Indocyanine-green fluorescence guided anatomical segmentectomy for HCC with portal thrombosis: the counter-fluorescence technique

A surgical technique to intra-operatively define segmental boundaries by US-guided bimanual liver compression has been described by the authors, but this procedure is contraindicated in case of portal tumor thrombus. A technique to overcome this limitation is described. A patient with a single hepatocarcinoma nodule and segment 8 (S8) portal branch thrombosis was submitted to the procedure. Anatomical demarcation of S8 was achieved by hilar clamping of the common hepatic artery, intravenous injection of indocyanine green (ICG), and fluorescence imaging analyses of the liver. The procedure was feasible and the demarcation of S8 was visible within 2 min from the iv injection of ICG in a counterstaining fashion. Then S8 segmentectomy was safely carried out. This novel approach seems feasible, providing a reliably anatomical and conservative removal of HCC with portal branch tumor thrombus.