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Laparoscopic Repeat Hepatectomy with Indocyanine Green Fluorescence Navigation: A Case Report

The indocyanine green (ICG) fluorescence method is reportedly useful for intraoperative visualization of hepatocellular carcinoma and metastatic liver cancer. Herein, we report the use of an ICG fluorescence navigation system for laparoscopic hepatectomy. The patient was a 73-year-old man with a surgical history of two laparotomies for hepatocellular carcinoma resection. During follow-up at our hospital, abdominal computed tomography revealed recurrence of hepatocellular carcinoma in the lateral area of the liver, after which the patient was hospitalized for surgery. His surgical history indicated that adhesions in the abdominal cavity were likely. We scheduled laparoscopic repeat hepatectomy (LRH) with an ICG fluorescence method in which ICG dye was injected intravenously 2 days before surgery. ICG fluorescence was easily detected intraoperatively. The advantages of the present approach are that it in-duces pneumoperitoneum and, with laparoscopic magnification, enables good visualization of the surgical field for LRH and clear intraoperative identification of the tumor, thus facilitating LRH. Laparoscopic partial resection of the liver (S3) was successfully performed; the operation time was 197 minutes and bleeding volume was 30 mL. Postoperative course was uneventful and he was discharged on postoperative day 10. (J Nippon Med Sch 2019; 86: 291 ― 295)


Introduction
Laparoscopic liver resection (LLR) is now performed much more frequently, with several modifications. Furthermore, we routinely perform laparoscopic repeat he- Herein, we report the successful performance of LRH for a patient who had undergone two previous hepatectomies.

Case Report
A 73-year-old man with nonalcoholic steatohepatitis (results of testing for hepatitis B surface antigen and hepatitis C virus antibody were negative) and diabetic nephropathy was followed-up at our outpatient clinic. The pa- intensively stained with a contrast agent early in the arterial phase and washed out in the venous phase ( Fig. 1).
On the basis of these findings, single recurrence of HCC in liver S3 was diagnosed, and partial laparoscopic resection of the segment was scheduled. As the patient had previously undergone two open hepatectomies, we predicted that adhesions in the abdominal cavity were likely and that accurate identification of the tumor location would be difficult. Nevertheless, we elected to perform a laparoscopic operation because of its minimal invasiveness and the magnification provided by the laparoscope.
Use of ICG fluorescence navigation was also planned, to enable easier identification of the tumor. ICG reagent (0.5 mg/kg) was injected intravenously 2 days before surgery.

Surgical Procedure
Use of intravenous ICG injection for intraoperative navigation was approved by the ethics committee of our institute. Although our patient had previously undergone upper abdominal laparotomy and had a surgical scar at the umbilicus, a 3-cm incision was created at the umbilicus, and a Lap Protector (Hakko, Nagano, Japan) was attached. A 12-mm port for a camera and two 5-mm ports for the multiaccess port system (EZ Access ; Hakko, Nagano, Japan) were also constructed (Fig. 2). In Preoperative three-dimensional CT imaging indicated that the tumor was located on the dorsal side of the liver ( Fig. 4a, 4b). Therefore, adhesions were detached or divided, as necessary, to create the surgical field for the planned hepatectomy. Adhesions from the abdominal wall, transverse colon, omentum, lateral extrahepatic area, and stomach were sufficiently detached to enable partial resection of liver segment S3, while adhesions not in the required surgical field were left intact (Fig. 5a, 5b,   5c). Because the tumor was located on the dorsal side of the liver, adhesions that could be used to lift the liver were left in situ. When the liver surface on which the tumor was predicted was exposed, the camera was switched to ICG fluorescence mode, enabling visualization of the tumor as a clearly demarcated region of green fluorescence (Fig. 6a, 6b). An ultrasonically activated scalpel was used to dissect the superficial layer, while the deep layer was dissected with a Cavitron ultrasonic surgical aspirator (Valley Lab; Medtronic, Minneapolis, MN, USA). The appropriate vessels in the liver were clipped and dissected, and partial resection of liver segment S3 was performed in accordance with the preoperative simulation (Fig. 6c, 6d). The operative time was 197 minutes, and bleeding volume was 30 mL. The postoperative  however, bile excretion is delayed. Some evidence indicates that bile excretion is impaired in normal liver parenchyma surrounding HCC 10 .
As mentioned above, it can be difficult to locate tumors by ultrasound examination of patients undergoing