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 associated with improved prognosis compared with non-AR or a narrow RM after hepatectomy^2,3. While a larger surgical margin may help prevent early recurrence of HCC, excessively wide margins can compromise the remaining liver parenchyma and lead to post-resection liver failure⁴. First described by Makuuchi et al. in 1985, anatomical resection involves removing the tumor along with the liver segment or subsegment that contains the tumor-bearing portal tributaries, as well as a major branch of the portal vein and hepatic artery⁵. In contrast, nonanatomic resection is a less extensive procedure that removes the lesion without regard to the liver's anatomical segments or lobar structure⁶. Thus, a novel strategy is needed to solve those clinical problems.

In 1802, Laennec first described a membrane distinct from the serosa, later termed Laennec’s capsule⁷. Previous study reported that Laennec’s capsule envelops the entire liver parenchyma independently of intrahepatic vessels and proposed its potential use as a basis for liver surgical anatomy^8,9. 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. Our previous study demonstrated that Laennec’s capsule can serve as an anatomical landmark for isolating the Glissonean pedicle and hepatic vein¹⁰. The application of the indocyanine green fluorescence (ICG) approach and the Glissonean approach in hepatectomy has shown its advantages¹¹. The clinical application of ICG has enabled the development of fluorescence laparoscopes, which help visualize tumor boundaries. In liver resection, ICG can be used in two ways: positive staining and negative staining. Positive staining causes the target tissue to fluoresce, clearly outlining the anatomical boundaries of the tumor-bearing segment and supporting precise resection. Negative staining causes the non-target liver segments to fluoresce, while the target segment remains unstained and appears dark¹². This strategy improves the removal of small residual tumor foci on the transection surface.

Given the development of various surgical methods, the combination of Lannec’s capsule and negative ICG staining has yet to be standardized due to the lack of supporting data. It offers significant advantages when the tumor is confined to a single hepatic segment. Thus, this study aims to demonstrate the technical feasibility of the fluorescence-guided laparoscopic regional anatomical combined subsegmental liver resection through the Laennec approach. This study describes the methodology in detail and reviews our findings to date.

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 × 23 mm. The Child-Pugh score was grade A. Based on a comprehensive evaluation, the diagnosis of hepatocellular carcinoma (CNLC stage IA, segments S5 and S6) was established. The patient subsequently underwent laparoscopic regional anatomical subsegmental liver resection under general anesthesia with endotracheal intubation. Materials of surgical instruments are listed in the Table of Materials.

1. ICG administration

1. Use a concentration of 0.025 mg/mL, achieved by a 1:1000 dilution. Taking 1 mL (containing 2.5 mg of ICG) from a 25 mg/10 mL ICG stock solution and adding it to 100 mL of normal saline. The dosage consists of 10 mL of this solution containing 0.125–0.25 mg of ICG, administered via peripheral intravenous injection after the target hepatic pedicle has been occluded intraoperatively.
2. Activate the laparoscopic fluorescence mode to visualize ICG distribution.
3. Inspect the target area and confirm that it exhibits no staining.

2. Anesthesia and access

1. Under general anesthesia, put patients in a moderate reverse Trendelenburg position with split legs.
2. Insert a 10 mm trocar 2 cm above the umbilicus at the right midclavicular line to establish pneumoperitoneum (10–14 mmHg, 20 L/min); use this port for the camera (Figure 1).
3. Place a total of five ports: a 10mm observation port (C) 2cm to the right of the umbilicus; a 12mm main operating port (B) at the right midclavicular line 4cm above the umbilicus; a 5mm auxiliary port (D) at the right midaxillary line‑costal margin junction; another 5m secondary operating port (D) on the midline 5cm above the umbilicus; and a 12mm operating port (E) at the midline below the xiphoid process. Figure 1 shows the trocar placement (Figure 1).

3. Surgical operation

1. Mobilize the gallbladder using the cystic plate–based Laennec capsule approach (yellow arrows, Figure 2A).
2. Maintain the dissection plane between the cystic plate and liver parenchyma and take care to avoid injury to the right hepatic pedicle.
3. Preserve the Laennec capsule, recognized as a glistening fibrous layer, to facilitate hemostasis.
4. After gallbladder dissection, expose the first hepatic hilum to identify the right anterior hepatic pedicle (RAHP) and right posterior hepatic pedicle (RPHP) (Figure 2B).
5. Encircle the hepatoduodenal ligament using an 8‑French catheter and carefully isolate the RAHP and RPHP.
6. Isolate the key portal vein branches, including the first branch of the Glissonean pedicle of segment 6 (S6v1) (Figures 2C–D), the second branch of the Glissonean pedicle of segment 6 (S6v2) (Figures 2E–F), and the ventral branch of the Glissonean pedicle of segment 5 (P5v) (Figures 2G–H).
7. Clamp each branch separately, producing well-demarcated ischemic zones (Figures 2E, G, I). Firstly, isolate and clamp S6v1 with a bulldog clamp, which immediately induced ischemic changes characterized by dusky discoloration and reduced pulsation. Then, dissect S6v1 using an ultrasonic scalpel. Similarly, isolate, clamp, and keep S6v2, which generated a second ischemic zone. Finally, we dissected P5v, producing a third ischemic region.
8. After dissolving the hepatoduodenal ligament, observe an unstained fluorescence area adjacent to the ischemic zones (Figures 2J–K). Fluorescence (ICG negative staining) shows a uniform, well-demarcated border exactly matching the ischemic zone, with no skip areas or spillover into adjacent segments. Clear delineation between perfused (fluorescent) and non‑perfused (non‑fluorescent) liver parenchyma under near‑infrared imaging.
9. Perform hepatectomy strictly along the fluorescence and ischemic demarcation lines using ultrasonic scalpel dissection combined with bipolar cautery. Then, the gallbladder was completely excised (Figures 2L–M).
10. Achieve meticulous hemostasis (Figure 2N). Place a closed-suction drain near the liver resection margin and secure it. Retrieved the specimen via a 10 cm incision below the xiphoid process. Confirmed correct instrument and sponge counts and closed all trocar and skin incisions (Supplementary Video 4).

4. Technical aids

1. Intraoperative ultrasound is often used to confirm the course of the pedicles and their relationship to the hepatic veins.
2. ICG fluorescence or temporary clamping with Doppler can also help confirm the ischemic zones corresponding to the anterior and posterior territories before division.

5. Safety, caution, and reproducibility

1. Dissect in a bloodless field using bipolar cautery or ultrasonic shears; avoid blind clipping or stapling near the main biliary confluence.
2. Identify the right hepatic artery and portal vein branches early; confirm anatomy with intraoperative ultrasound (IOUS) before dividing any structure thought to be a Glissonean pedicle.
3. Use a “hanging” maneuver or vessel loops to gently retract structures, avoiding excessive traction that may cause intimal injury or vasospasm.
4. Consistent identification relies on systematic hilar dissection, maintaining the hilar plate integrity, and using a combination of blunt dissection, bipolar cautery, and meticulous hemostasis to avoid injury to aberrant bile ducts or small vascular branches.
5. In all patients, the final resection margin was located within the area defined intraoperatively by the combination of the ischemic line and the fluorescence border. The distance from the margin to the tumor was measured, and no positive margin occurred where the transection line followed the combined guidance.

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.