Near‐infrared laparoscopic fluorescence to guide fascial plane identification in total mesorectal excision for rectal cancer: A Video Vignette

Abstract

Fluorescence lymph node mapping in colorectal cancer has most often being examined for utility in its identification of specific nodes either within or without standard resection fields. Indeed, we have detailed is use elsewhere in this supplement for determination of potentially significant lymph node basins on the pelvic side wall 1 and also previously regarding mescolic node mapping for colon cancer 2. Others have suggested its incorporation alongside TEM resection 3 where the mesorectal nodes may be selectively targetted from within the rectum via the mural excision site. However it may also be of more elementary value in simply guiding the surgeon easily and efficently along embryological planes in order to ensure explicit intraoperative clarity of dissection in total mesorectal or complete mesocolic excision (TME or CME respectively). It may also guide the level of high arterial ligation to secure inclusion of the apex node within the resected specimen. The associated video demonstrates this. The concept is based on the fact that submucosal injection of 2–3 ml indocyanine green (ICG) at the tumor site will provide a depot of dye that continally and passively leaches into and through the lymphatics and nodal basin within the fascial compartment targeted with TME or CME surgery. While early laparoscopic assessment may allow identification of the first draining lymph node, re-examination of the same areas later in the operation will show additional and perhaps all of the lymph nodes within the fascial envelope being resected. This can help guide the surgeon or interested and especially perhaps inexperienced observers, trainees or students in understanding the embryological planes required for effective and efficient oncological surgery. This may be especially useful when the rectum and mesorectum are being mobilised and also for determining precisely the level of arterial ligation to ensure the highest node is included and specifically labelled with the specimen sent for pathological analysis. The authors have no conflicts of interest to declare. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.