Takashi Mizuno1,2, Rahul Sheth3, Masakazu Yamamoto4, Hyun Seon C Kang5, Suguru Yamashita1, Thomas A Aloia1, Yun Shin Chun1, Jeffrey E Lee1, Jean-Nicolas Vauthey1, C Conrad6,7. 1. Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. 2. Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan. 3. Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. 4. Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan. 5. Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. 6. Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. cconrad1@mdanderson.org. 7. Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. cconrad1@mdanderson.org.
Abstract
BACKGROUND: The portal pedicles are wrapped in connective tissue known as the Walaeus sheath, which abut Laennec's capsule covering the liver parenchyma. Precise knowledge of this anatomic relationship allows for dissection of this interspace and early control of the segmental portal pedicle (Glissonean pedicle transection method [GPTM], Takasaki approach). 1,2 Subsequent systemic administration of indocyanine green (ICG) leads to negative counterstaining of the segment to be resected. PATIENT: The patient was a 60-year-old healthy woman with invasive lobular breast cancer, grade 2, which was estrogen receptor-positive (ER +), progesterone receptor-positive (PR +), human epidermal growth factor-negative (HER2-), Ki-67 80%, and cT2N0M1. A synchronous solitary liver metastasis between segments 6 and 7 was diagnosed. After treatment with letrozole and palbociclib for 1 year had achieved stable disease, the patient was considered for liver metastasectomy. 3,4 METHODS: After an intraoperative ultrasound, the patient was placed in the French position, 5 and the gallbladder was disconnected from the cystic duct for exposure of the hepatoduodenal ligament. The hilar plate was lowered, and the portal pedicle of segment 6 was dissected out using the GPTM approach. After test-clamping, an appropriate demarcation was observed, and ICG was administered systemically. This led to negative counterstaining of segment 6 and allowed for precise anatomic dissection under near-infrared vision. CONCLUSIONS: Laparoscopic application of GPTM facilitates anatomically precise liver resection through early pedicle control. Negative counterstaining using ICG under near-infrared vision leads to visual enhancement of the anatomically precise borders. They typically do not follow straight lines and are therefore difficult to dissect precisely. Counterstaining with ICG shows patient-specific anatomic variations that would be a challenge to determine, especially laparoscopically.
BACKGROUND: The portal pedicles are wrapped in connective tissue known as the Walaeus sheath, which abut Laennec's capsule covering the liver parenchyma. Precise knowledge of this anatomic relationship allows for dissection of this interspace and early control of the segmental portal pedicle (Glissonean pedicle transection method [GPTM], Takasaki approach). 1,2 Subsequent systemic administration of indocyanine green (ICG) leads to negative counterstaining of the segment to be resected. PATIENT: The patient was a 60-year-old healthy woman with invasive lobular breast cancer, grade 2, which was estrogen receptor-positive (ER +), progesterone receptor-positive (PR +), human epidermal growth factor-negative (HER2-), Ki-67 80%, and cT2N0M1. A synchronous solitary liver metastasis between segments 6 and 7 was diagnosed. After treatment with letrozole and palbociclib for 1 year had achieved stable disease, the patient was considered for liver metastasectomy. 3,4 METHODS: After an intraoperative ultrasound, the patient was placed in the French position, 5 and the gallbladder was disconnected from the cystic duct for exposure of the hepatoduodenal ligament. The hilar plate was lowered, and the portal pedicle of segment 6 was dissected out using the GPTM approach. After test-clamping, an appropriate demarcation was observed, and ICG was administered systemically. This led to negative counterstaining of segment 6 and allowed for precise anatomic dissection under near-infrared vision. CONCLUSIONS: Laparoscopic application of GPTM facilitates anatomically precise liver resection through early pedicle control. Negative counterstaining using ICG under near-infrared vision leads to visual enhancement of the anatomically precise borders. They typically do not follow straight lines and are therefore difficult to dissect precisely. Counterstaining with ICG shows patient-specific anatomic variations that would be a challenge to determine, especially laparoscopically.
Authors: Demetrios Moris; Amir A Rahnemai-Azar; Diamantis I Tsilimigras; Ioannis Ntanasis-Stathopoulos; Hugo P Marques; Eleftherios Spartalis; Evangelos Felekouras; Timothy M Pawlik Journal: J Gastrointest Surg Date: 2017-11-03 Impact factor: 3.452
Authors: Jordan M Cloyd; Takashi Mizuno; Yoshikuni Kawaguchi; Heather A Lillemoe; Georgios Karagkounis; Kiyohiko Omichi; Yun Shin Chun; Claudius Conrad; Ching-Wei D Tzeng; Bruno C Odisio; Steven Y Huang; Marshall Hicks; Steven H Wei; Thomas A Aloia; Jean-Nicolas Vauthey Journal: Ann Surg Date: 2020-04 Impact factor: 13.787