Suprapancreatic Lymph Nodes Dissection Using a Novel Multijoint Articulating Instrument and Simultaneous Near-Infrared Image in Patient with Gastric Cancer

Abstract

Introduction: Optical imaging using near-infrared (NIR) fluorescence is now actively used to observe structures during real-time surgery. The advantages of NIR fluorescent light (700–900 nm) include high tissue penetration and low autofluorescence, which enable sufficient contrast.1 Lymph node dissection along the suprapancreatic area (e.g., nodes 7, 8a, 9, 11p, and 12a) during laparoscopic gastrectomy remains challenging even for an experienced surgeon. Fluorescent lymphography may be useful for performing a complete lymphadenectomy by assessing the adequacy of lymphadenectomy in real time.2 To facilitate this procedure, a sophisticated articulation device was used with NIR fluorescence imaging guidance.3 Materials and Methods: A 54-year-old man was found to have gastric adenocarcinoma located at the midbody along the lesser curvature of the stomach. An abdominal computed tomography scan revealed clinical stage T2N1M0. No metastatic lesions were found on preoperative testing. Laparoscopic distal gastrectomy was performed with a D2 lymph node dissection. The laparoscopic articulating instrument with a multijointed structure that synchronized with the surgeon's hand, wrist, and finger movements was used to facilitate the lymph node dissection. Of note, indocyanine green was injected submucosally at four sites around the cancerous tissues during intraoperative endoscopy before the lymph node dissection. Results: The operating time was 150 minutes, and the estimated blood loss was 30 mL. The patient recovered well, and he was started on a liquid diet on postoperative day 3. He was discharged on postoperative day 6 without any complications. The final pathologic report revealed that 45 lymph nodes had been retrieved and 2 were metastatic. He received adjuvant therapy and is alive at 1.6 years follow-up without recurrence. Conclusion: The suprapancreatic lymph node dissection procedure can be accomplished by using a novel multijointed articulating instrument and simultaneous NIR imaging in a patient with gastric cancer. No competing financial interests exist. Runtime of video: 7 mins 41 secs