2.
With the advancement of precision liver surgery, anatomical hepatectomy has developed rapidly. However, the method to accurately determine the resection plane of hepatectomy is a key point and area of uncertainty. Generally, the Glisson pedicle is ligated to delimit the surface boundary according to the ischemic area4. For control of the deep plane, anatomical landmarks, including hepatic veins and portal branches, are often used under intraoperative ultrasound guidance during the transection5. Makuuchi&#39;s method shows the resection margin by injecting methylene blue into the portal vein under ultrasound guidance, exposing important hepatic veins at the liver resection plane after removing the specimen5,6,7.
Because hepatocytes specifically absorb indocyanine green (ICG), its fluorescence clearly shows the resection boundary. Anatomical hepatectomy guided by ICG fluorescence was first reported by Aoki in 20088. ICG fluorescent staining methods can be divided into positive and negative staining9. The negative staining technique is performed by intravenous ICG injection after clamping the segmental portal pedicle10. Then, the remnant liver displays fluorescence, but the portal territory does not. Compared with traditional methods, anatomical hepatectomy under fluorescence navigation can not only display the resection boundary on the surface of the liver, but also guide the deep resection plane. For hemihepatectomy and segmental hepatectomy, negative staining technology is recommended. To date, anatomical hepatectomy using fluorescence navigation has become a popular method for liver surgery11,12. This article describes a negative staining technique for fluorescent laparoscopic central hepatectomy. The patients were classified preoperatively by the Child-Pugh scoring system, and accordingly, patients with class A scores were selected13.

<table><tbody><tr><td>BK Flex Focus 800</td><td>BK Medical</td><td>8666-RF</td><td>Intraoperative ultrasound</td></tr><tr><td>Entecavir</td><td>Bristol Myers Squibb</td><td>H20052237</td><td>Antiviral drugs</td></tr><tr><td>Hakko Sonoguide PTC Needle</td><td>Hakko-medical</td><td>&amp;nbsp;PTC-B 18G/20G</td><td>Portal vein puncture</td></tr><tr><td>Indocyanine green</td><td>Dandong Yichuang Pharmaceutical</td><td>0902007 GH102</td><td>Fluorescent dye</td></tr><tr><td>PINPOINT Endoscopic Fluorescence Imaging System</td><td>Stryker</td><td>PC9000</td><td>Fluorescent laparoscope</td></tr><tr><td>Tenofovir</td><td>GILEAD</td><td>H20180060</td><td>Antiviral drugs</td></tr><tr><td>Trocar</td><td>Ethicon Endo-Surgery</td><td>B5LT/B12LT</td><td>Trocar</td></tr></tbody></table>

fluorescent laparoscopic central hepatectomy for liver cancer using indocyanine green negative staining

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ultrasound, important vascular structures, and surgeon experience. With the development of anatomical hepatectomy, visual surgery technology has gradually been applied to this type of surgery, particularly indocyanine green (ICG)-guided anatomical hepatectomy. As ICG can be specifically ingested by hepatocytes and used for fluorescence tracing, negative staining techniques have been applied according to different tumor positions. Under ICG fluorescent guidance, the surface boundary and deep resection plane can be more accurately displayed during liver resection. Thus, the tumor-bearing liver segment can be anatomically removed, which helps to avoid damage to important vessels and reduce ischemia or congestion of the remaining liver tissue. Finally, the incidence of postoperative biliary fistula and liver dysfunction is reduced; therefore, a better prognosis is obtained after the resection of liver cancer. Centrally located liver cancer is usually defined as a tumor located at segments 4, 5, or 8 that requires resection of the middle section of the liver. These are among the most difficult hepatectomies to perform because of the large surgical wounds and multiple vessel transections. Based on the specific tumor location, we formulated the required resection ranges by designing personalized fluorescent staining strategies. By completing anatomical resection based on the portal territory, this work aims to achieve the best therapeutic effect.

From 2020 to 2022, six patients with HCC underwent fluorescent laparoscopic central hepatectomy. Among these, four patients underwent resection of segments 4, 5, and 8, and two patients underwent resection only of segments 5 and 8 (Table 1). None of the patients were converted to open surgery. Their ages ranged from 46 to 74 years. The tumor sizes ranged from 5 to 9 cm. The median operative time was 240 min, and the median intraoperative blood loss was 450 mL. The median postoperative hospital stay was 7...

Watch this Scientific Journal Video about Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining at JoVE.com

Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining

The present protocol describes fluorescent negative staining in laparoscopic central hepatectomy. This technique can make hepatectomy more accurate and precise.

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ...

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Medicine

652 Views.  Sun Yat-sen University. The present protocol describes fluorescent negative staining in laparoscopic central hepatectomy. This technique can make hepatectomy more accurate and precise. 

Video: Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining

Multispectral Real-time Fluorescence Imaging for Intraoperative Detection of the Sentinel Lymph Node in Gynecologic Oncology

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical excision of the tumor with a full lymphadenectomy in the drainage area of the tumor. However, removal of lymph nodes is associated with increased morbidity due to infection, wound breakdown and lymphedema.4,5 As an alternative, the sentinel lymph node procedure (SLN) was developed several decades ago to detect the first draining lymph node from the tumor.6 In case of lymphogenic dissemination, the SLN is the first lymph node that is affected (Figure 1). Hence, if the SLN does not contain metastases, downstream lymph nodes will also be free from tumor metastases and need not to be removed. The SLN procedure is part of the treatment for many tumor types, like breast cancer and melanoma, but also for cancer of the vulva and cervix.7 The current standard methodology for SLN-detection is by peritumoral injection of radiocolloid one day prior to surgery, and a colored dye intraoperatively. Disadvantages of the procedure in cervical and vulvar cancer are multiple injections in the genital area, leading to increased psychological distress for the patient, and the use of radioactive colloid.
Multispectral fluorescence imaging is an emerging imaging modality that can be applied intraoperatively without the need for injection of radiocolloid. For intraoperative fluorescence imaging, two components are needed: a fluorescent agent and a quantitative optical system for intraoperative imaging. As a fluorophore we have used indocyanine green (ICG). ICG has been used for many decades to assess cardiac function, cerebral perfusion and liver perfusion.8 It is an inert drug with a safe pharmaco-biological profile. When excited at around 750 nm, it emits light in the near-infrared spectrum around 800 nm. A custom-made multispectral fluorescence imaging camera system was used.9.
The aim of this video article is to demonstrate the detection of the SLN using intraoperative fluorescence imaging in patients with cervical and vulvar cancer. Fluorescence imaging is used in conjunction with the standard procedure, consisting of radiocolloid and a blue dye. In the future, intraoperative fluorescence imaging might replace the current method and is also easily transferable to other indications like breast cancer and melanoma.

Fluorescence imaging is a promising innovative modality for image-guided surgery in surgical oncology. In this video we describe the technical procedure for detection of the sentinel lymph node using fluorescence imaging as showcased in gynecologic oncologicy. A multispectral fluorescence camera system, together with the fluorescent agent indocyanine green, is applied.

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical ...

Sentinel Lymph Node Mapping and Biopsy for Endometrial Cancer at Early Stage with Laparoscopy

Sentinel lymph node (SLN) mapping and biopsy is a promising technique for visualizing and evaluating lymph node status in cancer. This approach has been recommended for low-risk endometrial cancer (EC) patients by authoritative international guidelines, but it has not been performed broadly in China and worldwide. This work aims to describe detailed SLN mapping and biopsy procedures to promote the clinical application. SLN mapping and postoperative pathologic ultrastaging were conducted in a patient with low-risk EC using indocyanine green (ICG) dye to track the SLNs under laparoscopy and resecting them completely for ultrastaging. In conclusion, this protocol describes details of ICG injection, and SLN mapping and biopsy in EC patients based on the experiences gained during clinical practice.

This protocol describes the identification and resection of sentinel lymph nodes to make the operation as easy and minimally invasive as possible.

Sentinel lymph node (SLN) mapping and biopsy is a promising technique for visualizing and evaluating lymph node status in cancer. This approach has been ...

Cancer Research

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

Laparoscopic Technique for Serial Collection of Liver and Mesenteric Lymph Nodes in Macaques

The mesenteric lymph nodes (MLN) and the liver are exposed to microbes and microbial products from the gastrointestinal (GI) tract, making them immunologically unique. The GI tract and associated MLN are sites of early viral replication in human immunodeficiency virus (HIV) infection and the MLN are likely important reservoir sites that harbor latently-infected cells even after prolonged antiretroviral therapy (ART). The liver has been shown to play a significant role in immune responses to lentiviruses and appears to play a significant role in clearance of virus from circulation. Nonhuman primate (NHP) models for HIV and Acquired Immunodeficiency Syndrome (AIDS) closely mimic these aspects of HIV infection and serial longitudinal sampling of primary sites of viral replication and the associated immune responses in this model will help to elucidate critical events in infection, pathogenesis, and the impact of various intervention strategies on these events. Current published techniques to sample liver and MLN together involve major surgery and/or necropsy, which limits the ability to investigate these important sites in a serial fashion in the same animal. We have previously described a laparoscopic technique for collection of MLN. Here, we describe a minimally invasive laparoscopic technique for serial longitudinal sampling of liver and MLN through the same two port locations required for the collection of MLN. The use of the same two ports minimizes the impact to the animals as no additional incisions are required. This technique can be used with increased sampling frequency compared to major abdominal surgery and reduces the potential for surgical complications and associated local and systemic inflammatory responses that could complicate interpretation of results. This procedure has potential to facilitate studies involving NHP models while improving animal welfare.

Here, we describe a minimally invasive laparoscopic technique for serial sampling of liver and mesenteric lymph nodes (MLN) in macaques that allows for increased sampling frequency, and reduces the potential for surgical complications when compared to performing a laparotomy.

The mesenteric lymph nodes (MLN) and the liver are exposed to microbes and microbial products from the gastrointestinal (GI) tract, making them ...

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing pancreatitis, if it does not resolve or is accompanied with infected necrosis in the retroperitoneum. As there are rarely any visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is accompanied with the risk of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae. In view of the above disadvantages, we apply real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) during VARD, which enables visualization of the well-perfused adjacent normal tissues. This modified technique (ICG-guided VARD) can provide a clear separating surface during debridement and reduce the risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing ...

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. Surgery is the cornerstone treatment for patients with BC. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection. In recent years, minimally invasive liver surgery (MILS) including robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. Robotic major MILS is still considered technically demanding and a detailed description of the technical approach during robotic major MILS has only been limitedly discussed in the literature. The current article describes the main steps for a robotic left hepatectomy in a patient with a large BC Todani Type V. The patient is in French position with 5 trocars placed (4 robotic, 1 laparoscopic assistant). After mobilizing the left hemiliver, the left and right hepatic artery are dissected carefully followed by a cholecystectomy. Intraoperative ultrasound is performed to confirm localization and margins of the BC. The Left hepatic artery and left portal vein are isolated, clipped, and divided. Indocyanine green (ICG) fluorescence imaging is used regularly during the entire procedure to visualize and confirm biliary tract anatomy and the BC. Parenchymal transection is performed with robotic cautery hook for the superficial part and robotic cautery spatula, bipolar cautery, and vessel sealer for the deeper parenchyma. The postoperative course was uncomplicated. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging aids in delineating the BC and bile duct anatomy. Further, comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic ...

Complete Laparoscopic Radical Resection of Perihilar Cholangiocarcinoma Type IIIb

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With continuous advancements in laparoscopic techniques and instruments, laparoscopic radical surgery for pCCA is now considered technically safe and feasible. However, due to the high complexity of the surgery and the lack of evidence-based clinical support, laparoscopic radical surgery for type IIIb pCCA is performed only in a few large hepatobiliary centers. Current guidelines recommend left hemihepatectomy combined with total caudate lobectomy and standardized lymphadenectomy for resectable type IIIb pCCA. Therefore, in this article, we provide a detailed description of the surgical steps and technical points of complete laparoscopic left hemihepatectomy combined with total caudate lobectomy, regional lymphadenectomy, and right hepatic duct-jejunal Roux-en-Y anastomosis in patients with type IIIb pCCA, using fluorescence navigation technology to enhance surgical precision and safety. By adhering to standardized surgical procedures and precise intraoperative techniques, we offer an effective means to improve patient outcomes.

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With ...

The Role of Indocyanine Green Fluorescence in Complex Laparoscopic Cholecystectomy Navigation

Laparoscopic cholecystectomy (LC) is the gold-standard treatment for cholelithiasis and cholecystitis. In difficult cases with severe inflammation and adhesions, the risk of bile duct injury (BDI) is significantly higher. Precise identification of anatomical biliary structures is essential to prevent such injuries. Conventional intraoperative visualization techniques (IVT) have limited clinical application due to their complexity, increased trauma, and high error rates. Near-infrared fluorescence (NIRF) imaging, utilizing indocyanine green (ICG) as a fluorescent dye, has emerged as an innovative IVT technique. It is increasingly recognized as a feasible, safe, and effective approach for LC. However, the efficacy of NIRF in difficult LC procedures remains unclear, and the optimal timing and dosage of ICG administration are yet to be established. This article outlines the main steps for performing fluorescence-guided difficult LC in a patient with acute gangrenous cholecystitis and evaluates the imaging effects of NIRF in various scenarios. The patient was positioned supine, with four trocars placed. Upon switching to fluorescence mode, the fluorescently labeled bile ducts were readily identified. Following fluorescence guidance, Calot's triangle was carefully dissected. The cystic duct (CD) and cystic artery (CA) were individually identified and clipped before the gallbladder was extracted. Finally, the surgical field was inspected in fluorescence mode to detect bile leakage. With satisfactory ICG imaging and a smooth procedure, the patient's postoperative recovery was uneventful. NIRF is a safe and effective technology that shows great promise for future clinical applications.

This protocol outlines the steps for fluorescence-guided laparoscopic cholecystectomy and elucidates the role of fluorescence navigation in diverse surgical scenarios.

Laparoscopic cholecystectomy (LC) is the gold-standard treatment for cholelithiasis and cholecystitis. In difficult cases with severe inflammation and ...

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

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.

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.

Anatomical hepatectomy for resectable hepatocellular carcinoma (HCC) is performed with precision using the Glissonean system, ultrasound imaging, and ...