Onishi Shun, Kawano Takafumi, Nishida Nanako, Kedoin Chihiro, Nagano Ayaka, Murakami Masakazu, Sugita Koshiro, Harumatsu Toshio, Muto Mitsuru, Ieiri Satoshi
Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.
Front Pediatr. 2023 Jul 6;11:1221596. doi: 10.3389/fped.2023.1221596. eCollection 2023.
Near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) has gained popularity in pediatric surgery as it has in general surgery. In addition, a water-jet dissector (WJD) has been successfully introduced in adult hepatic surgery. Tissue structures are dissected selectively and gently by the WJD. However, there have been no reports of hepatic resection for pediatric patients using a WJD. We applied NIR fluorescence imaging with ICG to visualize the resection line of the liver and used a WJD for liver parenchyma dissection in pediatric hepatoblastoma. The patient was a 3-year-old girl with a large liver tumor. Enhanced computed tomography revealed a liver tumor (maximum diameter: 120 mm) in the right lobe and three small lung metastases. The liver tumor was diagnosed as hepatoblastoma (PRETEXT 2) based on an open biopsy. We performed right hepatectomy after neoadjuvant chemotherapy. The right lobe was mobilized from the diaphragm, and then intraoperative ultrasound was performed to detect the localization of the tumor and its proximity to the vascular structures. We detected the right hepatic artery (RHA), right portal vein (RPV), and right hepatic vein (RHV). The middle hepatic vein was not involved. After ligation of the RHA and RPV to selectively control the right lobe inflow, ICG was administered intravenously and observed by an NIR endoscope. The resection line was clearly visualized by overlaying images in comparison to conventional demarcation line detection. Then, we used a WJD to dissect the parenchyma. Small vessels were divided from parenchymal tissue and were clearly visible. We resected them after clamping with metal clips. Finally, the RHV was transected by a linear stapler, and right hepatectomy was completed with 25 ml of blood loss. There was no postoperative hemorrhage. We performed hepaticojejunostomy because of stricture of the common bile duct on postoperative day 302. The patient was discharged after adjuvant chemotherapy. NIR imaging clearly showed the resection line. The WJD automatically separated, and thus made visible, the more resistant duct and vessel structures from the parenchyma. The combined use of NIR imaging and WJD was useful for pediatric hepatectomy.
近红外(NIR)荧光成像联合吲哚菁绿(ICG)在小儿外科中已如在普通外科中一样受到欢迎。此外,水刀解剖器(WJD)已成功应用于成人肝脏手术。WJD能选择性且轻柔地解剖组织结构。然而,尚无关于使用WJD对小儿患者进行肝切除术的报道。我们应用NIR荧光成像联合ICG来可视化肝脏的切除线,并在小儿肝母细胞瘤手术中使用WJD进行肝实质解剖。该患者为一名3岁女童,患有巨大肝脏肿瘤。增强计算机断层扫描显示右叶有一个肝脏肿瘤(最大直径:120 mm)以及三处小的肺转移灶。经开放活检,肝脏肿瘤被诊断为肝母细胞瘤(PRETEXT 2)。我们在新辅助化疗后进行了右半肝切除术。将右叶从膈肌游离,然后进行术中超声检查以检测肿瘤的位置及其与血管结构的关系。我们探测到了右肝动脉(RHA)、右门静脉(RPV)和右肝静脉(RHV)。肝中静脉未受累。在结扎RHA和RPV以选择性控制右叶血流后,静脉注射ICG并通过NIR内镜观察。与传统的分界线检测相比,通过叠加图像能清晰地看到切除线。然后,我们使用WJD解剖肝实质。小血管从实质组织中分离出来且清晰可见。用金属夹夹闭后将它们切断。最后,用直线缝合器横断RHV,右半肝切除术完成,失血25 ml。术后无出血。术后第302天,由于胆总管狭窄,我们进行了肝空肠吻合术。辅助化疗后患者出院。NIR成像清晰地显示了切除线。WJD能自动从肝实质中分离并使更坚韧的胆管和血管结构可见。NIR成像与WJD联合应用对小儿肝切除术很有用。