Laparoscopic Anatomical Hepatectomy Using Takasaki's Approach and Indocyanine Green Fluorescence Navigation

[Narrator] This study centers on the application of Takasaki's approach and indocyanine green staining to improve the accuracy and effectiveness of anatomical liver resection. Takasaki's extrahepatic pedicle occlusion technique combined with indocyanine green counter staining is currently used to ensure tumor-free margins and minimize blood loss during anatomical liver resection. After exposing the Calot's triangle, dissecting the cystic duct and cystic artery, and double-ligating their proximal ends, transect the vessels and duct and dissect the gallbladder from the liver bed. Achieve hemostasis on the liver bed surface with electrocautery. Using an ultrasound scalpel, dissect the round ligament of the liver, falciform ligament, and partial right coronary ligament. Expose the second hepatic portal and the roots of the right, middle, and left hepatic veins. Identify the root of the middle hepatic vein and mark the left hepatic transection line one centimeter to the right of the falciform ligament with an electrocoagulation hook. Preempt a number 12 catheter as the first hepatic portal block band for the Pringle procedure. Perform an intraoperative ultrasound scan to screen the entire liver to exclude any lesions not detected preoperatively. Scan the tumor's location, size, and edge with focus on its proximity to the right and middle hepatic veins. Then scan the right and left Glisson's pedicles and right and left hepatic vein locations. Using the intraoperative ultrasound scan, mark the tumor margin with an electrocoagulation hook, ensuring the resection margin is greater than one centimeter. Perform the Pringle maneuver to occlude the hepatic hilum inflow. Then dissect the right anterior hepatic pedicle using an extraperitoneal approach. Divide a few small branches of G5 and moderately free the right anterior hepatic pedicle using a laparoscopic bulldog to facilitate occlusion. This will facilitate the division of the pedicle after the liver parenchyma is split. Release the occlusion and observe the ischemia line forming on the liver surface. Administer three to five milliliters of indocyanine green intravenously at a concentration of 0.025 of a milligram per milliliter after closing the right anterior Glissonean pedicle. Use the fluorescent staining to observe the extent of the right anterior segment. Mark the left resection line on the visceral surface along the right of the falciform ligament inclined toward the right anterior hepatic pedicle. Then mark the right resection line according to the fluorescent staining. Using ultrasonic scalpels and harmonic devices, initiate the transection of liver parenchyma along the marked line. On the left side, divide several branches of the G4 and V4 until reaching the root of the middle hepatic vein. Then split the right liver parenchyma and divide the right anterior hepatic pedicle and the middle hepatic vein. Carefully dissect the tumor in S7 near the right hepatic vein. Separate the resected liver from the surrounding tissues. Resect the targeted segments with caution, ensuring all major vessels are secured. Retrieve the liver segments using an endoscopic retrieval bag through the largest port or an additional incision if required. This table summarizes the key intraoperative and postoperative outcomes, including blood loss, procedure duration, hospital stay, and drainage volume over time. The estimated blood loss during the procedure was 150 milliliters, indicating minimal intraoperative hemorrhage. The total surgical duration was 205 minutes, which is within the expected range for laparoscopic liver resections. The patient was discharged after six days of hospital stay without complications. Postoperative drainage decreased from 200 milliliters on day one to 50 milliliters by day four, indicating stable recovery without fluid accumulation.