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Case Reports
. 2020 Feb 25;14(1):110-115.
doi: 10.1159/000506361. eCollection Jan-Apr 2020.

Identifying Cystic Vein Perfusion Area Employing Indocyanine Green Fluorescence Imaging During Laparoscopic Extended Cholecystectomy for Clinical T2 Gallbladder Cancer

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Free PMC article
Case Reports

Identifying Cystic Vein Perfusion Area Employing Indocyanine Green Fluorescence Imaging During Laparoscopic Extended Cholecystectomy for Clinical T2 Gallbladder Cancer

Akira Umemura et al. Case Rep Gastroenterol. .
Free PMC article

Abstract

We present an original surgical technique for identifying the perfusion area of the cystic vein with indocyanine green (ICG) fluorescence imaging and laparoscopic extended cholecystectomy with lymphadenectomy for a 56-year-old woman with diagnosis of clinical T2 gallbladder cancer (GBC). First, we encircled Calot's triangle using the Glissonean approach from the ventral side of the gallbladder plate and then taped the hilar Glissonean pedicles; these were temporally clamped, and ICG was injected into the vein. The perfusion area of the cystic vein was scrutinized, specifically the stained area of the hepatic parenchyma was marked, and extended cholecystectomy was performed along the resection line. Subsequently, we performed lymphadenectomy of the hepatoduodenal ligament to complete the operation. A postoperative histopathological examination revealed moderately differentiated adenocarcinoma with pathological T1bN0M0. Although extended cholecystectomy is currently recommended for clinical T2 GBC, there is no consensus on the definition of the gallbladder bed, and the ideal extent of hepatic resection has, therefore, not yet been determined. In addition, gallbladder bed resection with 2-3 cm of surgical margin is an empirical procedure that lacks scientific verification. Regarding anatomical features, the cystic vein sometimes drains directly into the anterior branch of the portal vein, penetrating the gallbladder plate and Laennec's capsule of the anterior Glissonean pedicle. To address this background, we have developed a technique to identify the perfusion area of the cystic vein to determine the extent of hepatic parenchyma that should be resected during laparoscopic extended cholecystectomy for clinical T2 GBC.

Keywords: Extended cholecystectomy; Gallbladder bed resection; Gallbladder cancer; Indocyanine green fluorescence; Laparoscopic hepatectomy.

Conflict of interest statement

The authors declare no financial conflicts of interest.

Figures

Fig. 1
Fig. 1
a, b Contrast-enhanced computed tomography revealed a right renal tumor and gallbladder tumor of the neck. The enhanced gallbladder tumor did not invade into the hepatic parenchyma (arrow). c, d Magnetic resonance imaging of T2-weighted image revealed a clearly capsulized renal tumor of the right kidney, and magnetic resonance cholangiopancreatography also revealed the defect of the gallbladder neck (arrow).
Fig. 2
Fig. 2
Operative procedure. a The hilar Glissonean pedicle was taped to clamp the inflow from the proper hepatic artery without cystic artery flow. b Under ICG mode, the stained area of the hepatic parenchyma was marked by electrocautery to identify the perfusion area of the cystic vein. c Extended cholecystectomy was performed along the demarcation line. d We performed lymphadenectomy of the hepatoduodenal ligament. ICG, indocyanine green.
Fig. 3
Fig. 3
a, b This patient was a living donor for liver transplantation. The stained area of this patient was dominant in S4a. c, d This patient was also a living donor for liver transplantation. The cystic vein of this patient covered the broad perfusion area from S4a to S5.

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