Pure Laparoscopic Anatomic Resection of Liver Segment 4 with Middle Hepatic Vein Involvement Using Indocyanine Green Fluorescence Staining.

Background: Laparoscopic anatomic resection of liver segment 4 is a technically challenging operation, which is rarely reported owing to the difficulty of defining the demarcation of a hepatic segment 4 on a monitor. The portal territory staining method is technically feasible to identify tumors and segment boundaries during hepatectomy. Herein, we describe the laparoscopic hepatectomy of segment 4 using the fluorescent-positive staining method.

Methods: A 72-year-old man recurred colorectal liver metastases after colectomy, positron emission tomography (PET)/computed tomography (CT) showed metastases located in segment 4 with involvement of the middle hepatic vein (MHV) and caudate lobe; no other organ metastasis or recurrence occurred. We performed an anatomical hepatectomy 4 with MHV and parenchymal resection of segment 1 (H1'/4-MHV). The key point of the procedure was dividing and clamping Glisson's branches for segment 2 and segment 3 using the hepatic round ligament approach; the G2 and G3 were dissected along the right side of round ligament via the extrahepatic Glissonian approach, then the left hepatic artery (LHA) was divided and injected with ICG in the left portal vein (LPV). Finally, transection was performed along the fluorescent stain location line and ischemic demarcation line.

Results: The operation time was 263 min; the Pringle lasted 110 min, and the estimated blood loss was 400 g. The patient was discharged on postoperative day 5 without complications. Sigmoid carcinoma and R0 margin were confirmed by histopathology.

Conclusions: Laparoscopic anatomic hepatectomy 4 with middle hepatic vein invasion using indocyanine green (ICG) fluorescence staining is a feasible and effective technique.