VIII 段的微创切除在技术上是一项具有挑战性的手术，当切除扩展到 IV 段和/或 VII 段时，难度更大。保留实质切除术经常用于治疗肝转移，但存在 R1 切除的风险，特别是采用微创方法。术前3D重建手术计划和术中肝静脉引导有助于腹腔镜肿瘤性肝切除术。1-3患者和方法：我们介绍了一名58岁女性的病例，她患有三处异时性肛门表皮样癌肝转移。停止化疗后6个月病情稳定。转移瘤主要位于第 VIII 节（其中有一个较大的第 VIII 节背侧），但也位于第 IV 和 VII 节的 glissonian 蒂区域。手术前，三维 (3D) 重建显示段切除术 VIII 不足以具有安全裕度，并显示了转移灶和肝静脉之间的关系。用超声波解剖器进行肝脏横切。通过使用超声装置的非活动刀片从静脉轻轻拉动肝组织来暴露肝静脉。超声波能量的激活仅用于封闭和分割小侧支静脉。需要三个横断线。通过术中超声 (IOUS) 在转移瘤下方 1 cm 处确定第 VII 段的后横断线。仅表面横切肝脏。 IV 段的内侧横断线是用 IOUS 确定的，位于转移灶左侧 1 cm 处，与肝中静脉平行。最后，用IOUS大致确定V段和VIII段之间的下横断线，与V段的肝静脉垂直对齐。夹紧VIII段的滑蒂后，根据荧光进一步校正横断线。外科手术从动员右肝脏开始，包括分割肝腔韧带，然后浅层切断第七段后缘。然后，在肝中静脉末端附近进行 IV 段横断，并通过头尾入路进一步暴露，以尽量减少静脉损伤的风险。然后将 V 段的肝静脉用作识别 VIII 段的 Glissonian 蒂的标志，并对其进行横切。4 然后确定右肝静脉 (RHV) 的终止，并横切 RHV 的腹侧分支。通过颅尾入路暴露 RHV 的背支。最后，朝着最初制作的横断线进行第七节段的横断。手术时间为360分钟，失血450mL。 Pringle 机动的使用时间为 148 分钟。患者于术后第七天出院。病理检查证实R0切除，三个肝转移灶坏死20-60%。切除的肝脏重量为225克。肝切除术后六个月，患者腹腔淋巴结复发，并接受放射治疗。肝切除术后十五个月，患者无需积极治疗即可痊愈。术前虚拟肝切除术通过增加对肿瘤与血管关系的了解来促进手术计划。采用颅尾入路的术中肝静脉引导能够遵循术前手术计划并进行安全的复杂腹腔镜肝切除术。© 2024。外科肿瘤学会。

Minimally invasive resection of segment VIII is a technically challenging procedure, made even more challenging when the resection is extended to segment IV and/or segment VII. Parenchymal-sparing resections are frequently used in the management of liver metastases but expose to the risk of R1 resection, especially with a minimally invasive approach. Preoperative surgical planning with 3D reconstruction and intraoperative guidance with hepatic vein is helpful for laparoscopic oncological liver resection.1-3 PATIENT AND METHODS: We present the case of a 58-year-old female with three metachronous liver metastases from epidermoid anal cancer. The disease was stable 6 months after cessation of chemotherapy. Metastases were mainly located in segment VIII (with a large segment VIII dorsal) but also in the territory of glissonian pedicles from segments IV and VII. Prior to surgery, three-dimensional (3D) reconstruction showed that a segmentectomy VIII would not be sufficient to have a safety margin and showed the relation between metastases and hepatic veins. Transection of the liver was performed with an ultrasonic dissector. Exposure of the hepatic veins was performed by gently pulling of the hepatic tissue from the vein, using the nonactive blade of the ultrasonic device. Activation of ultrasonic energy was performed only for sealing and dividing small collateral veins. Three transection lines were necessary. The posterior transection line, in segment VII, was determined with intraoperative ultrasound (IOUS), at 1 cm below the metastasis. The liver was transected superficially only. The medial transection line, in segment IV, was determined with IOUS, at 1 cm on the left of the metastasis, parallel to the middle hepatic vein. Finally, the inferior transection line, between segment V and segment VIII, was approximately determined with IOUS, vertically aligned with the hepatic vein of segment V. The transection line was further corrected after clamping the glissonian pedicle of segment VIII, according to fluorescence. The surgical procedure began with the mobilization of the right liver, including division of the hepato-caval ligament, followed by the superficial transection of the posterior margin in segment VII. Then, transection of segment IV was performed near the termination of the middle hepatic vein, which was further exposed with a cranio-caudal approach to minimize the risk of vein injury. The hepatic vein of segment V was then used as a landmark for the identification of the Glissonian pedicle of segment VIII, which was transected.4 Termination of the right hepatic vein (RHV) was then identified, and the ventral branch of the RHV was transected. The dorsal branch of the RHV was exposed with a cranio-caudal approach. Finally, transection of segment VII was performed toward the transection line made initially.Operative time was 360 min with 450 mL blood loss. The Pringle maneuver was used during 148 min. The patient was discharged on the seventh postoperative day. Pathological examination confirmed R0 resection, with 20-60% necrosis of the three liver metastases. The resected liver weight was 225 g. Six months after liver resection, the patient had a recurrence in a celiac lymph node, which was treated by radiotherapy. Fifteen months after liver resection, the patient is free of disease without active treatment.Preoperative virtual hepatectomy facilitates surgical planning by increasing the understanding of the tumors-vessels relationship. Intraoperative hepatic vein guidance with a cranio-caudal approach enables to follow preoperative surgical planning and to perform safe complex laparoscopic liver resection.© 2024. Society of Surgical Oncology.