Laparoscopic Glissonean Pedicle Transection (Takasaki) for Negative Fluorescent Counterstaining of Segment 6

Background. The portal pedicles are wrapped in connective tissue known as the Walaeus sheath, which abut Laennec's capsule covering the liver parenchyma. Precise knowledge of this anatomic relationship allows for dissection of this interspace and early control of the segmental portal pedicle (Glissonean pedicle transection method [GPTM], Takasaki approach). (1,2) Subsequent systemic administration of indocyanine green (ICG) leads to negative counterstaining of the segment to be resected. Patient. The patient was a 60-year-old healthy woman with invasive lobular breast cancer, grade 2, which was estrogen receptor-positive (ER +), progesterone receptor-positive (PR +), human epidermal growth factor-negative (HER2-), Ki-67 80%, and cT2N0M1. A synchronous solitary liver metastasis between segments 6 and 7 was diagnosed. After treatment with letrozole and palbociclib for 1 year had achieved stable disease, the patient was considered for liver metastasectomy. (3,4) Methods. After an intraoperative ultrasound, the patient was placed in the French position, (5) and the gallbladder was disconnected from the cystic duct for exposure of the hepatoduodenal ligament. The hilar plate was lowered, and the portal pedicle of segment 6 was dissected out using the GPTM approach. After test-clamping, an appropriate demarcation was observed, and ICG was administered systemically. This led to negative counterstaining of segment 6 and allowed for precise anatomic dissection under near-infrared vision. Conclusions. Laparoscopic application of GPTM facilitates anatomically precise liver resection through early pedicle control. Negative counterstaining using ICG under near-infrared vision leads to visual enhancement of the anatomically precise borders. They typically do not follow straight lines and are therefore difficult to dissect precisely. Counterstaining with ICG shows patient-specific anatomic variations that would be a challenge to determine, especially laparoscopically.