Laparoscopic Anatomical S4/5/8+S3v Hepatectomy: Umbilical Fissure Approach Combined with Indocyanine Green Fluorescence Imaging.

Abstract

For tumors located in the central and partially left lateral lobe of the liver without left Glisson pedicle invasion, anatomical central combined with (sub) segment of left lobe hepatectomy is an alternative to extended left hepatectomy (EH), achieving radical resection while preserving more liver parenchyma.^1,2 However, this procedure is technically challenging, especially under laparoscopy, which has not been reported.^3,4 PATIENT AND METHODS: A 40 year-old male presented with hepatic tumor and liver cirrhosis. A three-dimensional model confirmed a tumor in the central lobe (S4/S5/S8) with partial invasion of the ventral subsegment of segment 3(S3v) (Fig. 1A). Therefore, anatomical resection of S4/S5/S8 and S3v was performed, instead of EH in which the remaining liver volume was only 28.2%. Intraoperatively, the umbilical fissure approach was adopted to sequentially transect Glisson pedicles of S4 and S3v (Fig. 1B). Then, the ischemic line was demarcated to guide the left resection margin, consistent with preoperative planning (Fig. 1C). After blocking the right anterior Glisson pedicle, the boundary between right anterior and posterior sectors was clearly delineated (Fig. 1D), using indocyanine green (ICG) negative staining. Parenchyma transection was performed under fluorescence tracing. Finally, the tumor was completely resected, with full exposure of the right hepatic vein trunk. Fig.1 Procedure of laparoscopic anatomical S4/5/8+3v hepatectomy. A The precise tumor location. B The G4 and G3v were cut off through the umbilical fissure approach. C Transect parenchyma along the left ischemic line. D Right boundary between RAS and RPS guided by ICG negative staining after blocking RAGP. UFV umbilical fissure vein, MHV middle hepatic vein, RAPV right anterior portal vein, RAGP right anterior Glisson pedicle, IVC inferior vena cava, PV portal vein, RAS right anterior sector, RPS right posterior sector, S3v ventral subsegment of segment 3, S4 segment 4, S5 segment 5, S8 segment 8 RESULTS: The operation lasted 270 min with 50 mL of intraoperative blood loss. Histopathology confirmed moderate-to-poorly differentiated hepatocellular carcinoma with negative resection margins. The patient was discharged on postoperative day 8 without any complications. Laparoscopic anatomical central combined with (sub) segment of left lobe hepatectomy guided by umbilical fissure approach and ICG fluorescence imaging is feasible for complex centrally located hepatocellular carcinoma.