穿刺正染ICG荧光导航腹腔镜解剖性肝Ⅶ段切除术1例报告(附视频)
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中国人民解放军陆军军医大学第二附属医院 肝胆外科,重庆 400037

作者简介:

王峥,中国人民解放军陆军军医大学第二附属医院主治医师,主要从事肝胆疾病临床方面的研究。

基金项目:

重庆市科卫联合医学科研项目面上基金资助项目(2023MSXM004);中国人民解放军陆军军医大学科技创新能力提升专项基金资助项目(2022XJS20);中国人民解放军陆军军医大学第二附属医院青年博士人才孵化计划基金资助项目(2022YQB031)。


A case report on laparoscopic anatomical liver segment Ⅶ resection with ICG fluorescence-guided puncture positive staining (with video)
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Department of Hepatobiliary Surgery, the Second Affifiliated Hospital of Army Medical University, PLA, Chongqing 400037, China

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    摘要:

    背景与目的 腹腔镜解剖性肝切除术已成为肝后叶Ⅶ段(S7)占位性病变的主要手术方式。然而,受限于S7肝蒂复杂解剖结构,在肝表面可有缺血线,而在肝实质内缺乏有效引导。鉴于此,笔者团队采用吲哚菁绿(ICG)荧光穿刺正染技术实施腹腔镜解剖性肝S7切除术。本文对此做一汇报。方法 回顾性分析中国人民解放军陆军军医大学第二附属医院肝胆外科采用ICG荧光穿刺正染技术行腹腔镜解剖性肝S7切除术的1例患者临床资料。结果 按照术前三维重建模拟成功获得肝S7 ICG荧光染色区域后采取足侧入路方式行解剖性肝S7切除,术中循荧光边界及右肝静脉断肝,过程中先后离断S7门静脉(P7)及右肝静脉S7各属支。患者术后恢复良好,术后1个月复查腹部超声见肝S7已切除,未见肿瘤复发征象。结论 ICG荧光穿刺正染技术对腹腔镜解剖性肝S7切除术起到良好的辅助指引作用,可提高手术安全性和保证肿瘤R0切缘。

    Abstract:

    Background and Aims Laparoscopic anatomical liver resection has become the main surgical approach for space-occupying lesions located in segment Ⅶ (S7) of the posterior lobe of the liver. However, due to the complex anatomical structure of the S7 hepatic pedicle, there may be ischemic lines on the liver surface, but a lack of effective guidance within the liver parenchyma. Given this, our team adopted indocyanine green (ICG) fluorescence-guided puncture positive staining technique for laparoscopic anatomical liver S7 resection. This paper reports on this technique.Methods The clinical data of one patient who underwent laparoscopic anatomical liver S7 resection using the ICG fluorescence-guided puncture positive staining technique in the Department of Hepatobiliary Surgery, Second Affiliated Hospital of Army Medical University were retrospectively analyzed.Results Following successful preoperative 3D reconstruction simulation to obtain the ICG fluorescent staining region of liver S7, an anatomical liver S7 resection was performed using a caudal approach. During surgery, the liver was transected along the fluorescent boundary and the right hepatic vein, with sequential division of the S7 portal vein (P7) and tributaries of the right hepatic vein from S7. The patient recovered well after surgery, and one month later, an abdominal ultrasound review showed that liver S7 had been resected with no signs of tumor recurrence.Conclusion The ICG fluorescence-guided puncture positive staining technique provides excellent assistance in laparoscopic anatomical liver S7 resection, improving surgical safety and ensuring R0 resection margins.

    图1 术前MRI影像资料 A:肝右后叶结节,增强扫描动脉期不均匀强化;B:门静脉期强化减低;C:延迟期强化减低;D:肝胆期呈低信号Fig.1 Preoperative MRI imaging data A: Nodular mass in the right posterior hepatic lobe, with uneven enhancement in the arterial phase on contrast-enhanced scan; B: Reduced enhancement in the portal venous phase; C: Decreased enhancement in the delayed phase; D: Low signal in the hepatobiliary phase
    图2 术前三维重建影像资料 A:肿瘤位于肝S7;B:门静脉右后支发出P7供应S7;C:出肝血流为肝右静脉属支;D:术前规划显示向S7门静脉进行穿刺并注射ICG的位置Fig.2 Preoperative 3D reconstruction imaging data A: The tumor mass located in the liver S7; B: The right posterior branch of the portal vein gives off P7 to supply S7; C: The outflow from the liver is a tributary of the right hepatic vein; D: Preoperative planning shows the location for puncturing and injecting ICG into the S7 portal vein
    图3 穿刺正染ICG荧光导航腹腔镜解剖性肝S7切除术过程 A:Trocar布局;B:右肝完全游离至下腔静脉旁;C:超声引导下穿刺P7;D:根据ICG荧光染色边界标记预切线;E:沿荧光染色界面断肝;F:肝右静脉;G:肝S7肝蒂G7;H:右肝静脉属支V7;I:完整切除肝S7Fig.3 Surgical process of laparoscopic anatomical liver S7 resection under the guidance of ICG fluorescence positive staining A: Trocar layout; B: Complete dissociation of the right liver to the inferior vena cava; C: Ultrasound guided puncture of P7; D: Marking pre-resection line based on ICG fluorescence staining boundaries; E: Liver transection along the fluorescence-stained interface; F: Right hepatic vein; G: Liver pedicle G7 in the liver S7; H: Hepatic vein tributary V7; I: Complete resection of liver S7
    Fig.
    图4 术后标本及病理图片 A:手术标本整体观;B-C:手术标本剖面观;D:肝右后叶肿物符合中分化肝细胞性肝癌,切缘阴性Fig.4 Postoperative specimens and pathological images A: Overall view of surgical specimen; B-C: Section view of surgical specimen; D: Tumor mass in the right posterior hepatic lobe corresponded to moderately differentiated hepatocellular carcinoma,negative margin of incision
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王峥,尤楠,贺永刚,艾麦提·牙森,郑璐.穿刺正染ICG荧光导航腹腔镜解剖性肝Ⅶ段切除术1例报告(附视频)[J].中国普通外科杂志,2024,33(7):1043-1050.
DOI:10.7659/j. issn.1005-6947.2024.07.003

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  • 收稿日期:2024-01-08
  • 最后修改日期:2024-02-26
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  • 在线发布日期: 2024-08-10