Goutaro Katsuno, MD, PhD1, Yasuhiko Nakata, MD, PhD1, Nobuyuki Kubota, MD, PhD1, Teruo Kaiga, MD, PhD1, Takao Mamiya, MD1, Naoaki Shimamoto, MD1, Hidetaka Arima1, Shuichi Sakamoto, MD, PhD2. 1Mitsuwadai General Hospital, 2Sakamoto Clinic
Introduction: Laparoscopic (LAP) complete mesocolic excision (CME) with central vascular ligation (CVL) is technically difficult on transverse colon cancer. The main reason for this technical difficulty lies in the anatomical complexity around the superior mesenteric vein (SMV).
Recently major developments in video imaging have been achieved for performing LAP CME. Indocyanine green (ICG) fluorescence imaging is already contributing greatly to making intraoperative decisions for keeping an intact visceral fascial layer, making suitable mesentery division lines and identifying anastomotic perfusions.
We present ICG image guided LAP CME with CVL using Pincer Maneuver.
Patients and Methods: We usually use the near-infrared (NIR) laparoscopy (Stryker Corporation, Michigan, USA) for LAP.
Pincer Manuever: Pincer maneuver refers to an original strategy used to simplify the anatomical complexity around the SMV by approaching the transverse mesocolon caudally and cranially.
Indocyanine green fluorescent imaging: Visualization of lymph flow: ICG (2.5 mg/1.0 mL) was injected into the submucosal layer around the tumor at 2 points with a 23-gauge localized injection before the lymph node dissection .
Visualization of blood flow: After complete colon mobilization, the mesocolon was completely divided at the planned proximal or distal transection line. Indocyanine green was injected intravenously and the transection location(s), if applicable, were re-assessed in fluorescent imaging mode.
Results: LAP CME with CVL using Pincer Maneuver was performed for 52 transverse colon cancer patients. All procedures were successful and there were no serious post-op complications. Of them, ICG-image-guided LAP CME was performed on 21 patients. TNM stage was 0-I in 11 patients, II in 13, and III in 28. The median (range) age of the patients was 68(55–77) years with a median (range) BMI of 24.8 (20–36.4) kg/m2. A high-quality intraoperative ICG lymphangiogram was achieved in all patients (100%). In high-quality lymphangiogram, the lymphatic ducts and lymph nodes were clearly visualized in real time, and this proved useful in keeping an intact visceral fascial layer. A high-quality intraoperative ICG angiogram was achieved in all patients. Anastomotic perfusion was satisfactory in all cases. Only 1 patient required the revision of the proximal colonic transection point before formation of the anastomosis.
1: Laparoscopic complete mesocolic excision (CME) with central vascular ligation for transverse colon cancer is safe and feasible by using Pincer maneuver.
2: ICG-fluorescence-image-system is a simple, safe and useful tool to help us complete LAP CME and check real-time anastomotic tissue perfusion.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 91670
Program Number: V006
Presentation Session: Colorectal I
Presentation Type: Video