Laparoscopic S7 Hepatectomy with Positive Fluorescence Staining

We used blood lesion staining to perform portal vein puncture through the visceral and diaphragmatic surfaces of the liver and successfully performed Laparoscopic resection of segment S7 within the portal territory anatomic liver. Successful portal vein puncture through the S7 segment of the liver simply finds the complexity of portal vein puncture in the S7 segment of the liver.

The main challenge lies in precise puncture of the portal vein branch to which the tumor belongs.

Follow up is performed every two months for two years, absolute follow up. The patients have survived so far without recurrence, and its overall survival has reached more than three years. Through tumor portal territory analysis, we can achieve tumor florescence staining and carry out more than precise anatomical liver resection.

[Narrator] To begin, the patient was placed supine on the operating table under general anesthesia. A horizontal incision was made one centimeter to the right of the navel using a surgical knife, and a 1.2 centimeter trocar was inserted as the observation port. Then a one centimeter trocar was inserted at the intersection of the midclavicular line, five centimeters below the right costal margin, followed by a 0.5 centimeter trocar below the right costal margin and the axilla. Another 1.2 centimeter trocar was inserted below the xiphoid process and a 0.5 centimeter trocar was inserted three centimeters to the left of the midpoint between the umbilicus and the xiphoid process. The surgeon stood to the right and the assistant to the left of the patient and the camera was placed into the observation port. Then intraoperative ultrasound scans were performed along the portal and hepatic veins to assess the relationship between the tumor and the duct. These findings were confirmed using three-dimensional reconstruction. The liver and abdominal cavity were explored laparoscopically to check for other lesions or metastases. Then the anterior portal and posterior portal were localized by ultrasound, and it was confirmed that the posterior portal was type B. The round and falciform ligaments of the liver were cut using an ultrasonic knife, and the second hepatic portal was dissected to expose the root of the right hepatic vein. The right coronary and triangular ligaments were then cut and a stitch was used to ligate the three short hepatic veins to the right of the inferior vena cava to completely mobilize the right liver. Next, using an ultrasonic knife, adhesions around the gallbladder were freed to expose the foramen of Venturi, and stomach gastric forceps were used through the foramen to place an occlusion band in the first hepatic portal. Under intraoperative ultrasound guidance, the probe was inserted, and the posterior portal vein C on the diaphragmatic surface and the posterior portal vein D on the visceral surface were punctured using a puncture hole. The probe was inserted through the right main operation port under the right costal margin. The long diameter of vein C was exposed and the puncture point was selected from its root. Then a 21-gauge percutaneous transhepatic cholangio needle was used to puncture the bile duct using the one face, three points and four horizontal fingers method. The midpoint between the left and right adjustment rods was used as the aiming point for in-plane puncture under ultrasound. The probe rod was used as the vertical reference plane, and the three points identified were the skin entry point, the intraoperative probe puncture hole, and the liver pedicle target point. The length of four horizontal fingers was used to measure the skin puncture point at the intersection of the probe rod's vertical plane and the skin. Next, the percutaneous transhepatic cholangio needle was held with the bevel facing the ventral distal side. The needle core was removed and three milliliters of 0.025 of a milligram per milliliter Indocyanine green was slowly injected. The diaphragmatic surface was visualized using fluorescence imaging. For visceral surface puncture, the probe was inserted under the xiphoid process. Posterior portal vein D was selected as the puncture site and three milliliters of 0.025 of a milligram per milliliter Indocyanine green was injected slowly. The fluorescent imaging of segment seven of the liver was observed to determine the resection margin. Then an elastic traction rope was used to pull the segment seven of the liver towards the left lower abdomen from the lower edge of segment six. The liver tissue was cut from the coddle to the cephalic side along the border between fluorescent and non fluorescent regions. The inter territory hepatic vein between segments S6 and S7 and the right hepatic vein were followed during resection. Then the liver segment seven reflux vein was ligated using ligating clips along the right edge of the right hepatic vein. It was disconnected from the two branch liver pedicles of segment seven. An ultrasonic scalpel and bipolar electrocoagulation were used to cut the liver under low central venous pressure assisted by anesthesia. Finally, the residual liver surface was carefully checked for bleeding points. The bleeding points were closed one by one using bipolar electrocoagulation, and the incision was closed using coated Vicryl antibacterial suture. The laparoscopic portal territory staining-guided anatomical liver resection of the S7 segment was successfully performed with positive staining along the diaphragmatic and visceral surfaces. A single one centimeter tumor was resected in 210 minutes. The postoperative MRI showed good improvement in the patient's condition.