Navigation value of intraoperative ultrasound combined with indocyanine green fluorescence in complex hepatocellular carcinoma resection

Abstract

BACKGROUND

Primary hepatocellular carcinoma (HCC) is a common malignancy worldwide, with surgical resection being the most effective treatment for long-term survival. For complex HCC (large diameter, central location, multiple lesions, or proximity to major vessels), traditional surgery relying on surgeon experience and palpation has limitations including difficulty identifying deep lesions and high positive margin rates. Intraoperative ultrasound (IOUS) provides real-time hepatic structural visualization but has limited capability for isoechoic lesions, while indocyanine green (ICG) fluorescence imaging enables real-time tumor visualization but lacks deep anatomical information. Combined application may offer complementary advantages, yet systematic evaluation studies in complex HCC resection remain scarce.

AIM

To evaluate the clinical application value of IOUS combined with ICG fluorescence imaging technology in radical resection of complex HCC.

METHODS

Clinical data of 200 patients with complex HCC who underwent radical hepatectomy from January 2019 to August 2024 were retrospectively analyzed. Patients were divided into a combined navigation group (n = 103) and a conventional surgery group (n = 97) based on whether IOUS and ICG fluorescence imaging technology were used in combination. Intraoperative indicators, oncological indicators, postoperative recovery indicators, and long-term prognosis were compared between the two groups. Logistic regression analysis was used to analyze factors influencing postoperative complications, and Cox regression analysis was used to analyze factors influencing survival prognosis.

RESULTS

Baseline characteristics were balanced between the two groups. The combined navigation group had shorter tumor localization time (P < 0.001), less intraoperative blood loss (P = 0.004), lower intraoperative transfusion rate (P = 0.021), higher detection rate of occult lesions (23.3% vs 6.2%, P < 0.001), and higher anatomical resection rate (P = 0.040). The combined navigation group had lower positive margin rate (2.9% vs 13.4%, P = 0.006), higher R0 resection rate (97.1% vs 86.6%, P = 0.006), and greater margin distance (P < 0.001). The combined navigation group had lower overall postoperative complication rate (18.4% vs 28.9%, P = 0.042) and severe complication rate (5.8% vs 12.4%, P = 0.042), and shorter postoperative hospital stay (P = 0.003). With a median follow-up of 28.6 months, the combined navigation group had higher 2-year overall survival rate (76.8% vs 65.2%, P = 0.033) and 2-year disease-free survival rate (58.4% vs 45.7%, P = 0.022), and lower postoperative recurrence rate (36.9% vs 50.5%, P = 0.048). Multivariate analysis showed that application of combined navigation technology was an independent protective factor for postoperative complications (odds ratio = 0.498, P = 0.027), and was also an independent protective factor for overall survival (hazard ratio = 0.584, P = 0.028) and disease-free survival (hazard ratio = 0.631, P = 0.025).

CONCLUSION

IOUS combined with ICG fluorescence imaging technology can improve tumor localization accuracy in complex HCC surgery, improve margin control, reduce intraoperative blood loss, decrease the incidence of postoperative complications, and improve long-term survival prognosis in patients, demonstrating important clinical application value.

Keywords: Hepatocellular carcinoma; Complex hepatocellular carcinoma; Intraoperative ultrasound; Indocyanine green fluorescence imaging; Surgical navigation; Precision hepatectomy

Core Tip: This retrospective study evaluated 200 patients with complex hepatocellular carcinoma undergoing radical hepatectomy. Intraoperative ultrasound combined with indocyanine green fluorescence imaging significantly improved tumor localization, increased R0 resection and anatomical hepatectomy rates, reduced intraoperative blood loss and postoperative complications, and enhanced long-term survival compared with conventional surgery. The combined navigation approach provides real-time visualization and precise resection guidance, offering a safe, effective, and clinically valuable strategy for precision hepatectomy in complex hepatocellular carcinoma.