Fluorescence-Guided Laparoscopic Regional Anatomical Subsegmental Liver Resection Combined with Cholecystectomy through the Laennec Approach

Summary

This article primarily introduces a surgical approach utilizing the advantages of Laennec’s capsule dissection with indocyanine green (ICG) fluorescence guidance. This represents a significant definitive surgical technique for early-stage hepatocellular carcinoma.

Abstract

Laparoscopic hepatectomy is widely used for treating liver diseases, but achieving precise tumor resection with negative margins while preserving healthy liver parenchyma remains challenging. The Laennec's capsule approach has recently gained widespread use in liver surgery. This membrane facilitates perihepatic dissection, hepatic pedicle isolation, exposure of the hepatic veins, and anatomical hepatectomy. To address these difficulties, a technique combining Laennec’s capsule dissection with indocyanine green (ICG) fluorescence guidance has been introduced. In this approach, the gallbladder is first removed via the Laennec capsule, after which the first and second branches of the segment 6 pedicle and the segment 5 pedicle are exposed and dissected. Hepatectomy is then performed under the guidance of fluorescence imaging and ischemic demarcation lines. The patient recovered uneventfully: the drainage tube was removed after five days, and he was successfully discharged on postoperative day five. Overall, the combination of ICG fluorescence and the Laennec approach offers a safe and effective strategy for precise hepatectomy.

Introduction

Laparoscopic hepatectomy is widely utilized for the treatment of liver diseases. Laparoscopic resection of liver tumors is generally performed using a conventional surgical approach, with the primary aim of precisely dissecting the portal pedicle. However, accessing the pedicle via the hepatic hilum often necessitates a relatively deep intrahepatic dissection, which increases the risk of losing anatomical orientation and inadvertently injuring adjacent pedicles¹.

In HCC, tumor recurrence remains a leading cause of patient mortality, and anatomical resection (AR) combined with a wide resection margin (RM) has been ass....

Protocol

The Institutional Review Board of the Nanjing Drum Tower Hospital approved the protocols (No. 2020-310-02). Written informed consent was obtained from all patients undergoing cardiac surgery at this institution. A 56-year-old male patient was admitted with a chief complaint of “liver mass detected during health examination for 1 week.” Laboratory tests revealed the following: Hepatitis B serology (+ - + - +), HBV-DNA 3.64×10⁵ IU/mL, AFP 1664.30 ng/mL, and PIVKA negative. Abdominal CT (non-contrast and contrast-enhanced) demonstrated a hepatic lesion located in segments S5 and S6 (Supplementary Video 1–3), measuring 37....

Results

The information about the patients was presented in Table 1.

Case 1: In detail, a 56-year-old male patient was admitted with a chief complaint of “liver mass detected during health examination for 1 week.” Laboratory tests revealed the following: Hepatitis B serology (+ - + - +), HBV-DNA 3.64×10⁵ IU/ml, AFP 1664.30 ng/ml, and PIVKA negative. The diagnosis was HCC (CNLC stage IA, segments S5 and S6). No distant metastasis was observed. Then the operation was performe.......

Discussion

The present case demonstrates the feasibility and safety of fluorescence-guided laparoscopic regional anatomical subsegmental liver resection via the Laennec approach for HCC located in Couinaud segments 5 and 6. This technique integrates three key surgical concepts: (1) anatomical resection (AR) based on precise dissection of the Glissonean pedicles; (2) intraoperative fluorescence navigation to ensure oncologically adequate margins; and (3) utilization of Laennec’s capsule as an anatomical landmark to facilitate .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
10 mm trocar	Mindray	K010102	Provided access for the assistant and specimen extraction
5 mm trocar	Mindray	K010101	Provided access for the assistant and specimen extraction
12 mm trocar	Mindray	K010103	Provided access for the assistant and specimen extraction
Laparoscope	Mindray	hypixel-ux7	intra-operative visualization
Scissors	KangJi	KJ-JD0205W	Divided the tissue
Dissecting forceps‌	KangJi	DJ-FL03	Used for precise tissue dissection and grasping, particularly in delicate anatomical operations requiring minimal tissue damage
Grasping forceps‌	KangJi	DJ-ZQ05	Primarily used for grasping and removing foreign objects or tissues, commonly employed in endoscopic procedures
Clip applier‌	KangJi	KJ-SJ0205	Used to place vascular or tissue clips, achieving hemostasis or luminal occlusion through mechanical compression.
Electrosurgical hook	KangJi	DJ-DNG05	Combines high-frequency current for tissue cutting or coagulation, ideal for precise dissection (e.g., nerve separation) or cauterization.
Ultrasonic shears‌	Mindray	FOA-36 Pro	Utilizes ultrasonic vibrations to simultaneously cut tissue and coagulate vessels, particularly effective in vascular-rich organs
Laparoscopic fluorescence System	Mindray	hypixel-ux7	Employs fluorescent markers (e.g., ICG) to visualize tissue perfusion, lymphatic drainage, or tumor margins in real-time, enhancing surgical precision. Critical for tumor resection and vascular anastomosis.