Abstract: Objective:To investigate the feasibility and safty of indocyanine green (ICG) fluorescence staining by laparoscopic ultrasound and three-dimensional (3D) visualization guided portal branch puncture approach in anatomical segmentectomy.
Methods:The retrospective cross-sectional study was conducted. The clinical data of 26 patients who underwent anatomical segmentectomy using ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach in the Zhongshan Hospital of Fudan University between December 2016 and April 2018 were collected. The preoperative 3D visualization reconstruction and areas of portal branch perfusion were analyzed, laparoscopic ultrasound localization was intraoperatively applied to tumor and portal vein of targeted hepatic segment, and then portal branch puncture and staining were done under laparoscopic ultrasound and 3D visualization, finally laparoscopic anatomical segmentectomy was performed. Observation indicators: (1) intraoperative situations: success rate of portal vein puncture, targeted hepatic segment, effect of ICG fluorescence staining, intraoperative complications, operation time, volume of intraoperative blood loss, blood transfusion, conversion to open surgery, tumor diameter, the minimum resection margin to tumor; (2) postoperative situations: postoperative complications (Clavien-Dindo classification as a criteria) and duration of hospital stay; (3) follow-up situations: cases with follow-up, follow-up time and postoperative tumor recurrence. Follow-up using outpatient examination and telephone interview was performed to detect postoperative tumor recurrence up to April 2018. Measurement data with normal distribution and count data were respectively described as average (range) and percentage.
Results:(1) Intraoperative situations: a success rate of laparoscopic ultrasound and 3D visualization guided portal branch puncture in 26 patients was 100.0%(26/26), and punctures in S8, S7, S2, S3, S6, S5 and S4 of the liver were respectively performed to 7, 6, 4, 3, 3, 2 and 1 patients. Of 26 patients, 22 achieved expected effect of ICG fluorescence staining, with a statisfaction of 84.6%(22/26) and 4 failed to get expected effect, including 2 with uneven dying, 1 with staining-uncovered partial areas of targeted liver segment and 1 with adjacent hepatic segmental staining induced to unclear boundary. All the 26 patients were not complicated with ICG injection induced to allergy. Average operation time and volume of intraoperative blood loss were 184 minutes (range, 60-315 minutes) and 97 mL (range, 10-400 mL), without intraoperative blood transfusion and conversion to open surgery. Average tumor diameter and average minimum resection margin to tumor in 26 patients were respectively 3.2 cm (range, 1.2-10.0 cm) and 1.5 cm (range, 0.4-3.0 cm). (2) Postoperative situations: of 26 patients, 2 with gradeⅠ-Ⅱ of Clavien-Dindo classification were improved by drug treatments (1 with deep venous thrombosis of the lower extremities and 1 with pleural effusion), no patient had grade Ⅲ and above complications, and there was no bile leakage, infection and hepatic dysfunction. Average duration of hospital stay in 26 patients was 6.9 days (range, 5.0-14.0 days). (3) Follow-up situations: 26 patients were followed up for 0.3-17.0 months, with a median time of 6.0 months. During the follow-up, 1 patient with hepatocellular carcinoma had adrenal metastasis and 25 had tumor-free survival.
Conclusions:Laparoscopic anatomical segmentectomy with ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach is safe and feasible, especially suitable in posterosuperior liver segments.