Laparoscopic Anatomic Segmentectomy of Segments VIII and IVa with Middle Hepatic Vein Excision Using Ultrasound-Guided ICG Positive Staining.

BACKGROUND

Anatomic liver resection traditionally relies on intraoperative ultrasound to identify hepatic veins as landmarks for parenchymal transection.1-3 Recently, portal territory staining with indocyanine green (ICG) has emerged as a key research focus in precision liver surgery, offering direct visualization of segmentation boundaries.4,5 However, a standardized technique for staining complex, multi-segmental tumors is lacking. This study evaluated a novel multi-subsegmental positive staining technique to achieve precise resection in such cases.

METHODS

The study enrolled a 59-year-old man with a 7.5-cm hepatocellular carcinoma (HCC) occupying segments Ⅷ and Ⅳa. Preoperative three-dimensional reconstruction mandated resection of both segments for adequate margins. Informed consent was obtained from the patient and his family. Intraoperatively, under ultrasound guidance, the portal veins supplying segments Ⅷ and Ⅳa were selectively punctured. A 1:1000 diluted ICG solution was injected into each, generating a composite positive staining map to delineate the combined resection territory. This approach was termed the "jigsaw-patterned staining technique."

RESULTS

The total operative time was 240 min, with the staining procedure requiring 30 min. Intraoperative blood loss was 50 mL. The fluorescent boundaries closely correlated with the subsequent ischemic planes after targeted pedicle division. Histopathology confirmed HCC with microvascular invasion and satisfied margins. At this writing, the patient has recovered without complications and has maintained a disease-free survival for more than 20 months.

CONCLUSIONS

The "jigsaw-patterned" multi-subsegmental portal vein ICG staining technique is technically feasible and safe. It enables precise anatomic resection for complex HCC spanning multiple segments, optimizing oncologic margin control while sparing functional parenchyma.