Tailored subsegmental resection using augmented reality navigation combined with fluorescence imaging for hepatocellular carcinoma in the right liver: a propensity score-matched cohort study on parenchymal preservation and oncologic outcomes

Background: For right hepatocellular carcinoma (HCC) involving multiple segments, right hemihepatectomy (RH) is standard but often precluded by insufficient future liver remnant (FLR). This study aimed to evaluate the feasibility and safety of augmented reality navigation and indocyanine green fluorescence imaging (ARN-FI)-guided tailored subsegmental resection (TSR) to optimize parenchymal preservation without compromising oncologic outcomes. Methods: A total of 89 consecutive patients with right HCC ineligible for RH due to insufficient FLR from January 2020 to October 2024 were retrospectively analyzed and divided into the TSR group ( n = 24) and the NAR (non-anatomical resection) group ( n = 65). Both groups utilized multimodal guidance but with different navigational strategies: TSR employed ARN-FI for anatomical subsegmental guidance, while NAR used it for tumor localization. Propensity score matching was used to balance baseline characteristics. Perioperative and survival outcomes were compared. Results: After matching, there were 24 patients in the TSR group and 48 patients in the NAR group. Preoperative three-dimensional planning showed that TSR significantly increased FLR% from 34.5% (simulated RH) to 57.6% ( P < 0.001). Compared with the NAR group, the TSR group exhibited longer operation time and postoperative hospital stays, higher alanine aminotransferase levels and total bilirubin on postoperative days 1 and 3, but lower incidences of ascites and pleural effusion. The 1- and 3-year recurrence-free survival (RFS) rates in the TSR and NAR groups were 90.9% versus 75.6%, and 74.7% versus 46.2%, respectively ( P = 0.028). Multivariable analysis identified TSR as a protective factor for recurrence (hazard ratio = 0.30, P = 0.015). Conclusions: For patients with right HCC ineligible for RH because of insufficient FLR, ARN-FI-guided TSR is associated with superior parenchymal preservation and RFS compared to NAR in this propensity-matched analysis, meriting consideration as a viable alternative surgical strategy.