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

Abstract

Background: Focal 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.

Aim: To summarize the technique and feasibility of robotic resection of FNH guided by indocyanine green (ICG) fluorescence imaging.

Methods: The 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.

Results: Among 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).

Conclusion: ICG 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.

Keywords: Focal nodal hyperplasia; Hepatectomy; Indocyanine green; Robotic surgery.

Figure 1

Robotic resection of liver focal nodal hyperplasia guided by indocyanine green fluorescence imaging. A: Magnetic resonance imaging showed focal nodal hyperplasia (FNH) located in segment VII; B: Three-dimensional reconstruction of computed tomography showed the relationship of FNH and the right hepatic vein; C and D: Robotic resection of liver FNH guided by indocyanine green (ICG) fluorescence imaging; E and F: The resected specimen and the mode of ICG imaging in FNH. RHV: Right hepatic vein.