Liu Yani, Peng Yufu, Wei Yonggang
Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China.
Ann Surg Oncol. 2024 Feb;31(2):1271. doi: 10.1245/s10434-023-14559-0. Epub 2023 Nov 28.
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.
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.
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.
Laparoscopic anatomic hepatectomy 4 with middle hepatic vein invasion using indocyanine green (ICG) fluorescence staining is a feasible and effective technique.
腹腔镜下肝IV段解剖性切除术是一项技术要求较高的手术，由于在监视器上难以界定肝IV段的边界，相关报道较少。门静脉区域染色法在肝切除术中识别肿瘤和肝段边界在技术上是可行的。在此，我们描述使用荧光阳性染色法进行的腹腔镜肝IV段切除术。
一名72岁男性在结肠切除术后出现结直肠癌肝转移，正电子发射断层扫描（PET）/计算机断层扫描（CT）显示转移灶位于IV段，累及肝中静脉（MHV）和尾状叶；未发生其他器官转移或复发。我们进行了保留MHV的肝IV段解剖性切除术及肝I段实质切除术（H1'/4-MHV）。该手术的关键步骤是采用肝圆韧带入路分离并夹闭肝II段和肝III段的肝蒂分支；通过肝外Glissonian入路沿圆韧带右侧分离G2和G3，然后切断左肝动脉（LHA）并在左门静脉（LPV）内注入吲哚菁绿（ICG）。最后，沿荧光染色定位线和缺血分界线进行肝实质离断。
手术时间为263分钟；肝门阻断时间为110分钟，估计失血量为400克。患者术后第5天出院，无并发症发生。组织病理学证实为乙状结肠癌且切缘为R0。
使用吲哚菁绿（ICG）荧光染色进行腹腔镜下侵犯肝中静脉的肝IV段解剖性切除术是一种可行且有效的技术。
