Fluorescence-guided Robotic Total Mesorectal Excision with Lateral Pelvic Lymph Node Dissection in Locally Advanced Rectal Cancer: A Video Presentation

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Lateral pelvic lymph node dissection (LPND), beyond the total mesorectal excision (TME) plane, is selectively suggested for treating suspected lymph node metastasis in the pelvic sidewall in patients with rectal cancer who have undergone preoperative chemoradiotherapy.1–3 However, technical difficulties can cause incomplete dissection of lateral pelvic lymph nodes, allowing them to remain in the pelvic sidewall.
Near-infrared fluorescence imaging (FI) in surgical fields provides real-time information on blood or lymphatic flow. Especially during cancer surgery, FI can provide landmarks to guide the dissection of lymph nodes by visualizing them in real time.4,5 Subsequently, it seems to be more helpful to completely dissect nonvisible lymph nodes under the conventional procedure.
In the present video, we demonstrate a novel application of FI using indocyanine green during robotic TME with LPND to identify lateral pelvic lymph nodes and prevent their incomplete dissection. In this procedure, indocyanine green at a dose of 2.5 mg was injected around the tumor transanally before surgery. The extent of LPND is considered as 6 zones: the internal iliac, midrectal, obturator, common iliac, external iliac, and aortic bifurcation areas.6,7 However, lymphadenectomy outside the external iliac vessels and in the para-aortic area is performed in the case of highly suspicious metastatic nodes being along those vessels. The entire procedure was performed by G.-S.C. using a totally robotic approach.
Lymph nodes around the inferior mesenteric artery and pelvic sidewall were clearly identified and removed under guidance of real-time FI. After completing LPND, FI was performed again to identify the remaining lymph nodes. Finally, only nerves and vessels without fluorescence-stained lymph nodes were observed in the pelvic sidewall.
Fluorescence imaging–guided robotic TME with LPND allows the surgeon to identify lymph nodes and lymphatic drainage of rectal cancer with great reliability. However, this technique should be more standardized and studied further to identify more benefits of its use in the surgical fields. See Video at http://links.lww.com/DCR/A439.

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