背景:为了最大程度地减少严重肝硬化和重复肝切除术以复发肝细胞癌(HCC)的情况下功能性肝体积的损失,解剖性肝切除术逐渐从主要肝切除术扩展到次要肝切除术(Miyama等人。“癌症”(巴塞尔):2021年13期;石泽等人。在AnnSurg256:959-964,2012)。对于位于当地的HCC,(亚)段切除术仍可被视为替代半肝切除术的选择。吲哚菁绿(ICG)已用于肿瘤定位,切除边缘和肝段的导航,和胆漏的鉴定。阴性染色ICG染料在阻断靶门静脉蒂后静脉给药更适用于部分切除术或半肝切除术。尤其是在多靶椎弓根存在或门静脉穿刺难以实现解剖切除的情况下。在这里,我们提供了使用Glisson椎弓根入路进行的带有ICG荧光阴性染色的腹腔镜下III和IV段切除术的视频。
方法:一名49岁的女性患有乙型肝炎相关性肝硬化2年,接受了IV段单个结节侵入左门静脉脐部的治疗。术前甲胎蛋白(AFP)为442ng/ml,维生素K缺失或拮抗剂II(PIVKA-II)诱导的蛋白质为122mAu/ml。肝功能为Child-PughA,15分钟吲哚菁绿保留试验(ICG-R15)为9.2%。外科手术包括以下步骤:(1)基于Laennec囊的肝外Glisson椎弓根解剖(Sugioka等。在J肝胆胰腺Sci24:17-23,2017)中,进行了针对脐窝III和IV段的椎弓根的隔离。(2)显示分界线,ICG(1ml,5mg/l)在分割目标椎弓根后,静脉内给予阴性染色。(3)沿阴性染色区域的边界在头颅和尾方向进行实质横切。
结果:手术时间为220分钟,失血量为150ml,不输血。在组织病理学中证实大小为2.5cm*1.7cm*1.2cm的HCC具有游离边缘且无微血管侵犯。肝实质的纤维化是基于Ishak系统的S4。患者于术后第6天出院,无任何并发症。随访9个月时,CT扫描未发现残肝复发。
结论:腹腔镜下III和IV段切除术是治疗HCC的有效方法,尤其是在需要保留肝实质的情况下。ICG导航和Glisson椎弓根方法可能特别有用。
To minimize the loss of functional liver volume in cases of severe cirrhosis and repeat hepatectomy for recurrence of hepatocellular carcinoma (HCC), anatomical hepatectomy is gradually extended from major to minor hepatectomy (Miyama et al. in Cancers (Basel):13, 2021; Ishizawa et al. in Ann Surg 256:959-964, 2012). For local located HCC, (sub)segmentectomy can yet be regarded as a choice instead of hemihepatectomy. Indocyanine green (ICG) has been used for tumor location, navigation of resected margin and liver segment, and identification of bile leakage. Negative stain that ICG dye was administered intravenously after occluding the target portal pedicle is more applicable to sectionectomy or hemihepatectomy, especially in cases where multiple target pedicles exist or portal vein puncture is difficult to carry out to achieve anatomic resection. Herein, we present a video of laparoscopic segmentectomy III and IV with ICG fluorescence negative stain using Glisson Pedicle approach.
A 49-year-old woman with hepatitis B related cirrhosis for 2 years was referred for treatment of a single nodule in segment IV invading the umbilical portion of left portal vein. The preoperative alpha-fetoprotein (AFP) was 442 ng/ml and protein induced by vitamin K absence or antagonist-II (PIVKA-II) was 122 mAu/ml. Liver function was Child-Pugh A and indocyanine green retention test at 15 min (ICG-R15) was 9.2%. The surgical procedure involved the following steps: (1) Extrahepatic Glisson pedicle dissection based on Laennec\'s s capsule (Sugioka et al. in J Hepatobiliary Pancreat Sci 24:17-23, 2017) was performed for isolation of the pedicles towards segments III and IV in the umbilical fossa. (2) Demarcation line was revealed and ICG (1 ml, 5 mg/l) was administered intravenously for the negative stain after dividing the target pedicles. (3) Parenchyma transection was performed along the border of the negative staining area in the cranial and caudal direction.
Operative time was 220 min and blood loss was 150 ml with no transfusion. HCC sized 2.5 cm*1.7 cm*1.2 cm was confirmed in histopathology with a free margin and no microvascular invasion. The fibrosis of the liver parenchyma was S4 based on Ishak system. The patient was discharged on the postoperative day 6 without any complications. No recurrence in residual liver was noted on the CT scan at 9 months during follow-up.
Laparoscopic segmentectomy III and IV is an effective procedure for HCC especially in cases with demands of hepatic parenchymal preservation. ICG navigation and Glisson Pedicle approach may be particularly helpful.