Simultaneous tumor identification, cholangiography, and securing surgical margin for recurrence of hepatocellular carcinoma using the Medical Imaging Projection System.

Background: Indocyanine green (ICG) fluorescence-guided surgery is a real-time navigation technology for tumor detection, securing surgical margins, segmentation mapping, and cholangiography in liver surgery [1]. According to recent reports, the Medical Imaging Projection System (MIPS) may be a useful new real-time navigation technology for open anatomical liver resection [2]. However, the efficacy of MIPS for tumor identification, cholangiography, and securing surgical margins is uncertain. In this report, we introduce MIPS-assisted liver resection for real-time navigation during simultaneous tumor identification, cholangiography, and securing surgical margins.
Methods: A 76-year-old man presented with a 30 × 30 mm recurrent hepatocellular carcinoma on the transection plane after right anterior sectionectomy. Eight radiofrequency ablations were performed after the first hepatectomy. Preoperative computed tomography and three-dimensional simulation revealed a tumor near the posterior Glissonean branch. One day before surgery, 2.5 mg/body ICG was administered. We analyzed whether MIPS could simultaneously facilitate tumor identification, cholangiography, and securing surgical margins. The relationship between fluorescent imaging and the surgical margin was evaluated with a fluorescent microscope [3].
Results: Simultaneous tumor identification, cholangiography, and securing the surgical margins were demonstrated by adjusting the image projection of MIPS, and R0 resection was achieved without biliary injury (Figs. 1 and 2). The operative time and estimated blood loss were 287 minutes and 394 mL, respectively. He was discharged on postoperative day 12 without any complications.
Conclusion: MIPS could be useful for real-time navigation for tumor identification, cholangiography, and securing surgical margins during liver surgery. The threshold of fluorescent intensity should be set for optimal image projection.
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