fig4

Figure 4. These images demonstrate the intraoperative hepatectomy views. (A) As there is the intention to preserve ventral segment 8, the decision is made to approach the dorsal pedicle via a hepatotomy rather than from the hilum. Hepatotomy is performed along the anterior fissure vein of the middle hepatic vein that has been identified with IOUS and with help from the 3D reconstruction. The dorsal segment 8 inflow pedicle is identified deep in the parenchyma and slung with a silk tie (marked with an arrow); (B) The dorsal segment 8 inflow pedicle is test clamped with a laparoscopic bulldog to confirm the ischemic demarcation and thereafter formally occluded with a Hem-o-lok; (C and D) Intravenous ICG is then administered for negative staining and the deep parenchymal transection proceeds with ICG-fluorescence overlay guidance in the anatomical plane. The ventral segment 8 does not stain with ICG as its inflow has been occluded. 3D: 3-dimensional; IOUS: intraoperative ultrasound; ICG: indocyanine green.