Real-time navigation system for sentinel lymph node biopsy in breast cancer patients using projection mapping with indocyanine green fluorescence

Background

Inability to visualize indocyanine green fluorescence images in the surgical field limits the application of current near-infrared fluorescence imaging (NIR) systems for real-time navigation during sentinel lymph node (SLN) biopsy in breast cancer patients. The aim of this study was to evaluate the usefulness of the Medical Imaging Projection System (MIPS), which uses active projection mapping, for SLN biopsy.

Methods

A total of 56 patients (59 procedures) underwent SLN biopsy using the MIPS between March 2016 and November 2017. After SLN biopsy using the MIPS, residual SLNs were removed using a conventional NIR camera and/or radioisotope method. The primary endpoint of this study was identification rate of SLNs using the MIPS.

Results

In all procedures, at least one SLN was detected by the MIPS, giving an SLN identification rate of 100% [95% confidence interval (CI) 94–100%]. SLN biopsy was successfully performed without operating lights in all procedures. In total, 3 positive SLNs were excised using MIPS, but were not included in the additional SLNs excised by other methods. The median number of SLNs excised using the MIPS was 3 (range 1–7). Of procedures performed after preoperative systemic therapy, the median number of SLNs excised using the MIPS was 3 (range 2–6).

Conclusions

The MIPS is effective in detecting SLNs in patients with breast cancer, providing continuous and accurate projection of fluorescence signals in the surgical field, without need for operating lights, and could be useful in real-time navigation surgery for SLN biopsy.

     

恶性肿瘤的光学分子影像手术导航*

光学分子影像是利用生物体自发荧光和荧光素酶的探针对分子和分子作用途径监测的一种无创技术,具有操作简单、无创伤、即时性、高敏感性、成像价格低的优点,被越来越多地应用于生物学、医学等生命科学领域。常用的光学分子影像研究的荧光探针主要有内源性的荧光素酶、外源性的绿色荧光蛋白及近红外荧光染料等。外科手术是恶性肿瘤的主要治疗方法之一,如何在手术中实时动态检测前哨淋巴结、确定肿瘤浸润和转移范围、判定肿瘤切缘是否安全及保护神经等功能是肿瘤外科医生面临的临床挑战。光学分子影像手术导航正在逐步应用到以上领域,期待可以解决以上问题,最终可以使恶性肿瘤被精准切除。本文就目前国内外光学分子影像技术在恶性肿瘤手术导航领域的应用进行综述。      

Real‐time identification of liver cancers by using indocyanine green fluorescent imaging

BACKGROUND:

We have often encountered difficulties in identifying small liver cancers during surgery. Fluorescent imaging using indocyanine green (ICG) has the potential to detect liver cancers through the visualization of the disordered biliary excretion of ICG in cancer tissues and noncancerous liver tissues compressed by the tumor.

METHODS:

ICG had been intravenously injected for a routine liver function test in 37 patients with hepatocellular carcinoma (HCC) and 12 patients with metastasis of colorectal carcinoma (CRC) before liver resection. Surgical specimens were investigated using a near‐infrared light camera system. Among the 49 subjects, the 26 patients examined during the latter period of the study (20 with HCC and 6 with metastasis) underwent ICG‐fluorescent imaging of the liver surfaces before resection.

RESULTS:

ICG‐fluorescent imaging identified all of the microscopically confirmed HCCs (n = 63) and CRC metastases (n = 28) in surgical specimens. Among the 63 HCCs, 8 tumors (13%, including 5 early HCCs) were not evident grossly unless observed by ICG‐fluorescent imaging. Five false‐positive nodules (4 large regenerative nodules and 1 bile duct proliferation) were identified among the fluorescent lesions. Well‐differentiated HCCs appeared as uniformly fluorescing lesions with higher lesion‐to‐liver contrast than that of moderately or poorly differentiated HCCs (162.6 [71.1‐218.2] per pixel vs 67.7 [‐6.3‐211.2] per pixel, P < .001), while CRC metastases were delineated as rim‐fluorescing lesions. Fluorescent microscopy confirmed that fluorescence originated in the cytoplasm and pseudoglands of HCC cells and in the noncancerous liver parenchyma surrounding metastases. ICG‐fluorescent imaging before resection identified 21 of the 41 HCCs (51%) and all of the 16 metastases that were examined.

CONCLUSIONS:

ICG‐fluorescent imaging enables the highly sensitive identification of small and grossly unidentifiable liver cancers in real time, enhancing the accuracy of liver resection and operative staging. Cancer 2009. © 2009 American Cancer Society.     

Laparoscopic radical hepatectomy and lymphadenectomy for incidental gallbladder cancer. Surgical technique with ICG fluorescence enhancement

BackgroundRadical re-resection has been demonstrated beneficial in incidental gallbladder cancer (iGBC) stages ≥ pT1b [1]. Anatomical resection (AR) of segments IVb-V is recommended, particularly for iGBC and liver-sided tumors [2]. Laparoscopically, this is a challenging procedure, as well as the regional lymphadenectomy, since inflammation from previous surgery can hinder identification of extrahepatic bile ducts. This difficult minimally invasive procedure, facilitated with indocyanine green (ICG) fluorescence enhancement [3] is herein didactically demonstrated.MethodsA 73 y. o. female patient underwent laparoscopic cholecystectomy for cholelithiasis. An iGBC -pT2b with positive cystic node-was found. Completion radical surgery was decided. Before surgery, 1.5mg of ICG was intravenously administered. A regional lymphadenectomy (stations 5-8-9-12-13) was safely performed: ICG allowed for bile duct visualization despite scarring from previous procedure. AR (IVb-V) was performed based on a glissonian-pedicle approach. After completing the procedure, a new dose of ICG was administered to discard ischemic areas in the remnant.ResultsTotal operative time was 359 min. Intermittent Pringle maneuver resulted in <50 ml bleeding. Hospital stay was 3 days. Pathological examination revealed no residual tumor in the liver bed. Ten lymph nodes were resected; 3 of them (2 retroportal and 1 common hepatic artery) showing tumoral invasion. After surgery, 6 cycles of adjuvant chemotherapy (Gemcitabine-Oxaliplatin) was administered.ConclusionsLaparoscopic radical surgery (AR of segments IVb-V plus regional lymphadenectomy) for iGBC is feasible and safe [4]. ICG fluorescence can be of help to identify hilar structures and rule out areas of ischemia.     

Transhiatal laparoscopic esophagectomy with extended lymphadenectomy guided by green-indocyanine imaging for adenocarcinoma of the esophagogastric junction

IntroductionSurgical treatment for adenocarcinoma of the esophagogastric junction (AEGJ) has been long-established, from resection margins to the extension of lymphadenectomy [1,2,4]. The addition of cyanine dye, namely indocyanine green (ICG), to identify suspicious lymph nodes (LN) and evaluate organ vascularization may improve results and outcomes [3].VideoA 58-year-old female patient with Siewert type II AEGJ was administered mFLOX neoadjuvant treatment. After three cycles, she underwent surgical treatment. The day before surgery, an upper endoscopy was performed to inject 0.2 ml ICG 0.5 cm from the proximal and distal tumor margins. The patient underwent laparoscopic transhiatal esophagectomy with extended lymphadenectomy due to a 4 cm distal esophagus compromised margin. We describe the primary steps of the procedure and demonstrate the role of the ICG in the lymphadenectomy.ResultsSurgery was carried out laparoscopically with a cervical approach (McKeown access), and posterior mediastinal gastric tube reconstruction and cervical gastroplasty were performed. During the standard lymphadenectomy, we observed an ICG-positive LN in station 10, which was found positive in the subsequent pathology examination. After these findings, we performed an extended lymphadenectomy through the splenic hilum. The final pathologic assessment was T3N2 (two perigastric and one positive LN at station 10 among 60 retrieved LN). The operative time was 360 min. The patient started a liquid diet on the seventh postoperative day, and she was discharged on the tenth postoperative day.ConclusionsICG may be helpful to guide both extended lymphadenectomy and distal margin evaluation in transhiatal laparoscopic esophagectomy.     

Digital intelligent technology assisted three-dimensional laparoscopic extended left hepatectomy with resection of the middle hepatic vein(Video)

IntroductionDigital intelligent technology represented by three-dimensional (3D) visualization technology and surgical navigation system may provide preoperative and intraoperative anatomical information more accurately than CT and MRI [1]. Besides, the fusion of 3D model with surgical visual field through surgical navigation system may also compensate for the defects of visual fields and tactile sense to some extent in laparoscopic liver surgery [2].VideoA 49-year-old male patient with a tumor mainly located at the left inner area of liver and oppressing the middle hepatic vein (MHV). We formulated preoperative planning by using the Medical Image 3D Visualization System (MI3DVS, software copyright No: 2008SR18798) [3]. It was acknowledged that the right hepatic vein (RHV) was strong enough to drain the right anterior hepatic sector. Ultimately, 3D laparoscopic extended left hepatectomy with resection of the MHV was selected as the optimal operation scheme for the patient due to the RHV would avoid hepatic venous congestion in segment V and VIII after resection of the MHV, and more liver parenchyma than left trisegmentectomy would be retained. The operation was performed under assistance of the Laparoscopic Hepatectomy Navigation System (LHNS, software copyright No. 2018SR840555) [4].ResultsThe total operation time was 180 min, estimated blood loss of 200 ml. The final histopathological diagnosis showed an 8*6*6-cm-sized hepatocellular carcinoma. And the patient was discharged on postoperative day 6 without any complications.ConclusionDigital intelligent technology may be helpful to formulate preoperative planning and identify intraoperative important anatomical structures in 3D laparoscopic extended left hepatectomy with resection of the MHV.     

近红外荧光成像技术在外科手术中的研究进展

作为术中导航的新兴领域,近红外荧光(near-infrared fluorescence,NIRF)成像技术能借助荧光探针对特定的生物组织进行显像,从而在外科手术中实时获取血管、淋巴管和特定组织的视觉信息,从而发现传统方法无法识别的微小灶,正确显示肿瘤切缘,帮助外科医生进行术中决策。该技术由于其操作简单,快速实时,安全无害,具有良好的应用前景。本文将就NIRF成像技术的基本原理,在实时引导肿瘤切除,前哨淋巴结定位,保护正常解剖结构等方面的临床进展进行综述,并且讨论了该技术的局限性和优势并展望其应用前景。     

Laparoscopic fluorescence navigation for left-sided colon and rectal cancer: Blood flow evaluation,vessel and ureteral navigation,clip marking and trans-anal tube insertion

BackgroundRecently, the indocyanine green (ICG) fluorescence navigation method has attracted much attention as a means of intraoperative navigation, especially during laparoscopic surgery. The newly developed near-infrared (NIR) fluorescent resin also emits NIR fluorescence, as does ICG. Presently, new devices made with this resin are being developed. The purpose of this study was to present our fluorescence navigation techniques for left-sided colon and rectal cancer.MethodFifty-nine patients with left-sided colon and rectal cancer underwent laparoscopic surgery with fluorescence navigation between July 2019 and April 2020. The surgeries included 54 intestinal blood flow (IBF) evaluations using ICG, 16 preoperative fluorescence clip marking (FCM) procedures, 7 fluorescence ureteral navigation procedures, 4 fluorescence vessel navigation (FVN) procedures during lateral lymph node dissection, and 3 fluorescence-guided trans-anal tube insertion procedures. Laparoscopic surgery and fluorescence observation were performed using a VISERA ELITE 2. In FCM, the Zeoclip FS device was used. In ureteral navigation and trans-anal tube insertion, the Near-Infrared Ray Catheter (NIRC™) fluorescent ureteral catheter (NIRFUC) was used.ResultsNo complications related to the fluorescence navigation techniques, including those involving ICG, the Zeoclip FS and the NIRFUC, occurred. In 5 cases, the surgical plan was changed according to the IBF evaluation with ICG, and no anastomotic leakage occurred in those cases. These fluorescence navigation techniques provide previously unavailable visual information regarding the IBF, vessel and ureter routes and accurate endoscopic clip and drainage tube locations in the intestinal tract.ConclusionsTechnology to visualize blood flow dynamics and structures using fluorescence can be considered innovative, especially when applied in laparoscopic surgery, which relies on vision. The popularity of fluorescence navigation has also appeared to increase the safety of colorectal surgery.Clinical trial registrationExamination of fluorescence navigation for laparoscopic colorectal cancer surgery.Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2020-3. https://kawaguchi-mmc.org/wp-content/uploads/clinicalresearch-r02.pdf.     

Snapshots of lymphatic pathways in colorectal cancer surgery using near-infrared fluorescence,in vivo and ex vivo

IntroductionIndocyanine green (ICG) fluorescence imaging has been used for blood flow assessment in anastomoses in the field of colorectal cancer surgery. However, whether ICG fluorescence is related to the presence of cancer cells in the lymph nodes is unclear. We explored the utilization of ICG fluorescence in colorectal cancer surgery.Materials and methodsICG was injected into the submucosa around the tumor before radical resection in colorectal cancer patients. Intraoperatively, near-infrared (NIR) fluorescence was used for lymphatic flow visualization. After specimen removal, harvested lymph nodes were classified as positive or negative based on the detection of fluorescence, followed by pathological examination. ICG distribution on a section of each lymph node was examined by fluorescence microscopy.ResultsOverall, 155 patients underwent real-time NIR fluorescence imaging-guided surgery. Altogether, 1,017 lymph nodes were retrieved from these patients. Metastatic lymph nodes were present in 36 (5.8%) of 622 fluorescence-negative lymph nodes, which was significantly higher than 11 (2.8%) of 395 fluorescence-positive lymph nodes (odds ratio: 2.15, P = 0.03). Fluorescence microscopy of metastatic lymph nodes showed that ICG fluorescence was present in the normal structural region but not in the cancerous region of the lymph nodes. Furthermore, ICG fluorescence was observed in all metastatic lymph nodes, except those with cancer cells occupying >90% of the total area.ConclusionsICG fluorescence detected only the normal parts of the lymph node draining from the peritumoral area and not the cancer tissues. This finding is important for developing appropriate strategies for navigation surgery using NIR fluorescence.     

Simultaneous,single-docking robotic resection for right colon cancer with synchronous liver metastases

BackgroundHow best to manage colorectal cancer patients presenting resectable synchronous liver metastasis is still a matter of debate. A number of different available therapeutic strategies exist, with significant differences in terms of optimal timing and/or sequence of resection of the primary tumor and liver disease [1]. Over the last years, simultaneous resections are increasingly adopted for properly selected patients [[1], [2], [3]]. However, the application of minimally invasive surgery to combined colorectal and liver surgery is still controversial, especially in the case of liver disease requiring technically demanding resections [2,3].VideoThe presented video illustrates the details of a single-docking robotic right colectomy combined with ultrasound-guided, parenchymal-sparing resection of liver segments 6 and 7, as performed to treat a patient with locally advanced colorectal cancer and metastatic disease isolated to the right liver. Port placement strategy and main instrumentation employed are illustrated in Fig. 1, and Fig. 2, respectively. The total duration of surgery was 380 minutes. The hepatic hilum was encircled to allow extracorporeal Pringle maneuver during liver resection, though no clamping was eventually required. Right colectomy with central vascular ligation was thus carried out and an intracorporeal ileocolic anastomosis performed. The patient had an uneventful postoperative course.ConclusionsWhen feasible, minimally invasive simultaneous resection may offer distinct advantages over conventional surgery while respecting the tenets of appropriate oncological resection [2,3]. The well-known benefits of minimally invasive surgery, including shorter overall hospital length of stay, reduced morbidity, and lower blood loss, are combined with the need to recover from a single major surgery. Robotic resection may be particularly suited for technically challenging procedures, such as colectomy combined with liver metastasectomies with unfavorable anatomical accessibility [3,4].     

Image navigation assisted joint-saving surgery for treatment of bone sarcoma around knee in skeletally immature patients

PurposeIt is challenge to perform a native joint preserving resection for skeletally immature patients with bone sarcomas around the knee. We determined whether tumor resection under image-guided navigation make joint-saving surgery possible for juxta-articular sarcomas around knee while adhering oncological principles.MethodsWe performed joint-saving limb salvage surgeries on eight patients with metaphyseal bone sarcomas (6 in proximal tibia, 2 in distal femur). Six tumors extend to and 2 beyond the epiphyseal line. Planned tumor resection under image-guided navigation was employed for obtaining clear surgical margin while maximizing host tissue preservation. All tumors were en bloc removed and intercalary defect were reconstructed by combination of allograft with vascularized fibula flap. All specimens were examined for resection margin. Patients were followed up at average of 40.5 months for evaluating of oncologic and functional outcomes.ResultEntire joints were preserved in 5 patients and partial joints were saved in 3 patients. Clear surgical margins were achieved in all patients. The minimum of surgical margin width in bone is 6 mm in this series. No patient experienced local recurrence. Bone union achieved in all cases during the study period. The average MSTS score was 27.1 at final follow-up.ConclusionsWith careful patient selection, image navigation aided bone tumor resection was proved to be an effective way in joint-saving limb salvage procedures for treating skeletally immature patients with juxta-articular bone sarcomas around the knee.     

Robotic resection of liver focal nodal hyperplasia guided by indocyanine green fluorescence imaging: A preliminary analysis of 23 cases

BACKGROUNDFocal nodal hyperplasia (FNH) is a common benign tumor of the liver. It occurs mostly in people aged 40-50 years and 90% of the patients are female. FNH can be cured by local resection. How to locate and judge the tumor boundary in real time is often a challenge for surgeons.AIMTo summarize the technique and feasibility of robotic resection of FNH guided by indocyanine green (ICG) fluorescence imaging.METHODSThe demographics and perioperative outcomes of a consecutive series of patients who underwent robotic resection of liver FNH guided by ICG fluorescence imaging between May 1, 2018 and September 30, 2019 were retrospectively analyzed. ICG was injected through the median elbow vein in all the patients at a dose of 0.25 mg/kg 48 h before the operation. During the operation, the position of FNH in the liver was located in the fluorescence mode of the Da Vinci Si robot operating system and the tumor boundary was determined during the resection.RESULTSAmong the 23 patients, there were 11 males and 12 females, with a mean age of 30.5 ± 9.3 years. Twenty-two cases completed robotic resection, while one (4.3%) case converted to open surgery. In the robotic surgery group, the operation time was 35-340 min with a median of 120 min, the intraoperative bleeding was 10-800 mL with a median of 50 mL, and the postoperative hospital stay was 1-7 d with a median of 4 d. Biliary fistula occurred in two (8.7%) patients after robotic operation and they both recovered after conservative treatment. One (4.3%) patient received blood transfusion and there was no death in this study. The postoperative hospital stay in the small tumor group was significantly shorter than that in the large tumor group (P < 0.05).CONCLUSIONICG fluorescence imaging can guide the surgeon to perform robotic resection of liver FNH by locating the tumor and displaying the tumor boundary in real time. It is a safe and feasible method to ensure the complete resection of the tumor.     

Absence of residual fluorescence in the surgical bed at near-infrared fluorescence imaging predicts negative margins at final pathology in patients treated with breast-conserving surgery for breast cancer

IntroductionPositive margins after breast-conserving surgery (BCS) for breast cancer (BC) remain a major concern. In this study we investigate the feasibility and accuracy of indocyanine green (ICG) fluorescence imaging (FI) for the in vivo assessment of surgical margins during BCS.Materials and methodsPatients with BC admitted for BCS from October 2015 to April 2016 were proposed to be included in the present study (NCT02027818). ICG (0.25 mg/kg) was intravenously injected at induction anesthesia and ICG-FI of the surgical beds was correlated with final pathology results.ResultsFifty patients consented to participate and thirty-five patients were retained for final analysis, 15 patients having been excluded for, respectively, incomplete video records data for signal to background ratio (SBR) calculation (11) and in situ tumors (4). The final pathological assessment of 35 breast specimens identified 5 (14.7%) positive margins. Intraoperative ICG-FI revealed hyperfluorescent signals in 15 (42.9%) patients and an absence of fluorescent signals in 20 (57.1%). Median SBR in patients with involved margins was 1.8 (SD 0.7) and was 1.25 (SD 0.6) in patients with clear margins (p = 0.05). The accuracy, specificity, positive and negative predictive value of ICG-FI for breast surgical margin assessment were 71%, 60%, 29% and 100%, respectively.ConclusionICG-FI of BC surgical beds has a high negative predictive value for surgical margin assessment during BCS. The absence of residual fluorescence in the surgical bed of patients with fluorescent tumors predicts negative margins at final pathology and allows the surgeon to avoid further intraoperative analysis.     

Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using retroperitoneal-first laparoscopic approach (Retlap): A novel minimally invasive approach for determining resectability and achieving tumor-free resection margins of locally advanced pancreatic body cancer

BackgroundConventional open distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using the ventral approach is technically challenging, highly invasive, and not easy to ensure ample dorsal surgical margins. Hence, we describe a novel minimally invasive strategy for DP-CAR using the retroperitoneal-first laparoscopic approach (Retlap), i.e., Retlap DP-CAR, for locally advanced pancreatic body cancer (LAPC), and assess its utility.MethodsRetlap DP-CAR was performed in 10 patients with LAPC that was categorized as either unresectable (UR-LA, n = 4) or borderline (BR-A, n = 6). Neoadjuvant chemotherapy was applied on 8 patients and upfront surgery on 2. Retlap was used to create a working space in the retroperitoneal cavity between the pancreatic body and the left kidney and confirm technical resectability, such as securing the celiac axis and preserving the superior mesenteric artery in an early operative stage. Retlap DP-CAR was laparoscopic in 8 patients and robotic in 2. Surgical procedures are directly manipulated from the dorsal side of the pancreas and tumor, facilitating confirmation of technical resectability and obtaining ample dorsal margins in a no-touch isolation approach. Once technical resectability was confirmed, the procedure was converted to the ventral approach for completing DP-CAR.ResultsMedian operating time and blood loss during Retlap were 271 min and 10 mL, respectively, while median resection time and intraoperative blood loss were 582 min and 412 mL, respectively. Tumor-free resection margins were obtained in all cases. The major morbidity rate (C-D > IIIa) was 10%. No mortality was recorded within 90 days. Median overall survival was 53.8 months [95% confidence interval 32.7–75.0].ConclusionsRetlap DP-CAR is a novel minimally invasive procedure for resecting LAPC located close to the celiac axis. It is both safe and feasible, enables determination of technical resectability, achieves dorsal surgical margins, and can improve outcomes and QOL in patients with LAPC.     

Laparoscopic liver resection of the Spiegel lobe by a left-sided approach preserving an accessory left hepatic artery

BackgroundCaudate lobe of the liver can be divided in three portions: Spiegel lobe, paracaval portion and caudate process [1]. The anatomy of the caudate lobe and its proximity to major vascular structures makes this operation a difficult resection, especially for laparoscopic liver surgery [2]. For that reason the Iwate criteria proposed to classify this surgery at the “2nd International Consensus Conference on Laparoscopic Liver Resection” as intermediate or advanced difficulty depending on the type of resection, and the size of the tumor [3]. For tumors located in the Spiegel lobe, the left side approach is preferred [4].MethodsWe present a 69-year-old woman with liver metastasis from previously resected sternal condrosarcoma on 30/05/2017. A unique recurrence in the caudate lobe was found on computed tomography and magnetic resonance imaging on April 2019.ResultsA Spiegel lobe resection with left side approach preserving an accessory left hepatic artery was performed. A resection of the artery was planned if the preservation was not possible. The operative time was 180 min and the total Pringle time was 30 min. Patient was discharged at the 4 postoperative day and there were no postoperative complicationsConclusionsLaparoscopic liver resection of the caudate lobe for condrosarcoma liver metastasis is feasible and safe. Left approach seems the best option for Spiegel lobe resections even in patients with accessory left hepatic artery.     

Laparoscopic anatomic combined subsegmentectomy of segment 8 via the tailored strategy using digital intelligent technology

IntroductionSegment 8 is considered the largest liver segment, and its portal vein branches are generally divided into four parts, including ventral, dorsal, dorsolateral and medial branches (Shindoh et al., 2010; Takayasu et al., 1985) [1,2]. An anatomic combined subsegmentectomy could satisfy both the oncological quality of anatomical resection and the safety of parenchyma sparing principle if a small hepatocellular carcinoma is located between the hepatic subsegments (Berardi et al., 2021) [3]. Yet, laparoscopic anatomic combined subsegmentectomy of segment 8 is still technically challenging. The development of digital intelligent technology has made it possible to tailored preoperative planning and accurate intraoperative navigation in laparoscopic surgery.VideoA 57-year-old man underwent a routine CT scan and was found to have a mass occupation in segment 8 of the liver. Three-dimensional reconstruction was performed to evaluate liver anatomy, vascular variations, and volume of each vascular unit as well as the location of the tumor, its relationship with the liver anatomy, and the Glissonian pedicles feeding the tumor-bearing area. Based on the reconstructed model, resection was planned aiming to the narrowest but oncologically safe anatomical tumor-bearing area. Upon evaluation, anatomic combined subsegmentectomy of segment 8 (ventral and medial subsegments) was confirmed. The operation was performed precisely under assistance of the Laparoscopic Hepatectomy Navigation System (LHNS, software copyright No. 2018SR840555) (Yang et al., 2020) [4].ResultsThe operation lasted 200 min with 50 ml intraoperative blood loss. There were no postoperative complications, and the patient was discharged after 6 days.ConclusionDigital intelligent technology could provide tailored strategy for laparoscopic liver surgery, which makes laparoscopic anatomic combined subsegmentectomy of segment 8 feasible and effective.     

Intraoperative Ultrasound and Oncoplastic Combined Approach: An Additional Tool for the Oncoplastic Surgeon to Obtain Tumor-Free Margins in Breast Conservative Surgery—A 2-Year Single-Center Prospective Study

BackgroundThe main goal of oncoplastic breast-conserving surgery (OBCS) is to obtain tumor-free resection margins after cancer excision with satisfactory cosmetic results. Positive tumor margins are associated with high rates of tumor recurrence requiring reoperation. The aim of this prospective clinical trial was to demonstrate the reliability of intraoperative ultrasound (IOUS) to obtain tumor-free resection margins in OBCS.Patients and MethodsBetween December 2016 and March 2018, data from 130 patients with by T1-2 breast cancer, either invasive or in situ, who underwent OBCS were prospectively collected. The oncoplastic surgeon performed IOUS in the operating theater to localize the lesion and mark its skin projection. Then specimens were examined to assess the presence of the lesion and margin adequacy. Definitive histologic reports were reviewed, with a focus on margin status.ResultsAll patients experienced oncoplastic approaches, and lesions were always found on the specimen at the histologic report. In 126 cases (97%), margins were considered adequate. In 17 cases (13%), IOUS showed positive margins, and resection was contextually enlarged. In 12 of these (9%), the pathologic report confirmed the need for enlarged resection. This study shows that IOUS-guided surgery can obtain a high percentage of tumor-free resection margins in OBCS without scheduling conflicts between radiology, nuclear, and surgery departments. Full cooperation between radiologists and oncoplastic surgeons is required to achieve high-standard oncologic and reconstructive outcomes.ConclusionIOUS represent an additional tool for the breast surgeon to improve margin-free management of neoplastic lesions, preventing reoperations in patients undergoing oncoplastic surgery.     

Robotic central hepatectomy for hepatocarcinoma by glissonean approach (with video)

BackgroundCentral bisegmentectomy of the liver implies excising Couinaud's segments IV, V and VIII (Couinaud and Le Foie, 1957) [1]. In a recent classification of laparoscopic liver resections, it belongs to the highly advanced level procedure group (Kawaguchi and et al., 2018 Jan) [2]. Improvement in laparoscopic devices should lead to a wider accessibility of such indications that are currently expert prerogatives. In order to illustrate the assets of robotic-assistance in the management of highly difficult mini-invasive hepatic resections, we present the case of a robotic central hepatectomy.MethodsThis video illustrates robotic central hepatectomy in a 70-year-old male. A liver tumor involving segments IV, V and VIII was incidentally detected during abdominal ultrasonography. CT scan and MRI suggested the diagnosis of a seventy-millimeter centrally located hepatocellular carcinoma and surgical resection was decided.ResultsThe patient was placed supine in anti-Trendelenburg position. Four robotic trocars were placed and the da Vinci X robotic system was docked. Two laparoscopic ports were placed for the second surgeon (ultrasonic dissector and suction/irrigation set). Central hepatectomy was performed with a glissonean approach. Robotic irrigated bipolar coagulation and laparoscopic ultrasonic dissector was used for parenchymal transection. Postoperative course was uneventful. The patient was discharged on postoperative day eight.ConclusionThe recent publication of an International consensus statement demonstrates the growing involvement of robotics in liver surgery (Liu and et al., 2019 March 28) [3]. Robotic advantages (flexibility, absence of fulcrum effect and visual field stability) could improve accessibility to minimal invasive approach for difficult liver resection.     

Primary soft tissue sarcoma of the breast

Opinion statement Primary soft tissue sarcoma (STS) of the breast is a rare and heterogeneous disease. The rarity of this tumor limits most studies to small retrospective case reviews and case reports. The optimal treatment of primary STS of the breast can best be determined through multidisciplinary discussions prior to the initiation of therapy. Whether chemotherapy is indicated is primarily determined by tumor size. There is evidence that tumors larger than 5 cm are associated with an elevated risk of systemic failure and a poor prognosis [1-3]. Negative surgical margins are more important for local recurrence and overall survival than is the extent of surgical resection [1]. Thus, neoadjuvant chemotherapy should be considered in order to shrink the tumor and help obtain negative surgical margins. After surgical resection, patients with chemosensitive tumors should undergo additional adjuvant chemotherapy to treat micrometastatic disease. Patients with tumors less than 5 cm that are easily resectable should undergo complete resection to the extent required to provide negative surgical margins. Radiation therapy should be used to improve local control in cases in which the tumor is larger than 5 cm and in cases with positive surgical margins [4-6]. The appropriate treatment of primary STS of the breast requires a multidisciplinary approach necessitating experienced surgeons, pathologists, radiotherapists, and medical oncologists.     

Retroperitoneal-first laparoscopic approach (Retlap)-assisted distal pancreatectomy with celiac axis resection (DP-CAR): A novel minimally invasive approach for achieving adequate dorsal surgical margin

BackgroundDistal pancreatectomy with celiac axis resection (DP-CAR) is a procedure to secure a surgical margin for a locally advanced pancreatic body cancer that invades the celiac axis. However, in patients with cancer close to the root of the celiac axis, obtaining adequate surgical margins can be difficult because the tumor obstructs the field of vision to the root of the celiac axis. Previously, we described the retroperitoneal-first laparoscopic approach (Retlap) to achieve both accurate evaluation of resectability for locally advanced pancreatic cancer requiring DP-CAR [1] and adequate surgical margin for laparoscopic distal pancreatectomy [2]. In this video, we introduce Retlap-assisted DP-CAR as a minimally invasive approach for performing an artery-first pancreatectomy [3, 4] and achieving sufficient dorsal surgical margin (Fig. 1).MethodsOur patient is a 67-year-old man with a 55 × 29-mm pancreatic body tumor after chemotherapy. Preoperative computed tomography revealed a tumor close to the root of the celiac axis. Because the area of tumor invasion on preoperative images was near the root of the celiac artery, Retlap-assisted DP-CAR was performed to determine whether the celiac axis can be secured and obtain an adequate dorsal surgical margin (Fig. 2).ResultsThe operative time and estimated blood loss was 715 min and 449 mL, respectively. In spite of the advanced tumor's location and size, R0 resection was achieved in a minimally invasive way.ConclusionRetlap-assisted DP-CAR is not only technically feasible and useful for achieving accurate evaluation of resectability but also facilitates obtaining an adequate surgical margin.