Abstract
Introduction:
In patients with liver metastases, robotic liver resection was reported to be safe and feasible. 1,2 Some researchers suggested that Indocyanine green (ICG) fluorescence imaging allowed to detect occult small-sized lesions which were not diagnosed preoperatively and was effective in real-time assessment of surgical margins by evaluating the integrity of the fluorescent rim around the tumour. 3,4 Here, we report a 70-year-old man with liver metastasis in segment VIII from sigmoid cancer who received robotic nonanatomical hepatectomy guided by ICG fluorescence.
Methods:
One day before operation, we gave the patient ICG 25 mg intravenously to guide the surgeon to perform robotic resection of liver metastasis in firefly mode. The operation was performed in supine position under general anesthesia. We inserted the robot trocars into the right axillary front line 3 cm away from the costal arch, the right clavicle midline 3 cm away from the costal arch, the right upper umbilicus, and the lower xiphoid process, respectively, and inserted a 12 mm trocar into the left upper umbilicus as an auxiliary port. After that, the position was adjusted to reverse Trendelenburg and left tilt. We explored the abdominal cavity and revealed the tumor in segment VIII of the liver. After converting to the firefly mode, in green fluorescent signals, we further confirmed the tumor, with a diameter of about 3 cm and showed suspicious small superficial lesions, not diagnosed preoperatively. We incised the falciform ligament and the ligamentum teres hepatis was ligated and cut routinely. In firefly mode, we marked the resection line and resected suspicious small superficial lesions. Before we performed nonanatomical hepatectomy in segment VIII, hepatic hilar occlusion was performed with a bulldog clamp. During the resection, the vessels were ligated and cut. In firefly mode, no fluorescence signal produced by the liver wound bed and we confirmed there should be no residual tumor. After resection, we removed the bulldog clamp. The hepatic inflow occlusion time was 20 minutes. Finally, meticulous hemostasis was performed. Two drainage tubes were placed, and the specimen was removed through the incision.
Results:
In this case, no intraoperative or postoperative complications were observed. The total operation time was 200 minutes and blood loss was 50 mL. Postoperative pathology showed the metastatic adenocarcinoma, and all margins were negative. The patient underwent an uneventful recovery and was discharged on postoperative day 7. The aspartate transaminase and alanine transaminase showed temporary abnormalities and recovered on postoperative day 4. Carcinoembryonic antigen and carbohydrate antigen 19-9 decreased obviously 1 month after operation.
Conclusion:
Robotic resection of liver metastases guided by ICG fluorescence was feasible in selected cases. Intravenous injection of ICG before surgery could help accurately locate tumor and detect occult small-sized lesions during the operation. In firefly mode, ICG fluorescence imaging could be adopted as a real-time guide to assessing surgical margins to obtain a margin-free resection.
Authors' Contributions:
H.Z. had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: H.Z. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: All authors. Critical revision of the manuscript for important intellectual content: All authors. Supervision: H.Z.
Ethical Approval:
This study was approved by the Ethics Committee of Changzheng Hospital.
Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.
No competing financial interests exist.
Runtime of video: 5 mins 9 secs
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