Super-selective intra-arterial hepatic injection of indocyanine green (ICG) for fluorescence image-guided segmental positive staining: preliminary data

Introduction: Intraoperative liver segmentation can be obtained by means of percutaneous intra-portal injection of a fluorophore and illumination with a near-infrared light source. However, the percutaneous approach is challenging in the minimally invasive setting. We aimed to evaluate the feasibility of fluorescence liver segmentation by super-selective intra-hepatic arterial injection of indocyanine green (ICG). Method: This was a IRB proven prospective study. The Patients with hepatocellular carcinoma(HCC) were involved in this study. Procedures were performed in a hybrid operative suite equipped with the Artis Zeego, multiaxis robotic angiography system or in conventional angiography room. The celiac trunk was catheterized, and a microcatheter was advanced into segmental hepatic artery branch which supply the HCC, then the ICG was injected into super-selective hepatic artery. Five laparoscopic ports were introduced as normal laparoscopic hepatectomy procedure and the pneumoperitoneum (12mmHg) was established. A near-infrared laparoscope was used to detect the fluorescent signal and assess the arterial-based fluorescence demarcation. The tumor was also detected by conventional intraoperative ultrasound and the laparoscopic hepatectomy was performed according to demarcation made by ultrasound. Result: Four patient was enrolled in our study. Two patients had S7 HCC and 2 patients had S3 HCC. The micro-angiocatheter was inserted into feeding vessel successfully. The fluorescence image showed the tumor feeding vessel demarcation including tumor immediately and confirmed by laparoscopic ultrasound. The hepatic segmentectomy was done as conventional method. After procedure , all specimens still showed the fluorescence image. Then he specimens were opened and all HCC were found within resected liver parenchyma with safety margin. No post op mortality and Morbidity were found. Conclusion: Fluorescence selective hepatic artery angiography show clear demarcation including tumor and provide easy method for assessing the resection margin in the laparoscopic hepatectomy even in deep tumor.