Huerta Martín, Tanaka Ryota, Ishizawa Takeaki
Department of General and Digestive Surgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.
Department of Hepatobiliary-Pancreatic Surgery, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan.
Transl Gastroenterol Hepatol. 2025 Jul 18;10:53. doi: 10.21037/tgh-24-156. eCollection 2025.
Iatrogenic bile duct injury (BDI) is a serious complication that affects patients' quality of life and survival. Surgical resection of the hepatic segment affected has been reported. We describe a case of anatomical resection of segment 5 (S5) using multiple applications of indocyanine green (ICG) fluorescence imaging. A 46-year-old female with BDI during laparoscopic cholecystectomy performed in 2010 was referred to Osaka Metropolitan University Hospital due to recurrent cholangitis. Abdominal computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP) identified stumps on bile duct draining segment 5 (B5s), significantly dilated, suggestive of sclerosing cholangitis. Drainage of B5s was not feasible via endoscopic approach and surgical resection of S5 was indicated. ICG (0.5 mg/kg) was administered 3 days prior to surgery [indocyanine green retention rate at 15 minutes (ICGR15): 3.6%]. After an inverted L-shaped incision, atrophic regions of S5 were identified by naked-eye examination and more clearly by near-infrared imaging. Intraoperative ultrasound also identified biliary dilatations in non-fluorescing regions of S5, which suggested abnormal biliary drainage surrounding the atrophic area. In order to remove whole responsible legions causing cholangitis, we decided to indicate anatomic resection of S5 with the use of positive staining technique. The medial and the cranial branch of S5 portal vein (P5) were punctured and stained (0.25 mg ICG mixed with indigo-carmine). Fluorescence imaging delineated S5, including the atrophic area. Hepatic parenchyma was transected using the clamp-crash method under Pringle maneuver. The two major branches of P5 stained previously were identified and ligated. Finally, the root of the dilated hepatic ducts with complete obstruction were identified and divided, 1 cm distal to metal clips. Fluorescence imaging was used to confirm the removal of all stained regions. Then, ICG (1.25 mg) was administered to confirm blood perfusion of the remaining hepatic parenchyma. No bile leaks were identified by naked-eye examination or fluorescence imaging. Postoperative course was uneventful and patient was discharged on day 8. This technique underscores the multifaceted applications of indocyanine green in liver surgery, from preoperative planning and intraoperative guidance to postoperative assessment, thereby enhancing the safety and efficacy of hepatic resections.
医源性胆管损伤（BDI）是一种严重的并发症，会影响患者的生活质量和生存。已有报道对受影响的肝段进行手术切除。我们描述了一例使用多次吲哚菁绿（ICG）荧光成像对第5段（S5）进行解剖性切除的病例。一名46岁女性在2010年腹腔镜胆囊切除术期间发生BDI，因复发性胆管炎转诊至大阪市立大学医院。腹部计算机断层扫描（CT）和磁共振胆胰管造影（MRCP）显示胆管引流第5段（B5s）的残端明显扩张，提示硬化性胆管炎。经内镜途径对B5s进行引流不可行，因此需要对S5进行手术切除。术前3天给予ICG（0.5mg/kg）[15分钟吲哚菁绿滞留率（ICGR15）：3.6%]。采用倒L形切口后，通过肉眼检查确定S5的萎缩区域，近红外成像则更清晰。术中超声还在S5的非荧光区域发现胆管扩张，提示萎缩区域周围存在异常胆管引流。为了切除导致胆管炎的所有责任病灶，我们决定使用阳性染色技术对S5进行解剖性切除。穿刺并染色S5门静脉（P5）的内侧和头侧分支（0.25mg ICG与靛胭脂混合）。荧光成像勾勒出S5，包括萎缩区域。在Pringle手法下，采用钳夹-挤压法横断肝实质。识别并结扎先前染色的P5的两个主要分支。最后，识别并离断完全阻塞的扩张肝管根部，在金属夹远端1cm处。使用荧光成像确认所有染色区域已被切除。然后，给予ICG（1.25mg）以确认剩余肝实质的血流灌注。肉眼检查和荧光成像均未发现胆漏。术后过程顺利，患者于术后第8天出院。该技术强调了吲哚菁绿在肝脏手术中的多方面应用，从术前规划、术中引导到术后评估，从而提高了肝切除术的安全性和有效性。
