| BackgroundHepatocellular carcinoma(HCC)is one of the most common malignancies and a leading cause of cancer-related deaths worldwide.Surgery is the treatment of choice for patients with early-stage HCC and is an important treatment that can lead to long-term survival or even cure for HCC patients.In recent years,laparoscopy has gained widespread popularity in many surgical fields with the development of laparoscopic equipment and energy instruments,as well as the improvement of surgeons’ skills in performing laparoscopic surgery.Laparoscopic liver resection(LLR)has become the first choice for most surgeons and patients and is one of the leading treatments for resectable HCC.The indications for LLR are expanding,and the use of high-resolution cameras and magnified views of the laparoscope can show surgeons the precise anatomy more clearly than ever before.More and more medical centers are choosing LLR as the modality of choice.However,the inherent limitations of LLR,including limited maneuverability,loss of palpation feedback,and overall loss of vision,can cause surgeons to become disoriented during surgical resection.The location,size,and number of tumors,invasion of vessels such as the portal vein and hepatic veins,and complex liver structures and anatomical variants can also make LLR difficult.In addition,complex LLR,i.e.LLR with special tumor locations and large resection areas,have some additional risks,such as increased surgical uncertainty and increased risk of intraoperative bleeding.In recent years,the development of digitally intelligent diagnostic techniques such as augmented reality navigation(ARN)and indocyanine green(ICG)fluorescence imaging has opened up new possibilities for performing complex LLR.Objectives1.To evaluate the feasibility of virtual liver segment projection combined with ICG fluorescence imaging for navigation of laparoscopic anatomical extended right posterior sectionectomy(AERPS).2.To compare the results of augmented reality navigation combined with ICG fluorescence imaging(ARN-FI)with conventional laparoscopy for centrally located hepatocellular carcinoma(CL-HCC)based on a post hoc analysis.3.To retrospectively analyze and explore the value of the ARN-FI technique in complex LLR.Methods1.We retrospectively included 15 patients who underwent AERPS at Zhujiang Hospital of Southern Medical University between January 2018 and December 2021,and collected and analyzed preoperative baseline data,intraoperative indicators,postoperative pathological data,and follow-up data,in addition to checking the concordance between preoperatively planned resection volume and actual resection volume.2.A post-hoc analysis based on a non-randomized clinical trial,which included a total of 76 patients with CL-HCC between June 2018 and June 2021,divided into their ARN-FI group(42 patients)and non-ARN-FI group(34 patients)according to whether the ARN-FI technique was used or not,to compare the differences in perioperative outcomes,short-term prognosis and long-term survival between the two groups.3.Clinical data were retrospectively collected from 436 patients who underwent complex LLR at Zhujiang Hospital,Southern Medical University from January 2018 to December 2021.They were divided into two groups according to whether the ARN-FI technique was used:214 patients in the ARN-FI group and 222 patients in the non-ARN-FI group.The clinical characteristics,preoperative data,surgical indicators,postoperative complications,and postoperative hospital days of the patients before and after propensity score matching(PSM)were compared,as well as the pathological characteristics and long-term survival data of patients with postoperatively confirmed HCC in the two groups.Data were statistically analyzed using SPSS 25.0 and R Studio 4.05 statistical software,and differences were considered statistically significant at p<0.05.Results1.Of the 15 patients who underwent AERPS,three were converted to open surgery intraoperatively and the remaining 12 were completed laparoscopically,all without perioperative death.The mean operative time was 495.3 minutes(range 300 to 720 minutes).The mean blood loss was 326.7 mL(range 100-600 mL)and the mean number of Pringle procedures used was 4.8(range 3-6),of which six required intraoperative transfusion(40%).There were two major complications and the remainder were minor.The mean postoperative hospital stay was 8.6 days(range 3-14 days).ARLV was significantly and positively correlated with PRLV(PRLV=0.989×ARLV-10.11;R2=0.7955;p<0.001)and Bland-Altman analysis suggested good agreement between ARLV and PRLV.2.The ARN-FI group had less intraoperative bleeding(median 275 vs 300 mL,p=0.013),lower intraoperative transfusion rates(14.3%vs 64.7%,p<0.01),shorter postoperative hospital stays(median 8 vs 9 days,p=0.005)and lower postoperative complication rates compared to the non-ARN-FI group of CL-HCC patients(35.7%vs 61.8%,p=0.024).There were no deaths in either group during the perioperative period or at follow-up,and there was no significant difference in recurrence-free survival between the two groups(p=0.161).3.After matching 436 patients undergoing complex LLR to PSM,159 patients were included in each of the two groups with no significant differences in baseline information regarding demographics,preoperative testing,history of cirrhosis,liver function classification,and lesion characteristics.After PSM,intraoperative blood loss(median 200 vs 300 mL,p<0.001)and intraoperative transfusion rates were significantly lower in the ARN-FI group(22.0%vs 39.0%,p=0.001)than in the non-ARN-FI group,but operative time was longer(median 335 vs 300 min,p<0.001).In addition,the rate of major postoperative complications was significantly lower in the ARN-FI group than in the non-ARN-FI group(21.4%vs 36.8%,p=0.047).In the post-matching cohort,there were 79 and 68 postoperative pathological diagnoses of HCC in the ARN-FI and Non-ARN-FI groups,respectively,with overall survival rates of 94.8%vs 90.1%and 82.6%vs 84.Recurrence-free survival rates at years 1 and 3 were 77.6%vs 65.3%and 66.7%vs 53.1%,respectively,but there was no significant difference in disease-free survival(p=0.069).Conclusions1.The ARN-FI technique provides a virtual liver segment projection-liver parenchyma approach to laparoscopic AERPS,which more conveniently and precisely guides the resection of the procedure,ensuring that patients receive anatomical hepatectomy while preserving as much functional liver parenchyma as possible,facilitating postoperative recovery and improving patient quality of life.2.The ARN-FI technique is of great value in improving the success rate of CL-HCC surgery,reducing postoperative complications,accelerating postoperative recovery and shortening postoperative hospital stay.3.The ARN-FI technique can significantly reduce intraoperative bleeding,transfusion rate and the incidence of major complications in complex LLR,but prolongs operative time.Although it did not improve overall survival and recurrence-free survival in the HCC subgroup analysis,it still demonstrates the good value of the technique for complex LLR. |
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