Case 1: The patient was a 60-year-old man with a liver mass detected during a routine checkup.
Case 2: The patient was a 73-year-old man diagnosed with colon cancer with liver metastases in September 2019.
Case 3: The patient was an 83-year-old man with a liver mass detected during a routine checkup.
Case 4: The patient was a 59-year-old woman who complained of frequent right upper quadrant abdominal pain for approximately 1 wk.
History of past illness
Cases 1, 3 and 4: Unremarkable.
Case 2: The patient was diagnosed with colon cancer with multiple liver metastases (3 masses located at segments II, V, and VIII) in September 2019. He underwent laparoscopic radical resection of left colon cancer. After surgery, he received adjuvant XELOX chemotherapy five times.
Case 1: The patient underwent magnetic resonance imaging (MRI) of the upper abdomen, which revealed a tumor approximately 35 mm in diameter located in liver segment V/VIII (Figure 1A and B). Preoperative 3-dimensional reconstruction revealed that the tumor invaded the right anterior branch of the portal vein (Figure 1C and D). With a presumptive diagnosis of hepatocellular carcinoma, he underwent laparoscopic hepatectomy (LH). We observed partial fluorescence of segment V during the operation (Figure 1E), and the intraoperative ultrasound examination indicated that the right anterior branch of the portal vein was compressed by the tumor (Figure 1F). From the cut surface of the postoperative specimen shown in Figure 1G and H, we confirmed that the Glissonian pedicle was invaded by the tumor, which caused fluorescent staining of segment V.
Figure 1 Imaging examinations of Case 1.
A and B: Preoperative magnetic resonance imaging showed a tumor approximately 35 mm in diameter located at segment V/VIII; C and D: Preoperative 3-dimensional reconstruction of the hepatic vein and portal vein revealed the tumor located at segment V/VIII, invading the right anterior branch of the portal vein; E: Partial fluorescence of segment V; F: Intraoperative ultrasound examination showed that the vein was compressed by the tumor; G and H: Postoperative specimen confirmed that the Glissonian pedicle was invaded by the tumor. T: Tumor; LHV: Left hepatic vein; MHV: Middle hepatic vein; RHV: Right hepatic vein; LBPV: Left branch of portal vein; RPPV: Right posterior branch of portal vein; RAPV: Right anterior branch of portal vein.
Case 2: Abdominal contrast-enhanced computed tomography (CT) in February 2020 showed that all three liver metastases were smaller after chemotherapy, and he was admitted to the hospital for partial hepatectomy. During the surgery, the tumors and their surrounding fluorescent rings were clearly observed only in segments V and VIII (Figure 2A and B). In the left lateral lobe of the liver, a large area showed strong fluorescence (Figure 2C and D), which was caused by the segment II tumor invading and oppressing the drainage of the bile duct of the corresponding liver segment. For this reason, we excided the tumors in segments V and VIII and then conducted left lateral lobe resection to remove the liver parenchyma with complete bile drainage obstruction.
Figure 2 Imaging examinations of Case 2.
A: The tumor and fluorescent ring in segment V; B: The tumor and fluorescent ring in segment VIII; C and D: The large area of strong fluorescence of the left lateral lobe of the liver.
Case 3: The patient underwent abdominal MRI examination and was diagnosed with a hepatocellular carcinoma approximately 20 mm in diameter located at segment VI (Figure 3A and B). Intraoperative ultrasound examination of segment VI showed a tumor 2 cm × 3 cm in size. Through fluorescence laparoscopy, a fluorescent area of approximately 5 cm × 6 cm could be observed in part of segment VI, which was much larger than the tumor itself (Figure 3C). Under the guidance of intraoperative ultrasound, we dissected and clipped the segment VI Glissonian pedicle. A few minutes later, an ischemic line appeared on the surface of the liver, almost coinciding with the fluorescence boundary (Figure 3D), which again suggested that the fluorescent staining part was due to tumor compression of the segment VI Glissonian pedicle. According to the fluorescence boundary and ischemic line, we completely removed the tumor and the liver segment with bile excretion obstruction caused by tumor compression. From the postoperative specimen shown in Figure 3E and F, we could see the stained segment and the Glissonian pedicle oppressed by the tumor.
Figure 3 Imaging examinations of Case 3.
A and B: Preoperative magnetic resonance imaging examination indicated a hepatocellular carcinoma approximately 20 mm in diameter located at segment VI; C: Fluorescent staining of segment VI; D: The ischemic line on the liver surface after clipping the segment VI pedicle; E and F: Postoperative specimen confirmed the Glissonian pedicle oppressed by the tumor and the stained segment.
Case 4: The CT scan of the abdomen indicated multiple stones in the bile duct of the right lobe of the liver (Figure 4A). During the surgery, we observed partial fluorescence ranging from approximately 5 cm × 4 cm in liver segments VI and VII (Figure 4B), with regional atrophy of the liver parenchyma, so we completely resected the atrophic liver parenchyma according to the fluorescence boundary and removed the stones.
Figure 4 Imaging examinations of Case 4.
A: Computed tomography scan indicated multiple intrahepatic stones; B: Partial fluorescence accumulation in segment VI/VII, approximately 5 cm × 4 cm; C and D: Postoperative pathological examination suggested intrahepatic cholangiocarcinoma.