Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Research Hospital - IRCCS, Humanitas University, Rozzano, Milan, Italy.
Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
Ann Surg Oncol. 2024 Jul;31(7):4445-4446. doi: 10.1245/s10434-024-15162-7. Epub 2024 Mar 22.
Minimally invasive anatomical resection (AR) for posterosuperior lesions is technically challenging. The Glissonean approach or puncture technique is generally selected. The tumor-feeding portal pedicle compression AR (C-AR) is an established procedure in open surgery. This technique has benefited from the association with indocyanine green (ICG) fluorescence, used to enhance the anatomical area to be resected. Recently, C-AR via the minimal access approach has been reported. Herein, we report the first cases of laparoscopic and robotic segment 7 (S7) segmentectomy using the ICG-enhanced compression technique.
Two cases of CHILD-class A hepatocellular carcinoma (HCC) in segment 7 with a liver stiffness less than 7 kPa treated by laparoscopic and robotic anatomical S7 segmentectomies were reported. Using the intraoperative ultrasound (IOUS), the tumor-bearing portal pedicle and the level targeted for compression were identified. The right hemiliver was adequately mobilized to allow handling of the organ during dissection. Using the grasper and the probe itself, the S7 Glissonean pedicle was transparenchymally compressed under real-time IOUS control. To further enhance the visibility of the discolored S7, ICG was administered intravenously, obtaining the compressed area to be resected as a non-stained one. Dissection was performed under intermittent Pringle maneuver up to exposing the right hepatic vein, dividing the Glissonean pedicle to segment 7 and then completing the resection.
Pathologic findings demonstrated a 4.9 cm and 7.3 cm HCC with a R0-resection margin (> 1 cm in both). Postoperative complications were nil. The patients were discharged 6 days after surgery.
This preliminary experience shows that the C-AR is a feasible and reliable technique in laparoscopic and robotic approach for posterosuperior lesions. Further studies are needed to investigate its applicability and standardization.
对于后上病变，微创解剖性切除术 (AR) 具有一定的技术挑战性。通常选择 Glisson 入路或穿刺技术。肿瘤供养门静脉蒂压迫 AR (C-AR) 是开放手术中已确立的术式。该技术得益于与吲哚菁绿 (ICG) 荧光的联合应用，可增强待切除的解剖区域。最近，微创入路的 C-AR 已被报道。本文报告首例采用 ICG 增强压缩技术的腹腔镜和机器人第 7 段 (S7) 节段切除术。
报告 2 例 CHILD 分级 A 肝癌 (HCC) 位于第 7 段，肝脏硬度小于 7kPa，行腹腔镜和机器人解剖性 S7 节段切除术。术中超声 (IOUS) 识别肿瘤所在的门静脉蒂和拟压迫的平面。充分游离右半肝，便于在解剖过程中处理肝脏。采用抓钳和探头本身，在实时 IOUS 控制下，对 S7 门腔静脉蒂进行透明隔压缩。为了进一步增强 S7 染色区域的可视性，静脉内给予 ICG，获得未染色的拟切除区域。间歇性阻断肝门直至显露右肝静脉，离断 S7 段 Glisson 蒂，完成切除。
病理检查显示 2 例 HCC 分别为 4.9cm 和 7.3cm，切缘均为 R0（均>1cm）。术后无并发症。患者术后 6 天出院。
初步经验表明，C-AR 是后上病变腹腔镜和机器人入路的一种可行且可靠的技术。需要进一步研究以评估其适用性和标准化。
