利用实时荧光成像引导经腹腔镜右半肝切除胆管阻塞区

由胆道肿瘤或血栓引起的肝脏阻胆区域可以通过吲哚菁绿（ICG）荧光成像清晰识别。1作者团队曾报道利用胆管阻塞区成像（BOAI）辅助开腹肝切除治疗肝内胆管细胞癌（ICC）伴胆道阻塞的经验。2本视频首次报道了利用3D-4K荧光成像系统的实时BOAI引导的三维（3D）腹腔镜肝切除手术。患者为一名65岁男性，因感染包虫病入院。术前CT和MRCP显示右肝管阻塞伴弥漫性扩张。术前5天注射ICG（ICG R15）15分钟，浓度为3.3%。术前计划在可视化技术辅助下进行腹腔镜右半肝切除伴区域淋巴结清扫。在手术过程中，荧光成像显示右肝明显荧光积聚。借助实时BOAI（图1）准确切除胆道阻塞区域，并被动充分暴露中肝静脉（MHV）。图1：实时胆管阻塞区域成像的操作步骤。A：术前3-5天静脉注射ICG，剂量为0.5 mg/kg。B：注射后几分钟内ICG在肝脏中积累。C：ICG被肝脏选择性吸收并排泄到肠道，阻塞区域中ICG得以保留。结果：病理诊断为右胆管肿瘤高分级上皮内瘤变，无淋巴结转移，伴包虫病。手术时间为300分钟，术中出血50毫升，无明显术后并发症，术后7天出院。利用实时BOAI引导的腹腔镜右半肝切除治疗胆管阻塞区域是可行且有效的。

The regions of the liver with cholestasis caused by biliary tumors or thrombosis can be distinctly identified using indocyanine green (ICG) fluorescence imaging.1 The authors' team reported the application of bile-duct obstructed area imaging (BOAI) to assist open hepatectomy for intrahepatic cholangiocarcinoma (ICC) combined with intrahepatic bile duct obstruction previously.2 This video is the first report of real-time BOAI-guided three-dimensional (3D) laparoscopic hepatectomy using a 3D-4K fluorescence imaging system.A 65-year-old man was admitted to the authors' institution with clonorchiasis. Preoperative computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) showed an obstruction and diffuse dilation of the right hepatic duct. A 15-min retention of ICG (ICG R15) was performed 5 days before the operation, with a 3.3% result. Preoperative planning involved performing laparoscopic right hemi-hepatectomy with regional lymph node dissection assisted by visualization technology.3 During the procedure, significant fluorescence accumulation in the right liver was shown by fluorescence imaging. With the guidance of real-time BOAI (Fig. 1), the regions of biliary obstruction were precisely resected, and the middle hepatic vein (MHV) was passively and adequately exposed on the cutting plane. Fig. 1 Administration steps for real-time bile duct-obstructed area imaging. A ICG is injected intravenously 3-5 days before operation at a dose of 0.5 mg/kg. B ICG is accumulated in the whole liver within a few minutes after injection. C ICG is selectively absorbed by the liver and excreted into the intestines, whereby it is retained in areas of biliary obstruction RESULTS: The histopathologic diagnosis indicated high-grade intraepithelial neoplasia of the right bile duct tumor without lymph node metastases and clonorchiasis. The duration of the operation was 300 min, with an intraoperative blood loss of 50 ml. No postoperative complications occurred, and the patient was discharged after 7 days.Laparoscopic right hemi-hepatectomy for the bile-duct obstructed area with the guidance of real-time BOAI is feasible and effective.