Lindsay M Kranker, MD1, Minia Hellan, MD, FACS2. 1Wright State University Boonshoft School of Medicine, 2Wright State University, Division of Surgical Oncology
This video portrays a novel technique for ureter identification using fluorescence imaging. Multiple near-infrared fluorescence video cameras are commercially available, including Firefly (Intuitive Surgical, Inc., Sunnyvale, CA) and Pinpoint (Novadaq Technologies Inc., Bonita Springs, FL). These imaging modalities are widely advertised for their role in assessing tissue perfusion intraoperatively; however, the added functionality of ureter identification depicted in this video is not yet advertised. In this case, a fifty-five year old patient presented with large bowel obstruction at the level of the sigmoid colon of unclear etiology. With the assistance of Urology, bilateral standard, lighted ureter stents were placed. The da Vinci Xi robot was utilized via four robotic arms and two laparoscopic assistant ports. Intraoperatively, a malignant mass of the sigmoid colon attached to the left pelvic side wall and ureter was found. A very distended proximal colon limited the surgical field and influenced the decision to proceed with end colostomy instead of primary anastomosis. A medial to lateral mobilization of the sigmoid and upper rectum was performed starting at the promontory up to the origin of the superior rectal artery. The previously-placed standard lighted ureter stent were hypervisible under near-infrared imaging. Sharp dissection of the upper mesorectum distal to the mass was performed. The superior rectal artery was divided at its origin followed by the sigmoid mesentery and the mid sigmoid colon. A penrose was placed around the proximal rectum for better retraction and exposure of the mass, which was densely adherent to the left pelvic sidewall and ureter. Again, switching between visible light and near-infrared imaging allowed for seamless verification of ureter location. The mass was sharply dissected from the ureter with increased speed and accuracy due to the fluorescence guidance. Finally, the upper rectum was transected with the robotic stapler. At the end of the case, Indocyanine green (ICG) was injected to evaluate the perfusion to the proximal and distal sites of transection. Final pathology showed a Grade II Adenocarcinoma, measuring four centimeters in diameter without lymph node involvement. In this case, the fluorescence imaging altered the planned site of colostomy creation; however, in cases of allergy to ICG, iodine, or iodine dyes, the fluorescence imaging ureter identification could still be completed as it requires no administration of ICG.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79195
Program Number: V182
Presentation Session: Video Loop
Presentation Type: VideoLoop