HPB and Liver Transplant Unit, Department of General Surgery, Clínica Universidad de Navarra, University of Navarra, Av. Pío XII, 36, 31008, Pamplona, Spain.
Institute of Health Research of Navarra (IdisNA), C. de Irunlarrea, 3, 31008, Pamplona, Navarra, Spain; Anesthesiology, University Clinic, University of Navarre, Pamplona, 31008, Spain.
Surg Oncol. 2022 Jun;42:101756. doi: 10.1016/j.suronc.2022.101756. Epub 2022 Apr 4.
Radical re-resection has been demonstrated beneficial in incidental gallbladder cancer (iGBC) stages ≥ pT1b [1]. Anatomical resection (AR) of segments IVb-V is recommended, particularly for iGBC and liver-sided tumors [2]. Laparoscopically, this is a challenging procedure, as well as the regional lymphadenectomy, since inflammation from previous surgery can hinder identification of extrahepatic bile ducts. This difficult minimally invasive procedure, facilitated with indocyanine green (ICG) fluorescence enhancement [3] is herein didactically demonstrated.
A 73 y. o. female patient underwent laparoscopic cholecystectomy for cholelithiasis. An iGBC -pT2b with positive cystic node-was found. Completion radical surgery was decided. Before surgery, 1.5mg of ICG was intravenously administered. A regional lymphadenectomy (stations 5-8-9-12-13) was safely performed: ICG allowed for bile duct visualization despite scarring from previous procedure. AR (IVb-V) was performed based on a glissonian-pedicle approach. After completing the procedure, a new dose of ICG was administered to discard ischemic areas in the remnant.
Total operative time was 359 min. Intermittent Pringle maneuver resulted in <50 ml bleeding. Hospital stay was 3 days. Pathological examination revealed no residual tumor in the liver bed. Ten lymph nodes were resected; 3 of them (2 retroportal and 1 common hepatic artery) showing tumoral invasion. After surgery, 6 cycles of adjuvant chemotherapy (Gemcitabine-Oxaliplatin) was administered.
Laparoscopic radical surgery (AR of segments IVb-V plus regional lymphadenectomy) for iGBC is feasible and safe [4]. ICG fluorescence can be of help to identify hilar structures and rule out areas of ischemia.
在偶然发现的胆囊癌（iGBC）≥pT1b 期[1]，激进性再次切除术已被证明是有益的。建议进行解剖性肝段 IVb-V 切除术，特别是对于 iGBC 和肝侧肿瘤[2]。腹腔镜下，由于先前手术的炎症可能会阻碍肝外胆管的识别，因此这是一种具有挑战性的程序，包括区域淋巴结清扫术。通过使用吲哚菁绿（ICG）荧光增强[3]，可以方便地进行这种困难的微创程序，并在此进行教学演示。
一名 73 岁女性患者因胆石症行腹腔镜胆囊切除术。发现 iGBC-pT2b 伴囊状淋巴结阳性。决定行根治性手术。手术前，静脉注射 1.5mgICG。安全地进行了区域淋巴结清扫术（站 5-8-9-12-13）：尽管先前的手术有疤痕，但 ICG 仍可用于显示胆管。根据 Glisson 蒂 approach 进行解剖性肝段 IVb-V 切除术。完成手术后，再次给予 ICG 以排除残肝中的缺血区域。
总手术时间为 359 分钟。间歇性 Pingle 操作导致出血量<50ml。住院时间为 3 天。病理检查显示肝床无残留肿瘤。切除了 10 个淋巴结；其中 3 个（2 个门后和 1 个肝总动脉）有肿瘤侵犯。手术后，给予 6 个周期的辅助化疗（吉西他滨-奥沙利铂）。
腹腔镜根治性手术（肝段 IVb-V 切除术加区域淋巴结清扫术）治疗 iGBC 是可行且安全的[4]。ICG 荧光有助于识别肝门结构并排除缺血区域。
