Laparoscopic Complete Mesocolic Excision and Fluorescence Lymphatic Mapping for Right Colectomy with Trasvaginal Specimen Extraction

Luigi Boni, MD, FACS, Elisa Cassinotti, MD, PhD, Alessandro Marzorati, MD, Matteo Lavazza, MD. Minimally Invasive Surgery Center, Univerisity of Insbubria

This video shows our technique for full laparoscopic right colectomy for cancer with complete mesocolic excision (CME) with fluorescence lymphatic mapping using indocyanine green (ICG) and trasvaginal specimen extraction.

The patient is placed in lithotomy and we use 4 tocars as shown in the video.

At this point, using a fine needle, the area where the cancer is located is injected with 3 cc of ICG inside the colonic wall.

After 3-5 minutes, switching from standard to near infra-red light the lymphatic channel draining from the area of the tumor start to became visible. In this specific case one route along the ileo-colic route and a second along the middle colic route are identified.

For the CME dissection starts at the level of the superior mesenteric vessels exposing and dissecting the route of the superior mesenteric vein (SMV) and ileo-colic artery and vein clipped and divided.  Following the route of the SMV dissection is carried on up to the origin of the middle colic (no right colic was present in this patient) and switching to NIR a third lymphatic route along the right branch of the middle colic vessels was identified. The middle colic were dissected, clipped and divided. At this point the transverse colon was divided using a linear stapler and the hepatic flexure mobilized. The mesentery of the terminal ileum was divided and the colectomy completed.

Perfusion of the ileum and transverse colon was checked using ICG fluorescence and side-to-side ileo-colic intra corporeal anastomoses is carried out.

At this point, a large endo-bag is introduced into the vagina and used as guide for posterior colpotomy performed using monopolar cautery.

The specimen is introduced into the endo-bag extracted through the vagina. colpotomy is closed  using absorbable suture.

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