Wanda Petz, MD, Dario Ribero, Emilio Bertani, Alessandra Piccioli, Simona Borin, Diana Baldassarri, Giuseppe Spinoglio. European Institute of Oncology
Background: In robotic right hemicolectomy for cancer, appropriate lymphadenectomy and anastomotic leak prevention are critical. Moreover, the identification of the site of an initial tumour can be demanding. Visualization of draining lymph nodes, site of primary tumour and blood flow with near-infrared (NIR) fluorescence DaVinci® imaging system is a recent development. We present the technique of robotic right colectomy with complete mesocolic excision (CME) and D3 lymphadenecomy using Indocyanine Green (ICG) fluorescence.
Methods: The day before surgery, in patients scheduled for robotic right colectomy a colonoscopy is performed and four injections of 1.5 ml of ICG solution of are realized around the tumor in the submucosa. Robotic right hemicolectomy is performed with suprapubic trocars layout and bottom to up dissection, realizing a CME with central vessel ligation and a D3 lymphadenectomy. Site of primary tumour is identified as a fluorescent colonic area, and lymphatic basin is visible with the Firefly camera modality. In the case of fluorescent lymph nodes (LN) detected outside standard lymphadenectomy area, these are removed with the “berry-picking” technique.
ICG is then intraoperatively administered intravenously (0.05 mg/kg of ICG solution at a dilution of 2.5 mg/ml) to objectively assess bowel perfusion before bowel anastomosis. After a short time (approximately 30–60 s), perfusion of terminal ileum and colon is visually confirmed. In cases of malperfusion the resection is extended. Facultatively intravenous ICG administration can be performed after anastomosis to confirm its adequate perfusion.
Results: From July 2016 to september 2017, 32 patients received a robotic right colectomy with CME, D3 lymphadenectomy and bottom-to-up approach with Da Vinvi Xi system.
ICG intravenous injection was realized in all patients, with a correct visualization of bowel stumps perfusion in 100% of cases.The site of bowel resection was never changed because of malperfusion. In 12 patients, ICG submucosal injection was performed: visualisation of the site of primary tumour was possible in all cases, LN in the D3 area were identified in 11/12 patients (92%); in 5/12 patients (42%), LN out from anatomical lymphatic basin were identified.
No side effects were observed.
Conclusions: In this series, intravenous and submucosal ICG injection confirmed to be feasible and safe; identification of site of orimary tumour and of bowel stumps perfusion were possible in all cases.
The accuracy in identification of D3 lymphatic basin was high, thus permitting an image-guided radical lymphadenectomy. Fluorescent technology represents an interesting innovation to ameliorate surgery of colon cancer
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87670
Program Number: S098
Presentation Session: Robotics 2 Session
Presentation Type: Podium
sages_adbutler_leaderboard