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Correspondence |

Positive and Negative Staining of Hepatic Segments by Use of Fluorescent Imaging Techniques During Laparoscopic Hepatectomy

Takeaki Ishizawa, MD, PhD; Noah B. Zuker, MD; Norihiro Kokudo, MD, PhD; Brice Gayet, MD, PhD
Arch Surg. 2012;147(4):393-394. doi:10.1001/archsurg.2012.59.
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Anatomic hepatic segmentectomy1 plays an important role in the modern treatment of malignant disease. Segmentectomy maximizes postoperative hepatic functional reserve without compromising oncologic principles.2 This approach is particularly appropriate for a hepatocellular carcinoma segmental resection and may also be useful for other indications, such as a segmental resection for colorectal metastases and other hepatic tumors. The classic hepatic segment identification technique involves puncture of a segmental portal branch under the guidance of intraoperative ultrasonography. Vital blue dye is injected after temporarily clamping the hepatic artery to avoid dye washout from the segment.1 This staining technique is simple and useful for open surgery; however, it is much more difficult to reproduce these procedures laparoscopically and to confirm demarcation of the hepatic segment visually on the monitor. This problem may reduce the accuracy and frequency of anatomic segmentectomy using a laparoscopic blue dye approach.3 Recently, we have developed a laparoscopic fluorescent imaging system that allows visualization of indocyanine green (ICG) fluorescence to identify the biliary tract4 and liver cancers5 intraoperatively. Herein, we report our initial experience of applying this system to the visualization of hepatic segments during laparoscopic surgery, by injecting ICG dye into the segmental portal branch6 (positive staining) or by intravenously administering ICG dye after clamping the segmental portal pedicle (negative staining).

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Figure. Positive-staining (A) and negative-staining (B) techniques of hepatic segments using indocyanine green (ICG) fluorescent imaging during laparoscopic hepatectomy. A, Despite the thick connective tissue (due to a previous hepatectomy [right]) around the liver surface, fluorescent imaging (right) clearly delineates demarcation between segment IV (with fluorescence of ICG dye) and its surrounding nonfluorescent segments (). B, Fluorescent imaging (right) clearly enables visualization of the demarcation between segment II (with portal uptake of ICG dye) and segment III (with ischemia after closure of the segmental portal branch). The normal color image shows minimal difference ([left]; ).

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