Augmented reality navigation-assisted laparoscopic radical resection guided by the middle hepatic vein for giant hepatocellular carcinoma in the caudate lobe after neoadjuvant therapy

Abstract

Surgical resection is an effective treatment for malignant tumors in the caudate lobe of the liver. In view of the deep anatomical location of the caudate lobe and the complex adjacent structures, this operation has a high risk. In this case, we adopted a strategy of first neoadjuvant therapy to reduce the volume of the tumor, and then with the help of augmented reality navigation (ARN) technology, the middle hepatic vein (MHV) was used to guide the operation, and the tumor was finally successfully removed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12672-026-04782-y.

Background

Left-sided hepatectomy combined with caudate lobectomy is an effective treatment strategy for malignant tumors in the caudate lobe of the liver [1]. However, the caudate lobe’s deep location and complex surrounding structures pose significant surgical risks, especially for patients with large tumors. In this case, we adopted a strategy of prioritizing neoadjuvant therapy to reduce tumor volume before proceeding with surgical resection [2]. The timing of surgery post-neoadjuvant therapy is challenging. To optimize decision-making, we used a combination of individualized three-dimensional (3D) reconstruction models and laboratory indicators for dynamic evaluation, alongside augmented reality navigation (ARN) technology and indocyanine green (ICG) fluorescence imaging to guide laparoscopic left hemihepatectomy and caudate lobectomy. (In the present case, the 3D reconstruction process was performed utilizing the “MI-3DVS” software platform. The augmented reality navigation system was implemented based on the “Laparoscopic Hepatectomy Navigation System (LHNS)” software platform.)

Methods

A 37-year-old male was diagnosed with hepatocellular carcinoma (HCC), BCLC stage A3. Due to the large tumor size in the caudate lobe and severe vascular compression, surgery was initially not prioritized. After three cycles of neoadjuvant therapy, the lesion showed a partial response (PR) according to the mRECIST criteria. Upon re-evaluation, the tumor volume was reduced by 219.19 ml (Fig. 1A), and compression of the left hepatic vein (LHV) was relieved. The compression of the inferior vena cava (IVC) by the tumor has also been relieved (Fig. 1B–C). The remnant liver volume increased from 53.64% to 61.88%, with an adequate resection margin (Fig. 1D). Based on these findings, left hemihepatectomy combined with caudate lobe hepatectomy was performed. We intravenously administered 27.5 mg of indocyanine green (ICG) to the patient 36 h before surgery for two purposes: first, to measure the patient’s ICG-R15 value, and second, to perform fluorescent staining of the liver [3]. Under the guidance of ARN, the four middle hepatic vein (MHV)-Vn branches were sequentially isolated to expose the middle hepatic vein, and the root of the LHV was dissected out along the MHV and divided (Fig. 1E). Under the guidance of ICG fluorescence imaging (Fig. 1F) and intraoperative ultrasound, anatomical hepatectomy was successfully completed. Four complications were monitored as potential outcomes: liver failure, biliary leakage, ascites, and surgical site infection. In this case, the patient did not experience any of the aforementioned complications within 90 days postoperatively. Furthermore, postoperative follow-up results indicated a sustained decline in the patient’s tumor markers. The three-month follow-up showed that the alpha-fetoprotein (AFP) level decreased from 25,163.0 µg/L preoperatively to 22.1 µg/L, with no signs of tumor recurrence detected on ultrasound or CT imaging examinations.

Fig. 1.

Visualization of liver tumor surgical planning based on CT and 3D reconstruction with ARN and intraoperative ICG fluorescence imaging application. A CT-Based tumor size assessment; B 3D Reconstruction: tumor compression on the LHV; C 3D Reconstruction: tumor compression on the IVC; D Surgical planning using 3D reconstruction; E Real-Time ARN in the navigation computer; F Intraoperative ICG fluorescence imaging for resection margin determination (The red dotted line in the picture is the boundary line between the left and right hemispheres of the liver and also the incision margin on the liver surface)

Results

The total operative time was 370 min, with an estimated blood loss of 200 ml. No postoperative complications occurred, and the patient was discharged on postoperative day 9. During the postoperative period until discharge, the patient was under close observation. Within 9 days, the patient demonstrated smooth recovery without developing any postoperative complications including but not limited to hemorrhage, bile leakage, liver failure, abdominal infection, wound infection, or pulmonary infection. Prior to discharge, the patient exhibited stable vital signs, restored bowel function, and tolerance to regular diet. The surgical incision appeared well - healed with no signs of erythema, swelling, or exudate. The patient regained independent ambulatory capacity.

Conclusion

Neoadjuvant therapy combined with 3D reconstruction, AR technology and ICG fluorescence imaging technology can reduce surgical risks in patients undergoing hepatic caudate lobe hepatectomy, providing a safer and more effective treatment approach.

Discussion

This video shows in detail the complete diagnosis and treatment of a 37-year-old patient with HCC who experienced significant tumor volume reduction after neoadjuvant therapy and finally successfully underwent successful tumor resection through precision surgery [4]. Throughout the treatment process, the team conducted multiple rigorous surgical feasibility assessments by integrating 3D reconstruction technology with imaging findings and laboratory indicators. Through comprehensive evaluation of tumor-related biomarkers, tumor dimensions, degree of vascular compression, and hepatic functional reserve, we precisely determined the optimal surgical timing following the third cycle of neoadjuvant therapy. Before the operation, 3D reconstruction technology was used to simulate the surgical scene, and ICG fluorescence staining technology was used to accurately define the surgical margin, which ensured the complete success of the operation.

At initial diagnosis, 3D reconstruction technology was used to comprehensively evaluate the patient’s condition, and continuous dynamic follow-up was then performed throughout the course of neoadjuvant therapy. During therapy, the patient was admitted monthly for evaluation, and CT scan data was obtained. The 3D images were then updated based on these scan data. The patient was evaluated using the 3D data along with other examination results, and a decision was made regarding whether to continue neoadjuvant therapy or proceed with surgical treatment. Compared with traditional 2D imaging modalities such as CT and MRI, 3D reconstruction technology offers improved clarity and precision, presenting intuitive, real-time 3D spatial data on tumor location and size. This greatly improves the efficiency and accuracy of surgical feasibility assessments and risk evaluation.

In addition, 3D reconstruction technology also serves as an auxiliary tool for preoperative planning. It not only provides detailed 3D spatial information about tumors and surrounding structures, but also supports the accurate segmentation and labeling of intrahepatic vascular supply regions. Its volume calculation function provides a scientific basis for the assessment of postoperative residual liver volume. By using this technology, surgeons can simulate the surgical procedure in advance, helping to prevent the damage to key anatomical structures, and thereby reducing surgical risk. In this case, the actual intraoperative findings were highly consistent with the preoperative 3D model, confirming fully verified the reliability of the technique [5].

During surgery, ARN technology was introduced to provide intuitive surgical guidance. By comparing the ARN display with the laparoscopic vision, the surgeon was able to anticipate the surrounding structures, particularly the course and branching of blood vessels. ARN technology clearly visualized vascular branches, helping to prevent vascular injury and improve surgical safety. Moreover, ARN facilitated more efficient and accurate intraoperative decision-making, contributing to a reduction in operative time.

ICG fluorescence technology was also used to assist in liver resection. Despite the ischemic line being unclear during surgery, ICG successfully accumulated at the tumor site, allowing us to easily capture the tumor’s location. Tao Haishu et al. explored the role of ARN combined with ICG fluorescence molecular navigation technology in liver segment 8 resection [6].

Traditional laparoscopic liver cancer resection primarily relies on intraoperative ultrasound for vascular and tumor localization. However, the positioning mode and imaging display of intraoperative ultrasound are limited to 2D planes, requiring repeated movement of the ultrasound probe combined with instruments like harmonic scalpels to determine the tumor’s projection position on the liver surface. Particularly regarding the spatial relationship between peritumoral vessels and the tumor itself, surgeons must mentally reconstruct 3D models of tumors and surrounding critical vessels based on 2D ultrasound or CT images, or visualize three-dimensional models of key vessels along planned resection paths. Furthermore, given that blood vessels exhibit elongated morphology with varying courses, even with intraoperative ultrasound assistance, vascular localization remains heavily dependent on the surgeon’s experience.

In conclusion, 3D reconstruction technology enables dynamic monitoring of tumor changes during neoadjuvant therapy and assists in identifying the optimal time for surgery. Preoperative assessment using 3D reconstruction, combined with ARN and ICG fluorescence technologies reduces the difficulty of caudate lobe tumor resection and improves the safety and accuracy of surgery. This integrated approach provides a safer and more effective treatment option for patients with caudate lobe liver cancer. With technological advancements, the precision of 3D reconstruction technology and ARN systems continues to improve, enabling recognition of increasingly finer anatomical structures. The iterative updates of these technologies and reduced software costs have created conditions for their comprehensive adoption in hepatobiliary surgery field. Simultaneously, laparoscopes equipped with ICG fluorescence imaging capabilities are becoming increasingly prevalent. More medical institutions are now applying ICG fluorescence imaging technology in clinical practice, marking its transition from specialized to mainstream surgical applications. However, despite the advantages of enhanced visualization and 3D reconstruction technologies, certain limitations remain. In particular, subtle vascular structures may occasionally be ignored, and there may be a margin of error when identifying some organs. In addition, intraoperative changes in organ morphology may affect the performance of enhanced visualization, which requires the necessary semi-manual adjustments by 3D navigation personnel to ensure accuracy and reliability [7]. Moreover, as this study is a single-case report, the application of 3D reconstruction technology in determining surgical timing, as well as the combined effect of ARN technology, intraoperative ultrasound, and indocyanine green fluorescence navigation in reducing surgical complications, the research team is conducting a multi-center and multi-cohort study to further verify these findings.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

J.M. contributed to manuscript writing and video editing. H.Z. contributed to manuscript writing. Y.Z. and X.Z. performed critical review and provided revision recommendations. P.C. collected and organized the case data.Z.L. was involved in the surgical procedure for this case. S.Z. secured funding and conducted manuscript review. N.Z. provided funding support and participated in the surgical intervention.

Funding

This work was supported by National Natural Science Foundation of China (C-class Youth Project) [82502416]; 2023 Macao Key Research and Development Funding Program [LCYJ230502]; Overseas Distinguished Professor Program of the Department of Science and Technology of Guangdong Province [SKJH22003]; the Guangdong Provincial Undergraduate Teaching Reform Research Project of Clinical Teaching Base [2021JD140]; Project on the Construction of Regional Innovation Capability and Support System in Guangdong Province [2023A141020025]; 2021 Appropriate Technology Promotion Project by the Guangdong Provincial Health Commission [210019921004]; 2023 Guangzhou Basic and Applied Basic Research Project [2023A04J0445]; Postdoctoral Fellowship Program and China Postdoctoral Science Foundation [BX20250243]; China Postdoctoral Science Foundation [2024M761321]; Guangzhou Basic and Applied Basic Research Program [2025A04J3871]; President’ s Fund of Zhujiang Hospital [yzjj2024qn04].

Data availability

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Declarations

Ethics approval and consent to participate

The study was approved by the Medical Ethics Committee of Zhujiang Hospital of Southern Medical University (Ethics Approval No. 2024-YK-274). All operations involving human participants have been conducted in accordance with the Helsinki Declaration. Written informed consent was obtained from all participants prior to surgery, including permission to use their anonymized clinical data for research.

Author disclosures

Our institution did not receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect of the submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.). There are no relevant conflicts of interest. Not planning, pending, or issued, broadly relevant to the job. No other relationships/conditions/circumstances that present a potential conflict of interest relationships.

Consent for publication

All participants gave consent for the publication of the article.

Competing interests

The authors declare no competing interests.