荧光腹腔镜中央肝切除术使用吲哚菁绿阴性染色治疗肝癌
1Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital,Sun Yat-sen University, 2Department of Hepatobiliary Surgery,Foshan Fosun Chancheng Hospital, 3Department of Gastrointestinal Surgery,The Eighth Affiliated Hospital of Sun Yat-sen University, 4Department of Hepatobiliary Surgery,The Second Affiliated Hospital of Guangzhou Medical University
Summary
本方案描述了腹腔镜中央肝切除术中的荧光阴性染色。这种技术可以使肝切除术更加准确和精确。
Abstract
腹腔镜肝切除术是肝癌的重要治疗方法。过去，切除边界通常由术中超声、重要的血管结构和外科医生的经验来确定。随着解剖肝切除术的发展，视觉外科技术已逐渐应用于此类手术，特别是吲哚菁绿（ICG）引导的解剖肝切除术。由于ICG可以被肝细胞特异性摄取并用于荧光示踪，因此已根据不同的肿瘤位置应用了阴性染色技术。在ICG荧光引导下，肝切除时可以更准确地显示表面边界和深切平面。因此，可以在解剖学上切除荷瘤肝段，这有助于避免对重要血管的损害，并减少剩余肝组织的缺血或充血。最后，术后胆瘘和肝功能障碍的发生率降低;因此，肝癌切除后可获得更好的预后。位于中央的肝癌通常被定义为位于第 4、5 或 8 节的肿瘤，需要切除肝脏的中间部分。这些是最难进行的肝切除术之一，因为手术伤口很大，而且有多个血管横断。根据具体的肿瘤位置，我们通过设计个性化的荧光染色策略来制定所需的切除范围。通过完成基于门静脉区域的解剖切除术，本工作旨在达到最佳的治疗效果。
Introduction
中央肝切除术是用于治疗位于第 4、5 和 8 节的肝脏恶性肿瘤的主要手术方法 1,2。标准中央肝切除术需要完全切除这些节段，这需要暴露矢状部分、中肝静脉 （MHV） 和右肝静脉 （RHV）3。第 4、5 和 8 段属于中央肝切除术2 的类别。
随着精准肝脏手术的进步，解剖肝切除术发展迅速。然而，准确确定肝切除切除平面的方法是一个关键点和不确定的领域。通常，根据缺血区4结扎Glisson椎弓根以划定表面边界。为了控制深平面，在横断术期间，通常在术中超声引导下使用解剖标志，包括肝静脉和门静脉分支 5。Makuuchi的方法通过在超声引导下将亚甲蓝注射到门静脉中来显示切除边缘，在取出标本后在肝切除平面上暴露重要的肝静脉5,6,7。
由于肝细胞特异性吸收吲哚菁绿 （ICG），因此其荧光清楚地显示了切除边界。青木于 2008 年首次报道了由 ICG 荧光引导的解剖肝切除术8.ICG荧光染色方法可分为阳性染色和阴性染色9。阴性染色技术在夹紧节段门静脉蒂10 后通过静脉注射 ICG 进行。然后，残余的肝脏显示荧光，但门静脉区域没有。与传统方法相比，荧光导航下的解剖肝切除术不仅可以在肝脏表面显示切除边界，还可以引导深切平面。对于半肝切除术和节段性肝切除术，建议采用阴性染色技术。迄今为止，使用荧光导航的解剖肝切除术已成为肝脏手术的流行方法11,12。本文介绍了荧光腹腔镜中央肝切除术的阴性染色技术。术前通过Child-Pugh评分系统对患者进行分类，并据此选择A级评分的患者13。
Protocol
本协议遵循中山大学中山纪念医院人体研究伦理委员会的指导方针。从患者那里获得了进行这项研究的书面知情同意书。 1. 患者选择 选择肝脏中部恶性肿瘤患者，包括肝细胞癌 （HCC） 和肝内胆管癌 （ICC） 患者。 确保这些患者没有门静脉或肝静脉受侵犯，也没有远处转移。 2. 患者准备 注…
Representative Results
2020-2022年，6例肝癌患者行荧光腹腔镜中央肝切除术。其中，4例患者接受了第4、5和8段的切除术，2例患者仅接受了第5段和第8段的切除术（表1）。没有患者转为开放手术。他们的年龄从46岁到74岁不等。肿瘤大小从 5 到 9 厘米不等。中位手术时间为 240 min，术中中位失血量为 450 mL。术后中位住院时间为7天。所有患者仍在随访中。 <im…
Discussion
解剖学肝切除术基于门静脉区域，其对肝癌的治疗效果仍在探索中。其理论依据是，肝癌沿门静脉扩散是其复发和转移的主要原因18。在20世纪，幕内首次提出解剖肝切除术，从最初的开放门静脉穿刺用亚甲蓝染色，揭示标志性的肝静脉，并已发展到目前的门静脉和腹腔镜荧光导航的术前分析5,6,7。ICG被公认为…
Disclosures
The authors have nothing to disclose.
Acknowledgements
本研究获得国家自然科学基金（第81702406号）和广东省自然科学基金（2016A030310207）资助。
Materials
| BK Flex Focus 800 | BK Medical | 8666-RF | Intraoperative ultrasound |
| Entecavir | Bristol Myers Squibb | H20052237 | Antiviral drugs |
| Hakko Sonoguide PTC Needle | Hakko-medical | PTC-B 18G/20G | Portal vein puncture |
| Indocyanine green | Dandong Yichuang Pharmaceutical | 0902007 GH102 | Fluorescent dye |
| PINPOINT Endoscopic Fluorescence Imaging System | Stryker | PC9000 | Fluorescent laparoscope |
| Tenofovir | GILEAD | H20180060 | Antiviral drugs |
| Trocar | Ethicon Endo-Surgery | B5LT/B12LT | Trocar |
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Cite This Article
Wei, J., Zhang, H., Zhong, J., Xie, J., Yang, W., Duan, J., Zhuo, W., Li, A., Shang, C., Min, J. Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining. J. Vis. Exp. (193), e64869, doi:10.3791/64869 (2023).