Laparoscopic Anatomical Segment VII Resection for Hepatocellular Carcinoma Using the Glissonian Approach with Indocyanine Green Dye Fluorescence

Background Many studies confirm that anatomical resection was associated with favorable oncologic outcomes for patients with HCC who had preserved as much of the remnant liver tissue as possible.(1,2) In recent years, laparoscopic liver resection has been widely extended from minor resection to complex hepatectomy,(3) However, surgery on tumors located in the posterosuperior segment remains a demanding procedure regardless of the extent of resection.(4) Laparoscopic anatomical segment VII resection has one of the highest difficulty scores based on the tumor location due to poor accessibility, hard to exposure, and difficulty in obtaining sufficient surgical margins.(5,6) Here, we report a totally laparoscopic anatomical VII resection using the Glissonian approach with indocyanine green dye fluorescence. Methods A 74-year-old man with a body mass index of 31.9 kg/m(2) suffered from HBV-related cirrhosis was admitted to our institution. The preoperative Gd-EOB-DTPA MRI showed a 2.7-cm HCC located in segment VIII. The preoperative AFP is 3431 ng/ml. A true anatomical segmentectomy was performed by using selective occlusion of segment VII Glissonian pedicle, which was identified from the liver hilum. Indocyanine green (ICG) dye demarcation was used as a guidance during parenchymal transection. Results The operative time was 270 min with an estimated blood loss of 200 mL. The postoperative course was uneventful. Drainage tube was pulled out on the fourth day. The pathology confirmed the diagnosis of hepatocellular carcinoma and the surgical margin was negative. The patient was discharged on the 8th day after operation. Conclusions Totally laparoscopic anatomical segment VII resection is a technically challenging operation. Advanced laparoscopic skills are necessary to complete such a difficult procedure safely. Glissonian approach and ICG fluorescence imaging guide parenchyma resection could be help.