Fluorescence-guided laparoscopic resection of liver segment 4 plus the right anterior ventral section for hepatocellular carcinoma adjacent to the left hepatic pedicle and middle hepatic vein: a case report

Introduction

Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third leading cause of cancer-related death worldwide (1). Laparoscopic hepatectomy has become a standard treatment approach for HCC, and has a number advantages, including that it is both safe and minimally invasive (2)—more important better outcome, less complications. Fluorescence-guided laparoscopic hepatectomy is increasingly being applied because of its effectiveness, safety, and lower complication rates (3,4). However, for HCC patients with liver cirrhosis, determining the optimal liver resection volume and ensuring an adequate future liver remnant (FLR) remain a significant challenge (5-7).

In this case, a HCC patient with liver cirrhosis, whose tumor was adjacent to the left hepatic pedicle (LP) and middle hepatic vein (MHV), the challenge of therapy is how to resect tumor while reserve liver function for patient. Correctly evaluating suitable treatment measure and successfully dealing with tumor region to gain optimal oncology benefit. Underwent fluorescence-guided laparoscopic resection of segment 4 (S4) plus the right anterior ventral section of segment 5 and 8 (S5v + S8v) (Video 1). Through meticulous preoperative planning and precise intraoperative fluorescence navigation, we successfully achieved radical tumor resection while maximizing the preservation of the FLR. The perioperative management timeline is shown in Figure 1. We present this article in accordance with the CARE and SUPER reporting checklists (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-650/rc).

Figure 1 The perioperative management timeline. HBV, hepatitis B virus.

Preoperative preparations and requirements

The patient was a 71-year-old male with a history of hepatitis B virus (HBV) infection and was not on antiviral therapy. His liver tumor was discovered incidentally at a local hospital. Upon his admission, comprehensive examinations were performed (Table S1). His laboratory results showed that he was hepatitis B surface antigen (HBsAg)-positive, anti-hepatitis B e antibody (anti-HBe)-positive, anti-hepatitis B core antibody (anti-HBc)-positive, hepatitis B e antigen (HBeAg)-negative, hepatitis B core antigen (HBcAg)-negative, and had an HBV-DNA level of 50 IU/mL. His alpha-fetoprotein (AFP) level was elevated at 7.50 ng/mL.

Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) revealed a 24 mm × 24 mm × 23 mm hepatic mass in S4, located near the LP and MHV, with accompanying signs of liver cirrhosis (Figure 2A,2B). MRI and the portal venous phase of enhanced computed tomography (CT) revealed similar findings (Figure 2C-2F). The patient had a Child-Pugh score of Grade A, and an indocyanine green (ICG) retention rate at 15 minutes of 6.3% which was less than 10%. While preoperative biopsy was not performed in this case, clinical diagnosis of HCC was clear supported by elevated serum AFP levels, typical imaging findings from CT and MRI, and patient’s history of liver cirrhosis. The patient was diagnosed with HCC of S4 [classified as China Liver Cancer Staging System (CNLC) stage Ia and Barcelona Clinic Liver Cancer Staging System (BCLC) stage A], chronic HBV infection, and liver cirrhosis.

Figure 2 Representative CT and MRI images of the patient before surgery. (A-D) Gd-EOB-DTPA-enhanced MRI (A,B), MRI T1-weighted sequence (C), and T2-weighted sequence (D) showing that the tumor was located in S4, adjacent to the LP and MHV. (E,F) The portal venous phase of enhanced CT identified a hepatic mass in S4. CT, computed tomography; Gd-EOB-DTPA, gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid; LP, left hepatic pedicle; MHV, middle hepatic vein; MRI, magnetic resonance imaging.

We collected the patient’s imaging data, and performed three-dimensional (3D) liver reconstruction, and a tumor portal venous and hepatic venous territories analysis using YORKTAL digital medical imaging system (Figure 3). The analysis revealed that the tumor predominantly involved S4, and was closely adjacent to the LP and MHV. Using the 3D reconstructed imaging model, we compared and discussed different surgical approaches. For each approach, we evaluated the FLR, and the ratio of the FLR to the standard liver volume (FLR/SLV) (Figure 4). Comparing 4 different strategies: (I) S4 resection; (II) left hepatectomy; (III) extended left hepatectomy (left hepatic lobe + S5v + S8v); (IV) central hepatectomy (S4 + S5 + S8); and (V) S4 + S5v + S8v hepatectomy. To preserve as much of the FLR as possible and considering a MHV infiltration we opted for resection of S4 + S5v + S8v, using the fluorescence-guided laparoscopic technique. The operation was performed at Sun Yat-sen Memorial Hospital. This study was conducted in compliance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Ethics Committee of Sun Yat-sen Memorial Hospital, which granted exemption from obtaining written informed consent for publication of this manuscript, accompanying images and video (approval No. SYSEC-AF-SS11-06.0).

Figure 3 Three-dimensional reconstruction revealed the location of the tumor and the tumor-bearing portal territory. (A) The tumor was located in S4. (B) Tumor-bearing portal territory, including S4, S5v, and S8v. IVC, inferior vena cava; LPV, left portal vein; MHV, middle hepatic vein; MPV, main portal vein; PPA, first branch of the right posterior hepatic pedicle; RAPV, right anterior portal vein; RPV, right portal vein; S4, segment 4; S5v, ventral section of segment 5; S8v, ventral section of segment 8.

Figure 4 Resection of liver segment 4 plus the right anterior ventral section was the ideal treatment according to the predicted FLR and FLR/SLV ratio of different surgical procedures. (A) The predicted FLR of different surgical procedures. (B) The predicted FLR/SLV ratio of different surgical procedures. FLR, future liver remnant; FLR/SLV, future liver remnant/standard liver volume; SLV, standard liver volume; TLV, total liver volume.

Step-by-step description

The patient was positioned supine with his legs apart, head-up, foot-down, right arm raised, and right side elevated. General anesthesia was administered with endotracheal intubation, and low central venous pressure (0–5 cmH₂O) was maintained throughout the liver transection.

A five-port trocar technique was used (Figure 5). Intraoperative exploration revealed moderate micronodular cirrhosis. Intraoperative ultrasound identified a 3.5 cm × 2 cm lesion in S4, located near the MHV and the main trunk of the LP, with no evidence of metastasis.

Figure 5 Diagram of trocar distribution for fluorescence-guided laparoscopic hepatectomy. The scope was located below the umbilicus. Assistant 1 was located below the xiphoid process. Assistant 2 was located 2 cm left of the midpoint between the xiphoid process and umbilicus. Operator 2 was located at the crossing point between the right midaxillary line and the penultimate intercostal space. Operator 1 was located 1 cm down to the right of the crossing point between Operator 2 and the umbilicus.

A urinary catheter was used for hilar clamping. The falciform ligament and surrounding ligaments were separated to access the second hepatic hilum. Intraoperative ultrasound was used to locate the MHV and umbilical fissure vein (UFV). The round ligament was deliberately preserved.

Using the Laennec membrane as a guide, the plane between the hepatic pedicle and liver parenchyma was identified. Next, the LP, right anterior hepatic pedicle (RAHP), and the first branch of the right posterior hepatic pedicle (PPA) were dissected (Figure 6A,6B).

Figure 6 Representative intraoperative images. (A) The hilar plate was lowered. (B) After lowering the hilar plate, the roots of the LP, RAHP, and PPA were exposed. (C-E) The ventral branches of the AP, including any unexpected branches that required ligation, were dissected. (F) The liver transection was performed along the left side of the falciform ligament and the UFV. (G) The branches supplying S4 were ligated. (H,I) Using ICG tumor staining, the tumor was revealed, which had an intact capsule. (J) The tumor was completely exposed, and all vessels entering the tumor were ligated. (K,L) The S5v branches of the PPA, including any unexpected branches that required ligation, were dissected. (M-O) The liver was transected along the fluorescent margins (M, caudal side; N, dorsal hepatic plane; O, cranial side). (P) The liver segments and ductal structures on the postoperative liver surface were preserved. AP, right anterior hepatic pedicle; LP, left hepatic pedicle; PPA, the first branch of the right posterior hepatic pedicle; S5d, dorsal section of segment 5; S5v, ventral section of segment 5; S8d, dorsal section of segment 8; UFV, umbilical fissure vein.

According to the 3D reconstruction results, three ventral branches of the AP including ventral Glissonean pedicles of segment 5 and segment 8 (G5v and G8v) were separated and ligated. Additional small branches were also ligated (Figure 6C-6E). Due to the numerous branches of the LP and to minimize potential tumor capsule damage during transection, the left transection plane was located using the liver parenchyma approach with the UFV serving as a guide (Figure 6F). During this process, the branches supplying S4 were ligated. We subsequently reached the LP trunk and identified the tumor with complete capsule according to the ICG tumor staining (residual ICG from the preoperative liver functional reserve test). Liver tissue was divided along the right edge of the umbilical vein toward the second hepatic pedicle. The tumor was carefully dissected from the LP with blunt forceps, during which vascular branches entering the tumor were encountered and divided. The tumor was separated from the LP carefully (Figure 6G-6J). We then transected the liver parenchyma along the right margin of the UFV until reaching the second hepatic hilum, where the MHV was separated and ligated at its root.

Based on the portal venous and hepatic venous territories and 3D reconstruction model, additional branches from the PPA supplying S5v were also ligated (Figure 6K,6L). These branches were reached by transecting the liver parenchyma.

Subsequently, all the planned hepatic inflow blood vessels to the targeted territories were ligated. Next, 4 mL of the prepared ICG (0.25 mg/mL) was injected intravenously (8). The ICG-negative staining delineated the right and dorsal transection planes (Figure 6M-6O). The transection planes were further transected along the green fluorescence boundary (Figure 6P). Finally, the sub-umbilical observation port was extended by approximately 5 cm for specimen removal (Figure 7).

Figure 7 Gross specimen image of liver tissue excised and the 3D reconstruction model. (A,B) The resected liver matched the tumor-bearing portal territory planned for surgery, which was delineated with a red line. (C) Gross examination of the specimen revealed an intact tumor capsule. 3D, three-dimensional; IVC, inferior vena cava; MHV, middle hepatic vein; S4, segment 4; S5v, ventral section of segment 5; S8v, ventral section of segment 8.

Postoperative considerations and tasks

The surgery lasted 360 minutes, and the intraoperative blood loss was 300 mL. The Pringle maneuver was performed nine times, with each cycle lasting 15–25 minutes, followed by a 5-minute release. Postoperative parameters were monitored closely (Figure 8). Based on enhanced recovery after surgery principles (9), the patient was encouraged to mobilize from day 1 and nutritional infusions were discontinued. The drainage tubes which were placed to reduce the severity of postoperative complications such as biliary fistula, ascites, and intra-abdominal bleeding were removed on postoperative day 6, and the patient was discharged on postoperative day 7. No major postoperative complications occurred. In this case, the postoperative performance status of patient was Eastern Cooperative Oncology Group performance status (ECOG PS) 0, which was identical to the preoperative status. The perioperative trends in tumor markers and specific liver function metrics are summarized in Figure 8. Preoperative and postoperative abdominal CT images were obtained for comparison (Figure 9).

Figure 8 The changing of some important test indicators (from 3 days pre-operation to 2 months post-operation). (A) AFP decreased following treatment. (B) TBIL increased slightly after surgery and decreased rapidly after treatment. (C,D) ALT and AST decreased rapidly after treatment. (E) PT increased slightly after surgery but returned to normal levels before discharge. (F) ALB gradually increased to a nearly normal level after discharge. (G) PIVKA-II remained at a normal level during treatment. AFP, alpha-fetoprotein; ALB, albumin; ALT, alanine transaminase; AST, aspartate transaminase; PIVKA-II, protein induced by vitamin K absence or antagonist-II; PT, prothrombin time; TBIL, total bilirubin.

Figure 9 Preoperative and postoperative abdominal CT comparison. (A) Preoperative CT showed that the tumor was located in S4. (B) Postoperative CT showed that the left hepatic lobe was enlarged, with partial localized postoperative absence of the right hepatic lobe and the formation of a residual cavity in the surgical area. CT, computed tomography.

Histopathological examination demonstrated that the tumor was encapsulated by an intact fibrous capsule, with no evidence of capsular breakthrough or extracapsular extension into the surrounding hepatic parenchyma. The lesion was identified as a moderately to well-differentiated HCC, corresponding to Edmondson-Steiner grade II (Figure 10). Surgical margins were negative, with a minimum clearance of 5 mm, and there was no evidence of perineural or microvascular invasion. The non-tumorous liver parenchyma adjacent to the lesion showed features of nodular cirrhosis.

Figure 10 Pathological pictures of excised liver tissue. (A) Pathological overview of HCC with 40 times magnification. (B) The pathological results with 40 times magnification indicated that the resected hepatic tumor exhibited glandular and trabecular growth patterns. (C) Pathological of HCC with 100 times magnification exhibited polygonal cells, an abundant eosinophilic cytoplasm, coarse nuclear chromatin, and prominent nucleoli. Hematoxylin erosin staining was performed for tumor sample slides. HCC, hepatocellular carcinoma.

Following his discharge, the patient continued lifelong anti-HBV treatment using tenofovir alafenamide fumarate. Lenvatinib therapy was initiated one month after surgery as an adjunctive treatment to reduce the risk of recurrence. At 10 months, the patient is fine with no signs of tumor recurrence.

Tips and pearls

In this case, the liver tumor of the patient was located in S4 adjacent to the LP and MHV. Before surgery, we first evaluated the tumor location using a 3D reconstruction model. In performing the surgery, we had to balance the extent of the hepatectomy against the extent of the FLR. Detailed surgical plans were compared, and we ultimately chose to perform a laparoscopic resection of S4 plus the right anterior ventral section to optimize the FLR and maximize the oncological radicality.

During the surgical process, the laparoscopic technique exposed the anatomical structure clearly. The correct identification of anatomical markers helped to ensure successful and safe liver resection. For example, the left transection plane was located using the UFV as a guide. Additionally, the use of ICG staining provided a clear resection margin that increased the precision of the hepatectomy. The transection planes followed he green fluorescence boundary.

In summary, fluorescence-guided laparoscopic resection of S4 plus the right anterior ventral section was suitable for our patient whose tumor was located in S4, adjacent to the LP and MHV. Sufficient preoperative preparation and the comprehensive application of the intraoperative navigation equipment enabled a successful surgery.

Discussion

For patients with cirrhosis, aiming for a parenchyma sparing resection seems valuable to reduce morbidity and mortality, even if the FLR is above 40%, it may still be insufficient after an anatomic resection (10) resulting in liver failure or prolonged compensated insufficiency. Furthermore, the ability of the liver to withstand external stimuli and medications (e.g., tyrosine kinase inhibitor therapy) diminishes, increasing the risk of liver failure in patients on adjuvant therapy. Thus, preserving the FLR to the greatest extent possible is crucial in improving postoperative outcome, liver function, and ultimately improving the quality of life of patients. An integrated multidisciplinary approach is needed to manage such patients (11).

In this case, the patient had the HBV infection for many years and signs of cirrhosis were seen on CT and MRI images. 3D reconstruction revealed more than one option for resection of a tumor in a difficult location.

In our case, both ablation and transarterial chemoembolization (TACE) were considered but not deemed appropriate. As ablation has been reported to be an ideal treatment for single small HCC, especially for those with BCLC stage A (12). The tumor was solitary but located adjacent to the LP, making ablation technically unsafe due to the risk of incomplete treatment from the heat-sink effect and potential biliary injury (13). TACE, on the other hand, is primarily indicated for patients with unresectable or multinodular disease (BCLC stage B), whereas our patient had a resectable solitary tumor and preserved liver function (14). Further more, it can sometimes increase injury to the liver and biliary system (15). Furthermore, TACE and other neoadjuvant treatment might have complicated any subsequent surgical resection due to local inflammation and adhesion between vessels and tumor region (16,17). Liver transplantation and robotic liver resection were other suitable treatments for HCC patients with cirrhosis, but they were not considered in this case, mainly due to the patient’s advanced age and economic constraints (18,19). Therefore, anatomical resection was considered the most suitable treatment to achieve complete tumor removal and optimize long-term outcomes.

Hepatectomy is suitable for HCC patients with a single tumor and preserved liver function, and thus was suitable for the patient in the present case (12). Zhu et al. performed a prospective cohort study of HCC patients with BCLC stage A, and found that laparoscopic and robotic hepatectomy were more effective and safer than open hepatectomy (20). Anterolateral laparoscopic liver resections were more advantageous compared to open in terms of less complications and length of stay (21). In relation to our patient, fluorescence-guided laparoscopic hepatectomy provided a clearer view of liver, reducing the trauma and decreasing the risk of postoperative complications, such as refractory ascites and liver failure (22).

To ensure optimal tumor eradication while preserving as much of the FLR as possible, we compared various surgical strategies (Figure 4). The laparoscopic resection of S4 plus the right anterior ventral section provided the patient with a radical resection of the tumor while preserving the FLR to the greatest extent possible (the FLR was 893 mL while the FLR/SLV ratio was 50%). An inadequate FLR is an important indicator of post-hepatectomy liver failure, and is related to higher morbidity and mortality (23,24). Conversely, the optimal remaining of the FLR can improve the liver volume recovery rate after surgery and the overall survival of patients (25,26). Based on these considerations, we made a personalized treatment plan for our patient, and ultimately performed S4 + S5v + S8v resection.

Additionally, during the surgery ICG staining was used to accurately guide our navigation of the portal venous and hepatic venous territories (27,28). There are two types of ICG staining (i.e., positive and negative staining) (8). For positive staining, ICG is injected into the portal vein branches responsible for the targeted excision liver segment under ultrasound guidance. Liu et al. successfully conducted laparoscopic anatomic hepatectomy 4 with MHV invasion using ICG fluorescence positive staining (29). However, it would have been difficult to reach numerous segmental portal vein branches in our case, interventional operations might damage the tumor or other vessels. We thus chose negative staining. We delineated the anatomical boundaries by injecting ICG into the peripheral vein. This helped us to clearly visualize the S4 + S5v + S8v territories, and thus finish the tumor excision easily and precisely. In our institution, 3D reconstruction is provided free of charge, and the cost of a single vial of ICG is low, resulting in minimal additional economic burden for patients. Importantly, ICG is considered a safe agent and ICG fluorescence navigation as a simple and safe intraoperative tool (30-32).

The present case underscores the clinical significance of integrating advanced imaging techniques with minimally invasive liver surgery, providing insights into both the feasibility and potential benefits of this approach in complex HCC management. In this case, the tumor was located adjacent to the LP and MHV, raising concern about achieving an adequate margin especially when we considered a relatively narrow rather than wide surgical margin which may bring higher risk of recurrence. At the same time, we attached great importance to enough FLR which could bring better living quality for our patient, so as to support patient for the next step of treatment. Our surgical plan was conducted under comprehensive consideration. In addition, the intraoperative video with step-by-step annotations provides a visual demonstration that may be particularly useful for surgeons in training. It worth mentioned that addition of ICG fluorescence guidance does not appear to significantly increase operative risk or complexity once the surgeon is already proficient with standard laparoscopic techniques (33). Therefore, we believe that while there may be a short adjustment period for surgeons new to ICG navigation, this does not translate into a substantial additional learning curve beyond that associated with mastering laparoscopic liver surgery itself (34,35).

There are some limitations of this case. Firstly, this is single case report without control group therefore cannot provide generalizable conclusions. Secondly, 10-month follow up is is short. Our aim was to highlight the technical feasibility and educational value of combining 3D planning and ICG fluorescence guidance in a highly challenging clinical scenario. This case report aims to illustrate our surgical philosophy and demonstrate the successful outcome of an individual case, thereby providing other surgeons with insights into a function-preserving surgical approach for HCC. Comparative studies with more samples are needed to further investigate the clinical significance of combining radical resection with a function-preserving surgical strategy.

In this case, we performed a suitable surgical procedure for an HCC patient with severe liver cirrhosis. We removed his tumor while preserving his FLR to the greatest extent possible to improve his quality of life. The application of a 3D construction model helped us to design a suitable surgical plan, while ICG staining provided us with a clear incision margin, which helped us to perform the laparoscopic hepatectomy precisely and safely. Our integrated approach resulted in considerable improvements in the patient. Our experience may inform our peers who have to make similar treatment decisions.

Conclusions

ICG guided minimally invasive Hepatectomy can be safely done even in difficult cases for HCC in cirrhosis after sufficient preop planning aiming at parenchyma sparing resections. More comparative studies with more samples are needed to further validate our surgical philosophy.

Acknowledgments

We would like to thank BioRender.com for the creation of the schematic illustration (Figure 5).

Footnote

Reporting Checklist: The authors have completed the CARE and SUPER reporting checklists. Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-650/rc

Peer Review File: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-650/prf

Funding: This research was funded by the National Natural Science Foundation of China (No. 82103090), and the Guangdong Basic and Applied Basic Research Foundation (Nos. 2023A1515010745 and 2023A1515220131).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-650/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in compliance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Ethics Committee of Sun Yat-sen Memorial Hospital, which granted exemption from obtaining written informed consent for publication of this manuscript, accompanying images and video (approval No. SYSEC-AF-SS11-06.0).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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