How to Perform Laparoscopic Right Posterior Sectionectomy when the Right Intersectional Plane is not Always Flat

The right hepatic vein (RHV) is a crucial anatomical landmark, usually fully exposed during laparoscopic right posterior sectionectomy (LRPS).¹ However, a discrepancy between the theoretical RHV-oriented plane and the actual right intersectional plane based on portal territory has been frequently observed in clinical practice.^2-4 The potential reason for this discrepancy is branches of the Segment VI portal vein run on the ventral side of the RHV (Ventral-P6).⁵ The complexity of the procedure lies in the precise determination of the intrahepatic transection plane. Our center attempted to employ indocyanine green (ICG) fluorescence imaging combined with augmented reality navigation (ARN) to address the challenge.

A 51-year-old male was diagnosed with hepatocellular carcinoma in the right posterior section. Three-dimensional (3D) analysis indicated that Segment 6 extended over the ventral side of the RHV, and Segment 8 extended over the dorsal side of the RHV, which leads to the right intersectional plane being irregular and curved. Following the blockage of the right posterior Glissonean pedicle (RPGP) guided by ARN, ICG negative staining was performed. The fluorescent boundaries demonstrated concordance with the preoperative 3D model. The intrahepatic transection plane was guided by fluorescence imaging navigation combined with the identification of hepatic veins through ARN.

The total operative time was 415 min with blood loss of 100 ml. The patient did not experience complications.

The utilization of ICG fluorescence imaging combined with ARN for LRPS in cases with irregular right intersectional planes has proven safe and feasible.