Laparoscopic Portal Territory Hepatectomy (Extended Segment 5) by an Indocyanine Green Fluorescent Dual Staining Technique (Video).

Background: Anatomical liver resections (ALR), which both remove the tumor and the corresponding segments, meet more with the surgical oncology's radical nature as reported by Makuuchi.1 Nevertheless, laparoscopic ALR remains a highly specialized procedure due to technical difficulty in the selection of the transection plane. This video aimed to present a novel laparoscopic ALR strategy of tumor-bearing portal territory hepatectomy with an indocyanine green (ICG) fluorescent dual staining technique. Video: A 42-year-old man admitted to our center for a single hepatic mass at the end of segment 5. To test liver reserve function and locate the tumor, we intravenously administrated ICG (0.5 mg/kg) 5 days before the operation. The ICG-R15 of the patient was 4.1%. The Glissonian pedicles of target portal territory were approached and temporally clamped with Takasaki's Glissonian method as discussed by Takasaki.2 Then, we intravenously administered ICG (1 mL, 5 mg/L) to negative stain the portal territory of segment 5 and expose biliary leak from the cut surface. Fusion ICG imaging of the tumor and positive fluorescent region were obtained using the PINPOINT image system (Stryker, Kalamazoo, MI). Liver parenchyma transection was performed alongside the boundary of negative fluorescence region using an ultrasonic scalpel and L-PMOD as reported by Cai et al..3 Since the tumor located at the junction of segments 5 and 8, we did some extended resection.

Results: Operative time was 195 min, and the estimated intraoperative blood loss was 100 mL. The patient was discharged on the seventh day, without any complications. HCC was confirmed in histopathology with a free margin (over 1.3 cm). No recurrence was noted in the follow-up period for 6 months after the operation.

Conclusion: Laparoscopic anatomical S5 segmentectomy using portal territory hepatectomy strategy in a dual staining method was technically feasible and safe for patients with HCC located in segment 5.