Robotic Low Ligation of the Inferior Mesenteric Artery for Rectal Cancer Using the Firefly Technique

Abstract

Purpose: By integrating intraoperative near infrared fluorescence imaging into a robotic system, surgeons can identify the vascular anatomy in real-time with the technical advantages of robotics that is useful for meticulous lymphovascular dissection. Herein, we report our initial experience of robotic low ligation of the inferior mesenteric artery (IMA) with real-time identification of the vascular system for rectal cancer using the Firefly technique.

Materials and methods: The study group included 11 patients who underwent a robotic total mesorectal excision with preservation of the left colic artery for rectal cancer using the Firefly technique between July 2013 and December 2013.

Results: The procedures included five low anterior resections and six ultra-low anterior resections with loop ileostomy. The median total operation time was 327 min (226-490). The low ligation time was 10 min (6-20), and the time interval between indocyanine green injection and division of the sigmoid artery was 5 min (2-8). The estimated blood loss was 200 mL (100-500). The median time to soft diet was 4 days (4-5), and the median length of stay was 7 days (5-9). Three patients developed postoperative complications; one patients developed anal stricture, one developed ileus, and one developed non-complicated intraabdominal fluid collection. The median total number of lymph nodes harvested was 17 (9-29).

Conclusion: Robotic low ligation of the IMA with real-time identification of the vascular system for rectal cancer using the Firefly technique is safe and feasible. This technique can allow for precise lymph node dissection along the IMA and facilitate the identification of the left colic branch of the IMA.

Keywords: Robotics; blood supply; colectomy; colonic neoplasm; fluorescence; indocyanine green.

Fig. 1. Port placement for totally robotic rectal surgery using the single docking dual phase technique. (A) Port placement in the colonic stage. (B) Port placement in the pelvic stage.

Fig. 2. Robotic-assisted lymph node dissection around the IMA with preservation of the LCA using the Firefly technique. (A) Dissection around the root of the IMA (white light image). (B) INIF image before visualizing the LCA by excited fluorescence. (C) INIF image of visualizing the LCA by excited fluorescence. (D)Skeletonization of the LCA and SRA from the IMA. (E) Low ligation of the IMA preserving the left colic branch. (F) Confirmation of blood flow of the LCA by INIF imaging. IMA, inferior mesenteric artery; LCA, left colic artery; INIF, intraoperative near infrared fluorescence; SRA, superior rectal artery.

Fig. 3. Identification of the collateral artery near the IMV and pancreas. (A) Assessing the anatomical blood supply around the pancreas and IMV (white light image). (B) INIF imaging before visualizing the vascular flow by excited fluorescence. (C) INIF image of visualized arterial flow by excited fluorescence. (D)High ligation of the IMV with avoidance of injury to collateral vessels. IMV, inferior mesenteric vein; INIF, intraoperative near infrared fluorescence.