HOW I DO IT
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Robotic fluorescence-guided anatomical segment IVb and V liver resection with radical lymphadenectomy for gall bladder cancer
Raja Kalayarasan, Sankar Narayanan, Mathews James
Department of Surgical Gastroenterology, Jawaharlal Institute of Post graduate Medical Education and Research, Puducherry, India
|Date of Submission||10-Jul-2021|
|Date of Acceptance||25-Oct-2021|
|Date of Web Publication||06-Jan-2022|
Department of Surgical Gastroenterology, Jawaharlal Institute of Post graduate Medical Education and Research, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
Radical surgery remains the primary treatment option for gall bladder cancer (GBC). Margin-negative liver resection is a critical component of radical cholecystectomy. Anatomical segment IVb and V resection is preferred in primary GBC with liver infiltration and incidental GBC patients with puckering of gall bladder (GB) bed. Despite the initial scepticism, minimally invasive radical cholecystectomy is recommended as a treatment option in selected GBC patients. However, anatomical Segment IVb and V resection using the minimally invasive approach is scarcely reported. The standardised technique of robotic (daVinci®XiTM) anatomical Segment IVb and V liver resection guided by indocyanine green fluorescence is described here. The systematic fluorescence-guided anatomical resection described in this report could facilitate minimally invasive Segment IVb and V resection with radical lymphadenectomy in selected patients with GBC.
Keywords: Gall bladder cancer, hepatectomy, laparoscopic, minimally invasive, robotic
|How to cite this URL:|
Kalayarasan R, Narayanan S, James M. Robotic fluorescence-guided anatomical segment IVb and V liver resection with radical lymphadenectomy for gall bladder cancer. J Min Access Surg [Epub ahead of print] [cited 2022 Jan 23]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=335071
| ¤ Introduction|| |
Surgery remains the potentially curative treatment option for gall bladder cancer (GBC). Margin-negative liver resection and adequate lymphadenectomy are the two essential components of radical surgery for GBC. Both wedge (2–3 cm) resection of gall bladder (GB) bed and anatomical Segment IVb and V resection are oncologically acceptable procedures if R0 resection can be achieved. However, in primary GBC patients with infiltration of Segment IVb or V, anatomical Segment IVb and V resection facilitate R0 resection., Furthermore, in incidental GBC patients with puckering of GB bed, anatomical resection is preferred. The open technique of anatomical Segment IVb/V resection has been previously reported. Despite the initial criticism, minimally invasive radical cholecystectomy is recommended as a treatment option in selected GBC patients. However, anatomical Segment IVb/V resection using the minimally invasive approach is scarcely reported. Furthermore, the use of indocyanine green (ICG) fluorescence to identify Segment IVb and V during minimally invasive radical cholecystectomy has not been previously described. The steps of robotic (daVinci®XiTM) anatomical Segment IV b and V liver resection guided by ICG fluorescence with radical lymphadenectomy for GBC are described in this report.
| ¤ Preoperative Preparation|| |
Contrast-enhanced (Triple phase) computed tomography is the preferred staging investigation in incidental GBC patients who do not have any metastasis on clinical evaluation. Magnetic resonance imaging with magnetic resonance cholangiopancreatography is recommended in GBC patients with jaundice. Positron emission tomography is indicated in patients with suspected metastatic disease. Before docking of robotic arms, a staging laparoscopy is performed to detect radiologically occult metastatic disease.
| ¤ Positioning Of Patient And Ports|| |
The patient was placed supine with a split leg position [Figure 1]. The Xi (daVinci®XiTM) robotic system is used, and docking of the patient cart is done from the patient's right side. The bedside assistant surgeon stands between the patient's legs. Four 8 mm robotic trocars are placed in a curvilinear line at the level of umbilicus with a 6 − 8 cm distance between trocars [Figure 1]. A 12-mm assistant trocar is placed in the infraumbilical region. The camera is placed in R2 during lymphadenectomy. During liver resection, both R2 and R3 are alternately used for the camera.
|Figure 1: Patient and port position. (a) Patient placed supine with a split leg position. (b) Four 8 mm robotic trocars are placed in a curvilinear line at the level of the umbilicus|
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| ¤ Operative Steps|| |
Before proceeding with radical lymphadenectomy, 16b1 (inter-aortocaval) lymph nodes are sampled and sent for frozen section evaluation to rule out metastatic disease [Figure 2]. Large lymphatic trunks are clipped to prevent postoperative chyle leak. Lymphadenectomy begins with a dissection of station 13a (posterosuperior pancreatic) lymph nodes, followed by dissection of station 17a (anterosuperior pancreatic) nodes [Figure 2]. Posterosuperior pancreaticoduodenal artery originating from the gastroduodenal artery can be visualised after clearance of 17a nodes [Figure 2]. For station 8 (hepatic artery) lymph node dissection, the origin of the right gastric artery is ligated. The hepatic artery is looped after dissection of 8a (anterosuperior group) nodes. 12p (lymph nodes along portal vein) nodes along with station 8p (posterior hepatic artery) nodes are dissected from the left border of the portal vein. Station 12 nodes are then dissected from the right edge of the portal vein. Lymph nodes on the left side of the portal vein are then taken to the right side en bloc to complete the radical lymphadenectomy [Figure 2].
|Figure 2: Key steps of lymphadenectomy. (a) Post-16b1 (inter-aortocaval) lymph nodes sampling. (b) Clearance of station 13a (posterosuperior pancreatic) and 17a (anterosuperior pancreatic) lymph nodes. (c) Posterosuperior pancreaticoduodenal artery originating from the Gastroduodenal artery is visualized after clearance of 17a nodes. (d) Lymph nodes on the left side of the portal vein are then taken to the right side enbloc (marked with an asterisk) to complete the radical lymphadenectomy|
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The technique of segment IVb and V resection
Anatomical segment IVb and V resection involves two key steps [Figure 3]:
|Figure 3: Schematic representation of two crucial steps of Segment IVb and V resection. (a) Identification of the parenchymal transection line between Segment IVa and Segment IVb by clamping IVb pedicle. (b) Identification of the parenchymal transection line between Segments V and VI by clamping the right posterior pedicle|
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- Identification of the parenchymal transection line between Segment IVa and Segment IVb
- Identification of the parenchymal transection line between Segments V and VI.
Identification of parenchymal transection line between segment IVa and segment IVb
The transection line between Segments IVa and IVb is identified by clamping the IVb pedicle in the umbilical fissure [Figure 4]. The extrahepatic origin of the IVb pedicle makes it a relatively straightforward procedure. However, when there is an intrahepatic origin, IVb pedicle control is achieved after parenchymal transection to the right of the falciform ligament. Trial clamping of the portal pedicle is recommended to prevent inadvertent division of the Segment IVa pedicle. Often there will be more than one IVb pedicle. Analysis of the preoperative cross-sectional imaging and reconstruction using image processing software facilitates intraoperative identification. If the line of demarcation is not clear after clamping the IVb pedicle, temporary clamping of the middle hepatic artery might better delineate the ischemic line of demarcation.
|Figure 4: Identification of the parenchymal transection line between Segment IVa and Segment IVb. (a) Preoperative computed tomography abdomen showing single Segment IVb pedicle (arrow). (b) A single Segment IVb pedicle dissected with Maryland dissecting forceps. (c) Segment IVb pedicle ligated with polymer clips. (d) Parenchymal transection line between Segments IVa and IVb can be clearly visualized|
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Identification of transection line between segment V and segment VI
The ischemic line of demarcation between Segments V and VI is identified by temporary clamping of the right posterior pedicle using a vascular clamp [Figure 5]. After lymphadenectomy right posterior pedicle can be easily identified at the level of the Rouvier sulcus. The junction between the right anterior and posterior branches should be identified before applying a vascular clamp [Figure 5]. Looping of the right posterior portal pedicle is not recommended to prevent iatrogenic damage.
|Figure 5: Identification of the parenchymal transection line between Segments V and VI. (a) Junction between the right anterior and posterior portal vein clearly identified. (b) Temporary clamping of the right posterior portal vein. (c) Ischemic demarcation of the right posterior sector. (d) Indocyanine green fluorescence better delineates the ischemic line of demarcation between the right anterior and posterior sector|
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Indocyanine green fluorescence-guided marking of segment IVb and V
With right posterior and Segment IVb pedicle vascular clamps in situ, intravenous ICG is injected at a dose of 0.5 mg/kg body weight. Well-perfused right anterior sector and Segment IVa can be identified by bright ICG fluorescence. The vertical line of demarcation between Segments V and VI is marked [Figure 6]. Next, the horizontal line of demarcation between Segments IVa and IVb is marked [Figure 6]. Marking of Segments IVb and V is completed by joining the horizontal line of demarcation between IVa and IVb with the vertical line of demarcation between anterior and posterior sectors [Figure 6]. Vascular clamps are released after marking the line of transection.
|Figure 6: Indocyanine green fluorescence-guided marking of Segment IVb and V. (a) Marking of vertical line of demarcation between Segment V and VI. (b) Marking of the horizontal line of demarcation between Segment IVa and IVb. (c) Schematic representation of marking Segment IVb and V. (d) Segment IVb and V marked by joining the horizontal line of demarcation with the vertical line of demarcation|
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Liver resection is started from the left side. While monopolar cautery can be used for superficial parenchyma dissection, ultrasonic shears and Maryland bipolar devices are primarily used for liver transection. Intrahepatic Glissonean pedicles are securely ligated with polymer clips and divided. Tributaries to the middle hepatic vein encountered at the deeper transection surface are ligated and divided [Figure 7]. Dissection is then commenced on the right border. The branch to the right hepatic vein is ligated and divided [Figure 7]. Finally, the Segment V pedicle is identified and controlled to complete the anatomical Segment IVb and V resection [Figure 7].
|Figure 7: Segment IVb and V liver resection. (a) Dissection of the branch (arrow) to the middle hepatic vein. (b) Dissection of Segment V hepatic vein branch (arrow) to the right hepatic vein. (c) Preoperative computed tomography showing Segment V pedicle. (d) Dissection of Segment V pedicle (arrow)|
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| ¤ Post-Operative Care|| |
Oral feeds are started on the first or second post-operative day. In patients who underwent hepatopancreatoduodenectomy enteral feeds through feeding jejunostomy was initiated on the first or second post-operative day. The right subcostal drain is removed on the second postoperative day if there is no evidence of bile leak or bleeding. In patients who underwent hepatopancreatoduodenectomy, drains are removed on the third post-operative day if the drain fluid amylase is within the normal limits and drain volume is <100 mL. The follow-up protocol included clinical examination, ultrasound abdomen and serum tumour marker levels (CEA and CA 19-9) every 3 months for the initial 2 years, every 6 months for the next 3 years and yearly after 5 years. The clinical details and the operative parameters of five patients who underwent minimally invasive radical cholecystectomy utilising this technique are summarised in [Table 1].
|Table 1: Demographic, clinicopathological and operative parameters of patients (n=5) who underwent robotic fluorescence-guided anatomical segment IVb and V liver resection|
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| ¤ Discussion|| |
The fluorescence-guided technique described here facilitates standardisation of anatomical Segment IVb and V resection during minimally invasive radical cholecystectomy. Hepatic resection for GBC has two primary purposes. The first is to resect tumours that have directly invaded the liver from the GB bed. The second is to prevent micrometastases that may recur around the GB bed. The rationale of Segment IVb and V resection in GBC is based on anatomical studies demonstrating venous drainage from the GB predominantly into Segments IVb and V. It is suggested that an anatomical resection could prevent early micrometastasis through the cystic vein. On the other hand, a few reports have shown that Segment IVb and V resection cannot prevent liver metastasis. There was no significant difference in survival or recurrence rates between resection of the GB bed and Segment IVb and V resection for GBC patients without liver infiltration in a Japanese multicentre retrospective study. Yoshikawa et al., in their analysis of 201 patients with GBC, demonstrated the superiority of Segment IVb and V resection over an extended cholecystectomy in achieving curative resection in patients with liver invasion <20 mm. While wedge resection of GB bed and anatomical Segment IVb and V resection are comparable for GBC patients with no liver involvement, the latter is preferred for GBC patients with limited liver infiltration. Furthermore, in IGBC patients with puckering of GB bed, anatomical resection is preferred as arbitrary marking of liver wedge might sometimes result in the removal of more than the required portion of the liver.
Various techniques of anatomical Segment IVb and V resection have been described in open radical cholecystectomy. The parenchymal transection line between Segment V and VI can be identified by using the Glissonean pedicle approach or intraoperative ultrasound. Glissonean pedicle approach involves temporary clamping of anterior or posterior Glissonean pedicles. Alternatively, the Segment V pedicle can be separately controlled to delineate the ischemic line of demarcation. When the parenchymal transection along the right side of the falciform ligament reaches the anterior Glissonean pedicle, the Segment V pedicle can be isolated. As identification and dissection of the posterior Glissonean pedicle is relatively more straightforward, it is favoured in the present technique. Furthermore, vascular clamps are preferred over vessel loops and tourniquets for temporary occlusion of the pedicles. The application of vascular clamps does not require looping of the Glissonean pedicle, thereby precluding iatrogenic biliovascular injury. The umbilical portion of the left portal vein gives Segment IVa and IVb branches on the right side. The parenchymal transection line between Segment IVa and IVb can be identified by temporary clamping or injecting a blue dye (indigo-carmine) into the portal vein branch. Clamping of the pedicle with a vascular clamp is used in the present technique.
ICG has been widely used in fluorescence-guided liver surgery. The use of ICG fluorescence for robotic anatomical Segment IVb and V resection in GBC has not been previously reported. As in other liver surgeries, ICG fluorescence facilitates accurate delineation of the segmental anatomy during radical cholecystectomy. Conventional dye staining technique results in inconsistent staining as the liver does not take up the blue dye, and it disappears quickly with dilution. As the hepatocytes take up the ICG, it is more reliable in showing segmental borders. Furthermore, it allows intraoperative navigation by guiding deep parenchymal transection. Before ICG injection, accurate clamping of the pedicle should be ensured as it is difficult to cancel the fluorescence once the ICG is injected. Furthermore, the fluorescence stays in the liver for a long time, and reinjection to delineate Segments IVb and V may not be feasible. The fluorescence-guided anatomical resection described in the present report can be used for both primary and incidental GBC. Furthermore, in addition to robotic surgery, the technique is feasible for laparoscopic radical cholecystectomy.
| ¤ Conclusion|| |
The systematic fluorescence-guided anatomical resection described in this report could facilitate minimally invasive Segment IVb and V resection with radical lymphadenectomy in selected patients with GBC.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors would like to express special thanks to Prof. Anil K Agarwal (Director and Head of Department of GI surgery, GIPMER) for sharing his experience in minimally invasive radical cholecystectomy for GBC.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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