Background : Indocyanine green (ICG) fluorescence positive staining can visualize intrahepatic and extrahepatic intersegmental interfaces for laparoscopic anatomical combined subsegmental resection of segment 8 (S8). However, some unexpected staining situations still occur in clinical practice, such as incomplete staining of target liver segments and staining of adjacent subsegments. Few case reports have explained in detail how to continue to perform the combined subsegmentectomy as planned in such cases.

Methods : In this study, a 56-year-old man with a liver tumor located in the S8 underwent S8dor+S8med combined subsegmental resection guided by ICG fluorescence positive staining. To solve the unexpected staining situation during the operation, we first used the preoperative three-dimensional (3D) model to identify the correct fluorescence border, after which laparoscopic intraoperative ultrasound was used to extend the border. In the second step, we transected the liver parenchyma into the deep layer along the correct fluorescence border, dissected and clipped the S8dor Glissonean pedicle. Then, the ischemic line was used to modify the original fluorescence border. Finally, S8dor+S8med combined subsegmentectomy was performed under the guidance of the modified fluorescence border and hepatic vein.

Results : The operation was completed in 240 min, with a blood loss of 50 ml. The histopathologic diagnosis indicated a moderately differentiated HCC. The patient was discharged on postoperative day 7 without any complications.

Conclusions : In the unexpected situation of ICG positive staining, it is feasible to accurately perform laparoscopic anatomical combined subsegment resection by using a two-step strategy.