Aim: Minimally invasive procedures have been increasingly performed in liver surgery. Benefits include lower intraoperative blood loss, reduced postoperative morbidity and shorter lengths of hospital stay in comparison to open liver surgery. Exact resection margins seem advantageous in primary liver cancer but challenging to implement with minimally invasive techniques. In this case report, we aimed to increase surgical precision by combining the Glissonean pedicle approach and intraoperative fluorescence guidance.

Indication: A 73-year-old female patient with CHILD A liver cirrhosis with chronic hepatitis C virus infection was transferred to our hospital with high levels of alpha-fetoprotein (792 ng/ml). Sectional imaging confirmed the suspected diagnosis of a single hepatocellular carcinoma (HCC) with a size of 2.2 cm in segments VI/VII. In line with the local tumour board recommendation, an anatomical posterolateral sectionectomy using the Glissonean pedicle approach was planned.

After mobilisation of the right liver, the posterolateral pedicle was encircled and transected. 0.2 mg/kg of body mass indocyanine green (ICG) was then injected intravenously. The perfused parenchyma of segments I-V and VIII turned green, but the unperfused posterolateral segment VI and VII remained native. The transection line was marked under ICG-imaging to indicate the transition of the posterolateral to the anteromedial sector. Parenchymal transection was performed under intermittent ICG-guided imaging. Pathological workup confirmed R0 resection of a well differentiated HCC in a cirrhotic liver (grade 4). The patient was discharged from the hospital on the 6th postoperative day after an uncomplicated course and was confirmed to be tumour-free six months after surgery.

Conclusion: As an additional intraoperative tool, ICG-imaging may provide visualisation of segment and sector boundaries and thus may enable precise anatomical resection. Prospective studies are needed to evaluate the added value of this technique, especially with regard to the rate of R0 resections.

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