Laparoscopic Anatomical Liver Resection Using Liver Mapping of Incidental Indocyanine Green Fluorescence due to Cholestasis.

BACKGROUND/AIM: Indocyanine green (ICG) fluorescence is useful in laparoscopic hepatectomy (LH) for tumor identification and staining, as well as determination of resection margins. At our Institution, patient-specific, three-dimensional simulations and rehearsal of surgical strategies are carried out preoperatively. We describe cases in which ICG administered preoperatively became stagnated and fluoresced in an area similar to the preoperatively established resection area and the pathological findings in these cases. PATIENTS AND METHODS: Four patients who underwent LH at our hospital between 2020 and 2023 (due to hepatocellular carcinoma in two and colorectal liver metastasis in two) were enrolled in the present study. The ICG-fluorescing liver segments were resected laparoscopically and their pathological characteristics were examined using a fluorescence microscope. RESULTS: In four cases, the areas of ICG fluorescence seen intraoperatively were due to stasis of preoperatively administered ICG, which fortuitously was equivalent to the planned resection area in the preoperative patient-specific simulation. The fluorescent areas were resected; there were no cases of bile leakage or recurrence. Fluorescence microscopy revealed areas with diffuse ICG fluorescence in normal hepatocytes on the tumor's peripheral side. CONCLUSION: It was suggested that resection of the liver area that was fluorescent due to stagnation of preoperatively administered ICG was rational and justified both anatomically and oncologically. This resection may also contribute to the prevention of bile leakage and recurrence.

Indocyanine Green Labeling of Tumors in the Liver Recurring After Radiofrequency Ablation Enables Complete Resection by Fluorescence-guided Surgery.

BACKGROUND/AIM: Radiofrequency ablation (RFA) is used to treat primary and metastatic tumors in the liver. However, local recurrence after RFA is frequent and subsequent salvage hepatectomy is often ineffective due to difficulty in visualization of tumor margins. PATIENTS AND METHODS: In the present retrospective clinical trial, seven patients from the Department of General and Gastro-enterological Surgery, Showa University School of Medicine underwent salvage hepatectomy for recurrent hepatocellular carcinoma (HCC) (n=2), colorectal liver metastasis (n=4) and lung-carcinoid liver metastasis (n=1), after RFA, between 2011 and 2020. Tumors were labeled with indocyanine green (ICG) and resected under fluorescence guidance. Resected specimens were evaluated under fluorescence microscopy as well as by standard histopathological techniques. RESULTS: Pathological findings revealed negative tumor margins in all patients after fluorescence-guided surgery. Six of seven resected tumors had a fluorescent rim, including both HCC and liver metastasis. Fluorescence microscopy demonstrated that viable cancer tumor cells were located only on the inside of the fluorescent rim, and no malignant cells were detected within the fluorescent rim surrounding the tumor. Fluorescence microscopy showed that the tumor margin was secured if the fluorescence signal was completely resected. CONCLUSION: The present results demonstrate that ICG labeling of liver tumors recurring after RFA enabled complete resection under fluorescence guidance. The present study is the first clinical study to demonstrate that tumor types that generally cannot be completely resected with bright light are fully resectable under fluorescence guidance.

Determinative Structural Features Identified With Probe-based Confocal Endomicroscopy for the Accurate Diagnosis of Gallbladder Malignancy.

BACKGROUND: Probe-based confocal laser endomicroscopy (pCLE) can visualize microscopic structures at high resolution but has not yet yielded definitive diagnostic features of gallbladder malignancy, as opposed to benign changes. PATIENTS AND METHODS: A total of 73 patients had their gallbladder evaluated with pCLE performed on resected benign and malignant gallbladder surgical specimens, which were sprayed with fluorescein. Malignant and benign features of pCLE findings were identified on the basis of Miami and Paris Classifications. Standard histopathological diagnoses and individual patient pCLE findings of gallbladder lesions were correlated. RESULTS: Of the 73 consecutive patients that had their gallbladder evaluated ex vivo with pCLE, 11 were identified with gallbladder malignancy. pCLE identified features of gallbladders examined ex vivo, including the presence of thick dark bands and dark clumps, which together correlated with histopathologically-determined biliary malignancy at 100% sensitivity. Thick white bands and visualized epithelium, also identified with pCLE, together correlated with histopathologically-determined malignancy at 100% specificity. CONCLUSION: pCLE can be used for real-time differentiation of cancerous/non-cancerous regions in the gallbladder using the diagnostic criteria identified in the present study.

Relationship Between Remnant Pancreatic Volume and Endocrine Function After Pancreaticoduodenectomy.

BACKGROUND: Decreased pancreatic volume (PV) is a predictive factor for diabetes mellitus (DM) after surgery. There are few reports on PV and endocrine function pre- and post-surgery. We investigated the correlation between PV and insulin secretion. METHODS: Seventeen patients underwent pancreaticoduodenectomy (PD) Pre- and post-surgery PV and C-peptide index (CPI) measurements were performed. Additionally, the correlation between PV and CPI was analyzed. RESULTS: The mean preoperative PV (PPV) was 55.1 ± 31.6 mL, postoperative remnant PV (RPV) was 25.3±17.3 mL, and PV reduction was 53%. The mean preoperative C-peptide immunoreactivity (CPR) was 1.39 ± .51 and postoperative CPR was .85±.51. The mean preoperative CPI was 1.29±.72 and postoperative CPI was .73 ± .48. Significant correlations were observed between RPV and post CPR (ρ = .507, P = .03) and post CPI (ρ = .619, P = .008). DISCUSSION: There was a significant correlation between RPV and CPI after PD. A smaller RPV resulted in lower insulin secretion ability, increasing the potential risk of new-onset DM after PD.

The Efficacy of Intraoperative Fluorescent Imaging Using Indocyanine Green for Cholangiography During Cholecystectomy and Hepatectomy.

PURPOSE: Bile duct injury is one of the most serious complications of laparoscopic cholecystectomy. Intraoperative indocyanine green (ICG) cholangiography is a safe and useful navigation modality for confirming the biliary anatomy. ICG cholangiography is expected to be a routine method for helping avoid bile duct injuries. PATIENTS AND METHODS: We examined 25 patients who underwent intraoperative cholangiography using ICG fluorescence. Two methods of ICG injection are used: intrabiliary injection (percutaneous transhepatic gallbladder drainage [PTGBD], gallbladder [GB] puncture and endoscopic nasobiliary drainage [ENBD]) at a dosage of 0.025 mg during the operation or intravenous injection with 2.5 mg ICG preoperatively. RESULTS: There were 24 patients who underwent laparoscopic cholecystectomy and 1 patient who underwent hepatectomy. For laparoscopic cholecystectomy, the average operation time was 127 (50-197) minutes, and estimated blood loss was 43.2 (0-400) g. The ICG administration route was intravenous injections in 12 cases and intrabiliary injection in 12 cases (GB injection: 3 cases, PTGBD: 8 cases, ENBD:1 case). The course of the biliary tree was able to be confirmed in all cases that received direct injection into the biliary tract, whereas bile structures were recognizable in only 10 cases (83.3%) with intravenous injection. The postoperative hospital stay was 4.6 (3-9) days, and no postoperative complications (Clavien-Dindo ≧IIIa) were observed. For hepatectomy, a tumor located near the left Glissonian pedicle was resected using a fluorescence image guide. Biliary structures were fluorescent without injury after resecting the tumor. No adverse events due to ICG administration were observed, and the procedure was able to be performed safely. CONCLUSION: ICG fluorescence imaging allows surgeons to visualize the course of the biliary tree in real time during cholecystectomy and hepatectomy. This is considered essential for hepatobiliary surgery to prevent biliary tree injury and ensure safe surgery.

Use of Transumbilical Incision as an Organ Removal Site in Laparoscopic Pancreatectomy.

BACKGROUND/AIM: To evaluate complications and risk factors associated with transumbilical incision as an organ removal site in laparoscopic pancreatectomy (LP). PATIENTS AND METHODS: In total, 52 patients who underwent LP between 2009 and 2017 were included in this study. The development of superficial surgical site infection (SSI) and transumbilical port-site incisional hernia was recorded. RESULTS: None of the patients had SSI. However, three (5.77%) presented with transumbilical incisional hernia. No variables were significantly associated with the risk of transumbilical incisional hernia. CONCLUSION: No evident risk factors correlated with hernia formation. Hence, incisional hernia might have occurred at a certain probability. In some cases, it was caused by technical problems. However, the use of transumbilical incision as an organ removal site was feasible, and a new incision for organ removal alone was not required.

Intraoperative Shear Wave Elastography as a Quantitative Predictor of Pancreatic Fibrosis and Exocrine Function.

BACKGROUND/AIM: Soft pancreatic texture is a risk factor for postoperative pancreatic fistula (POPF). However, conventional evaluation of pancreatic texture is largely dependent on subjective assessment and lacks quantitative parameters. The study aimed to use ultrasonic shear wave elastography (SWE) to evaluate pancreatic stiffness to determine if the intraoperative SWE measurement could be a quantitative predictor for POPF. PATIENTS AND METHODS: Fifteen patients scheduled for pancreaticoduodenectomy were included. Both pre- and intra-operative measurement of the pancreatic SWE index (SWEI) were evaluated. Relationships between intraoperative and preoperative SWEI, pathological fibrosis of the resected pancreatic specimen, postoperative exocrine function of the remnant pancreas, and the incidence of POPF were evaluated. RESULTS: The intraoperative SWEI was correlated with the preoperative SWEI, pathological fibrosis of pancreatic tissue, and pancreatic exocrine function. CONCLUSION: Intraoperative SWE measurement of pancreatic elasticity may be useful as a quantitative method for evaluating pancreatic fibrosis and exocrine function.

Laparoscopic Liver Surgery Guided by Virtual Real-time CT-Guided Volume Navigation.

BACKGROUND: Recently, virtual navigation system has been applied to hepatic surgery, enabling better visualization of intrahepatic vascular branches and location of tumor. Intraoperative ultrasonography (IOUS) is the most common form of image guidance during liver surgery. However, during laparoscopic hepatectomies (LH), IOUS has several limitations and its reliability has been poorly evaluated. The objective of this work is to evaluate VRCT (virtual real-time CT-guided volume navigation) during LH. This system aims to provide accurate anatomical orientation for surgeons enhancing the safety of LH. METHODS: Twenty-seven hepatic neoplasms were resected laparoscopically at our institution under reference guidance of VRCT. During operation, electromagnetic tracking of the surgical instrument was used for navigating the direction of accurate liver transection. RESULTS: Twenty-six (96.3%) of the 27 lesions (mean diameter 11 mm) were successfully performed under VRCT guidance. Average registration time was < 2 min. Average setup time was approximately 7 min per procedure. VRCT allows the surgeon to navigate liver transection with acceptable accuracy. The mean error was 12 mm. All surgical margins were negative and the mean histologic resection margin was 9 mm. CONCLUSIONS: VRCT-guided LH is feasible and provides valuable real-time anatomical feedback during hepatic resections. Advancement of such systems to improve accuracy might greatly compensate for the limitation of laparoscopic IOUS.

Usefulness of a Transumbilical Incision for Organ Removal in Laparoscopic Hepatectomy.

BACKGROUND/AIM: To evaluate the complication rates and risk factors associated with transumbilical wounds and investigate the usefulness of an incision for organ removal in laparoscopic hepatectomy (Lap-H). PATIENTS AND METHODS: We enrolled 42 patients who underwent Lap-H excluding a small partial resection in our hospital between 2013 and 2018. The occurrences of superficial surgical site infection (SSI) and transumbilical port-site incisional hernia were recorded. RESULTS: SSI was not observed, and hernia occurred in 3 patients (7.14%). Univariate analysis revealed that body mass index (BMI) (p=0.004) was significantly associated with the risk of hernia formation. CONCLUSION: High BMI is a risk factor for hernia formation in patients undergoing Lap-H with transumbilical incision; hence, wound closure should be performed carefully. The construction of the transumbilical wound for organ removal was feasible with rationality, with no need to create a new wound.

Corrigendum to "Solid Pseudopapillary Neoplasm of the Pancreas with High-Grade Malignant Transformation Involving p16-RB Pathway Alterations".

[This corrects the article DOI: 10.1155/2020/5980382.].

Laparoscopic Treatment of a Hepatoduodenal Ligament Schwannoma With Infrared Indocyanine Green Fluorescence.

Schwannomas occurring in the hepatoduodenal ligament are extremely rare, with only four cases reported. Here, we describe a case of a 30-mm schwannoma that originated in the hepatoduodenal ligament of a 38-year-old female found during a periodic medical check-up. Magnetic resonance imaging demonstrated a tumor in the hepatoduodenal ligament. Following an ultrasound-guided microbiopsy, histological examination showed solitary fibrous tumor or schwannomas in the liver or originating from the hepαtoduodenal ligament. The relationship between the tumor and associated organs was confirmed intraoperatively, and the tumor was removed safely in its entirety using indocyanine green. The postoperative histopathological examination revealed the presence of a schwannoma with typical characteristics. To our knowledge, this is the first case of hepatoduodenal ligament schwannoma treated by laparoscopic surgery using indocyanine green fluorescence imaging.

Pathological Validity of Using Near-infrared Fluorescence Imaging for Securing Surgical Margins During Liver Resection.

BACKGROUND/AIM: This study investigated the use of near-infrared fluorescent imaging for securing safe margins during liver resection. PATIENTS AND METHODS: This study included 125 patients who underwent liver tumor resection in 2014-2018. Indocyanine green testing was performed 2-14 days before surgery. Histopathological specimens of hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM) were evaluated using fluorescent microscopy. RESULTS: Fluorescence microscopy identified signals in 26/53 (49.0%) and 36/72 (50%) cases of HCC and CRLM, respectively. HCC demonstrated total, partial, rim, and combined fluorescence patterns; CRLM uniformly demonstrated rim fluorescence. Although rim fluorescence was seen in both HCC and CRLM, no malignancy was confirmed pathologically in the peritumoral area demonstrating fluorescence. The median widths of fluorescence from the tumor edge in HCC and CRLM were 1227.5 µm and 1608 µm, respectively, with no significant difference. CONCLUSION: Near-infrared fluorescent imaging can reliably detect safe surgical margins intraoperatively during liver resection.

Virtual reality with three-dimensional image guidance of individual patients' vessel anatomy in laparoscopic distal pancreatectomy.

PURPOSE: Three-dimensional virtual endoscopy (3DVE) has the potential advantage of enhanced anatomic delineation and spatial orientation during laparoscopic procedures. In the present study, we aimed to evaluate the impact of 3DVE guidance in laparoscopic distal pancreatectomy (LDP). METHODS: Thirty-eight patients presenting to our hospital with a variety of pancreatic tumors underwent preoperative computed tomography scanning to clearly define the major peripancreatic vasculature and correlate it with a 3DVE system (SYNAPSE VINCENT: Fujifilm Medical, Tokyo, Japan). This map served as the guide during preoperative planning, surgical education, and simulation and as intraoperative navigation reference for LDP. Operative records and pathological findings were analyzed for each procedure. Operative parameters were compared between the 38 patients in this study and 8 patients performed without 3DVE guidance at our institution. RESULTS: The 3DVE navigation system successfully created a preoperative resection map in all patients. Relevant peripancreatic vasculature displayed on the system was identified and compared during the intervention. The mean blood loss in LDP performed under 3DVE guidance versus LDP without 3DVE was 168.5 +/- 347.6 g versus 330.0 +/- 211.4 g, p = 0.008 while and the operative time was 171.9 +/- 51.7 min versus 240.6 +/- 24.8 min, p = 0.001. CONCLUSIONS: 3DVE in conjunction with a "laparoscopic eye" creates a preoperative and intraoperative three-dimensional data platform that potentially enhances the accuracy and safety of LDP.

Solid Pseudopapillary Neoplasm of the Pancreas with High-Grade Malignant Transformation Involving p16-RB Pathway Alterations.

Solid pseudopapillary neoplasm (SPN) of the pancreas has generally been regarded as a low-grade malignant tumour that preferentially develops in young women and can have a good prognosis with surgery. Among the few patients who have died from metastatic SPN are mostly those whose tumours harbour an undifferentiated component characterized by diffuse sheets of cells with increased nuclear atypia and proliferative index. We herein report a case of an aggressive, fatal, solid pseudopapillary neoplasm (SPN) of the pancreas in a 63-year-old woman complaining of epigastric pain. Despite having undergone surgical resection for a 10 cm pancreatic mass and multiple liver metastases, the patient later died due to uncontrollable metastases 36 months after the initial surgery. Histological examination showed that the tumour displayed unusual high-grade malignant features, showing diffuse sheets of cells with increased nuclear atypia and proliferative activity, along with conventional low-grade malignant features. The tumour was subsequently recognized as an SPN with foci of high-grade malignant transformation according to the 2010 World Health Organization classification. Immunohistochemical studies revealed that p16-RB pathway alterations contributed to the high-grade malignant transformation. The present case report suggests the necessity for developing diagnostic and treatment methods targeting p16 and RB for high-grade variants of SPN.

Individualized procedures for splenic artery dissection during laparoscopic distal pancreatectomy.

BACKGROUND: There are no established standard criteria for choosing the most appropriate procedure of splenic artery dissection during laparoscopic distal pancreatectomy (LDP). The aim of this study was to evaluate the clinical benefits of individualized procedures for splenic artery dissection during LDP based on the variations in arterial structure visualized on preoperative three-dimensional computed tomography (3D-CT). METHODS: Patients who underwent LDP following 3D-CT at a single center were retrospectively evaluated. 3D-CT images were used to construct virtual 3D laparoscopic images for surgical planning. The splenic artery was classified into two major anatomic types: type S that curves and runs suprapancreatic and type D that runs straight and dorsal to the pancreas. Splenic artery dissection was planned according to these two variations, with type S dissected using an suprapancreatic approach and type D using a dorsal approach. RESULTS: Type-specific dissection was applied for 30 patients: 25 (83%) with type S and 5 (17%) with type D splenic artery anatomies. In 25 (83%) patients, the splenic artery was successfully dissected using the planned surgical procedure, whereas the surgical plan had to be altered in 5 cases (17%) due to difficulty in dissecting the splenic artery. CONCLUSION: The individualized procedures for splenic artery dissection according to anatomic variations visualized on 3D-CT images can help improve the success and safety of LDP.

[Present and Future of Navigation Surgery in Hepatobiliary and Pancreatic Surgery].

Hepatobiliary and pancreatic surgery is recognized as technically demanding due to the complicated local anatomy and diverse anatomical variation that require precise techniques. Therefore, preoperative simulation to understand the detailed local anatomy and intraoperative navigation methods for surgical guidance are needed. Intraoperative navigation for anatomical hepatectomy originated with dye injection into the dominant portal pedicle under intraoperative ultrasound guidance to identify hepatic segments, which was reported by Makuuchi et al in 1985. In recent years, with advancing medical technology, newer medical devices that promote the safety and reliability of various surgical procedures have been developed. In this article, we will discuss the current state and future prospects of intraoperative navigation in hepatobiliary and pancreatic surgery.

Routes for virtually guided endoscopic liver resection of subdiaphragmatic liver tumors.

PURPOSE: Laparoscopic and thoracoscopic/laparoscopic hepatectomy is a safe procedure that has potential advantages over open surgery. However, deeply positioned liver tumors require expert laparoscopic and thoracoscopic/laparoscopic hepatectomy techniques. Using simulated preoperative three-dimensional virtual endoscopy (P3DVE) guidance, we demonstrate herein that a thoracoscopic approach (TA), thoracoscopic-laparoscopic approach (TLA), and laparoscopic approach (LA) are all feasible and safe routes for performing pure laparoscopic and thoracoscopic/laparoscopic resection of liver tumors located in the 4a, 7, and 8 liver subdiaphragmatic areas. METHODS: Thirty-eight patients underwent laparoscopic and thoracoscopic/laparoscopic partial liver resection (TA 13 cases, TLA two cases, and LA 23 cases) of the subdiaphragmatic area at Showa University Hospital. All surgical approaches were preoperatively determined based on preoperative 3D virtual endoscopic simulation (P3DVES) visualization and findings using the image processing software SYNAPSE VINCENT(®). RESULTS: Laparoscopic and thoracoscopic/laparoscopic liver resection was successfully performed for all cases under P3DVE instruction. The mean operative times using TA, TLA, and LA approaches were 193, 185, and 190 min, respectively. Mean blood loss during TA, TLA, and LA was 179, 138, and 73 g, respectively. No patients required conversion to open surgery, and there were no deaths, although there were three cases of Clavien-Dindo grade I in TA along with three cases of grade I and one case of grade II in LA. CONCLUSIONS: TA, TLA, and LA routes performed under P3DVE instruction are feasible and safe to perform for pure laparoscopic and thoracoscopic/laparoscopic liver resection in selected patients with lesions located in the hepatic subdiaphragmatic area.

Skeletonization and Isolation of the Glissonean and Venous Branches in Liver Surgery With an Ultrasonic Scalpel Technology.

This study describes a novel technique for skeletonization and isolation of Glissonean and venous branches during liver surgery using a harmonic scalpel (HS). Hepatic resections with HS were performed with the skeletonization and isolation technique in 50 patients (HS group). Variables evaluated were blood loss, operative time, biliary leak, and morbidity. The results were compared with 50 hepatic resections that were performed using a previously established technique: Cavitron ultrasonic surgical aspirator with electric cautery, ligatures, and hemoclips (NHS group). The HS group had shorter total operative times (285 versus 358 minutes; P = 0.01), less blood loss (389 versus 871 mL; P = 0.034), and less crystalloid infusion (2744 versus 3299 mL; P = 0.027) compared with the NHS group. Postoperative liver function and complication rates were similar when comparing the two groups. These data demonstrate that HS is a simple, easy, and effective instrument for the skeletonization and isolation of vessels during liver transection.