Objective: To establish consensus recommendations for the use of fluorescence imaging with indocyanine green (ICG) in hepatobiliary surgery. Background: ICG fluorescence imaging has gained popularity in hepatobiliary surgery in recent years. However, there is varied evidence on the use, dosage, and timing of administration of ICG in clinical practice. To standardize the use of this imaging modality in hepatobiliary surgery, a panel of pioneering experts from the Asia-Pacific region sought to establish a set of consensus recommendations by consolidating the available evidence and clinical experiences. Methods: A total of 13 surgeons experienced in hepatobiliary surgery and/or minimally invasive surgery formed an expert consensus panel in Shanghai, China in October 2018. By the modified Delphi method, they presented the relevant evidence, discussed clinical experiences, and derived consensus statements on the use of ICG in hepatobiliary surgery. Each statement was discussed and modified until a unanimous consensus was achieved. Results: A total of 7 recommendations for the clinical applications of ICG in hepatobiliary surgery were formulated. Conclusions: The Shanghai consensus recommendations offer practical tips and techniques to augment the safety and technical feasibility of ICG fluorescence-guided hepatobiliary surgery, including laparoscopic cholecystectomy, liver segmentectomy, and liver transplantation.

Introduction: laparoscopic right posterior sectionectomy is a major challenge for laparoscopic liver surgeons. The right posterior segment lays deep in the abdominal cavity; hence it is difficult to access during laparoscopic surgery. Methods: The patient was 61 years old man and diagnosed with 2 cm sized HCC on segment 7. During hepatectomy, We performed Pringle maneuver by laparoscopic Bull-dog and used Cavitron Ultrasonic Surgical Aspirator(CUSA) for the parenchymal transection. We used THUNDER-BEATÔ (Olympus) for sealing, and division of Small hepatic vein branches and small glissonian pedicles, and iDriveTM Ultra Powered Stapling device (Medtronic) for major glissonian pedicle and large hepatic veins resections. At the end of the procedure, we placed the specimen in an endo-bag and extracted through Pfannenstiel incision.Results: we had no specific event during operation and no complication after surgery. The operation time was 250 min and the estimated blood lost less than 200 ml. On postoperative day 3, the computed tomographic scan showed no pathological findings. The patient was discharged on postoperative day 6 without complications. Conclusions: We argue that the laparoscopic posterior sectionectomy is safe and feasible for HCC.

This is a case of a 42 y/o who presented with recurrent left flank pain. Work-ups revealed a mass at the pancreatic body, cystic mucinous epithelial neoplasm by FNAB, and an ovoid lesion attached to the left adrenal gland, to consider metastasis. Objectives of this video are: to present a case of simultaneous laparoscopic transabdominal adrenalectomy and spleen-preserving subtotal pancreatectomy using same-port placement; and to present the use of fluorescence imaging using ICG in vascular angiography, identification and preservation of splenic vessels.

abdominal pain. Operative time was 280 mins and estimated blood loss was 100ml. Post-operative recovery was uneventful and he was discharged on the 8 th postoperative day. Histology showed moderately differentiated ductal adenocarcinoma, pT3N1, (1/10) and margins were negative. He is currently well on follow up and was commenced on adjuvant chemotherapy. The video describes our operative technique of this procedure.

The development of portal vein thrombosis (PVT) in cirrhotic patients awaiting liver transplantation is unclear. PVT not only aggravates liver function but also challenges liver transplantation techniques. We aimed to investigate possible predictive factors relating with PVT and the outcome after liver transplantation (LT). Method: From January 2013 to December 2015, a total of 349 cirrhotic patients who were awaiting liver transplantation were included. PVT is defined by radiologyrevealed filling defect in portal vein (PV) in all patients. Of the patients had liver transplantation, PV was confirmed with a PV thrombus during operation. We have assessed the correlation of the development of portal vein thrombosis (PVT, n=48) and the opposite group (non-PVT, n=301) with clinicopathologic features by Pearson's chisquared test. Univariate and multivariate analyses were carried out to identify independent risk factors, followed by survival analysis. Result: Forty-eight (13.8%) among all patients had PVT. The average MELD score was 16.4AE7.5. Presence of esophageal varices (EV), a positive EV bleeding history, INR prolongation, thrombocytopenia and relative deficiency of protein C and protein S level were observed for patients with PVT. Eighteen of forty-eight patients and 145 of 301 patients received liver transplantation in PVT and non-PVT group, respectively. Multivariate analysis demonstrated low protein S level (P= 0.017, HR= 2.46, 95% CI=1.17-5.46) as the only independent risk factor for PVT development. Protein S deficiency demonstrated prognostic value on short-term survival, not only for cirrhotic patient awaiting LT (1-year OS: 69.9 v.s 84.1%, p=0.012), but also for whom after LT (1-year OS: 70.4 v.s 84.8%, p=0.047). Conclusion:In cirrhotic patients awaiting LT, PVT development cause lots of clinical complexity and surgical challenges. Protein S deficiency not only correlates with PVT but also acts as an indicative prognostic factor independently. We suggest early LT for certain cases for a better Result.