Abstract
The quality of mesorectal resection is crucial for resection in rectal cancer, which should be performed by laparoscopy for better outcome. The use of indocyanine green (ICG) fluorescence is now routinely used in some centers to evaluate bowel perfusion. Previous studies have demonstrated in animal models that selective intra-arterial ICG staining can be used to define and visualize resection margins in rectal cancer. In this animal study, we investigate if laparoscopic intra-arterial catheterization is feasible and the staining of resection margins when performing total mesorectal excision with a laparoscopic medial to lateral approach is possible. In 4 pigs, laparoscopic catheterization of the inferior mesenteric artery (IMA) is performed using a seldinger technique. After a bolus injection of 10 ml ICG with a concentration of 0.25 mg/ml, a continuous intra-arterial perfusion was established at a rate of 2 ml/min. The quality of the staining was evaluated qualitatively. Laparoscopic catheterization was possible in all cases, and the average time for this was 30.25 ± 3.54 min. We observed a significant fluorescent signal in all areas of the IMA supplied, but not in other parts of the abdominal cavity or organs. In addition, the mesorectum showed a sharp border between stained and unstained tissue. Intraoperative isolated fluorescence augmentation of the rectum, including the mesorectum by laparoscopic catheterization, is feasible. Inferior mesenteric artery catheterization and ICG perfusion can provide a fluorescence-guided roadmap to identify the correct plane in total mesorectal excision, which should be investigated in further studies.
Highlights
Intraarterial Indocyanine Green (ICG) perfusion into the main tumor supplying artery may help to identify the correct resection borders in oncological surgery
This suggests that the laparoscopic approach for lower rectal excision and total mesorectal excision (TME) might be the gold standard for surgery of rectal cancer
After an initial bolus of 10 ml of indocyanine green (ICG), we directly observed an infrared signal
Summary
Intraarterial Indocyanine Green (ICG) perfusion into the main tumor supplying artery may help to identify the correct resection borders in oncological surgery. Patients benefit from minimal-invasive rectal excision due to short-term recovery, fewer surgical site infections, and less overall blood loss[5] while the longterm oncological outcome seems to be comparable in the open versus laparoscopic approach[4,6]. This suggests that the laparoscopic approach for lower rectal excision and TME might be the gold standard for surgery of rectal cancer. There are few studies regarding laparoscopic liver surgery, examining if intraarterial ICG-injection can help identify resection borders In these studies, a hybrid operative suite with a transfemoral. Interventional catheterization would be an option, but just a few hospitals have access to a hybrid operative suite and the risk of complications is described between 0.05 and 2%12,13
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