Visualization of subcapsular hepatic malignancy by indocyanine-green fluorescence imaging during laparoscopic hepatectomy
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Although laparoscopic hepatectomy has increasingly been used to treat cancers in the liver, the accuracy of intraoperative diagnosis may be inferior to that of open surgery because the ability to visualize and palpate the liver surface during laparoscopy is relatively limited. Fluorescence imaging has the potential to provide a simple compensatory diagnostic tool for identification of cancers in the liver during laparoscopic hepatectomy.
In 17 patients who were to undergo laparoscopic hepatectomy, 0.5 mg/kg body weight of indocyanine green (ICG) was administered intravenously within the 2 weeks prior to surgery. Intraoperatively, a laparoscopic fluorescence imaging system obtained fluorescence images of its surfaces during mobilization of the liver.
In all, 16 hepatocellular carcinomas (HCCs) and 16 liver metastases (LMs) were resected. Of these, laparoscopic ICG fluorescence imaging identified 12 HCCs (75 %) and 11 LMs (69 %) on the liver surfaces distributed over Couinaud’s segments 1–8, including the 17 tumors that had not been identified by visual inspections of normal color images. The 23 tumors that were identified by fluorescence imaging were located closer to the liver surfaces than another nine tumors that were not identified by fluorescence imaging (median [range] depth 1 [0–5] vs. 11 [8–30] mm; p < 0.001).
Like palpation during open hepatectomy, laparoscopic ICG fluorescence imaging enables real-time identification of subcapsular liver cancers, thus facilitating estimation of the required extent of hepatic mobilization and determination of the location of an appropriate hepatic transection line.
KeywordsIndocyanine green Fluorescence imaging Laparoscopic hepatectomy Hepatocellular carcinoma Liver metastasis
Drs. Kudo, Ishizawa, Tani, Harada, Ichida, Shimizu, Kaneko, Aoki, Sakamoto, Sugawara, Hasegawa, and Kokudo have no conflicts of interest or financial ties to disclose.
This work was supported by grants from the Takeda Science Foundation (Ishizawa), the Kanae Foundation for the Promotion of Medical Science (Ishizawa), and the Ministry of Education, Culture, Sports, Science and Technology of Japan (Ishizawa; Nos. 23689060 and 2324
Supplementary Video 1 Fluorescence imaging of liver cancers during hepatic mobilization Patient 1 The right liver is mobilized using fluorescence imaging to confirm the exact location of an hepatocellular carcinoma in segment 7. Patient 2 Colorectal liver metastasis is located in segment 1. Although the tumor is exposed on ventral surface of the Spiegel’s lobe, it is identifiable from the dorsal aspect only by using fluorescence imaging. Based on the fluorescence images, the caudate vein is divided and the Spiegel’s lobe is completely mobilized before hepatic transection. (MOV 24918 kb)
Supplementary Video 2 Determination of a hepatic transection line using fluorescence imaging Patient 3 Boundary of a colorectal metastasis located in segment 6 is confirmed by fluorescence imaging, and then minimal hepatic transection line is marked with an electric cautery on the liver surface prior to hepatic transection. (MOV 38108 kb)