Laparoscopic extended colectomy is a standard procedure for hepatic flexure tumours. Complete mesocolic excision improves specimen quality and lymph node yield [1-3]. In the case of cT4b colon cancer, the laparoscopic procedure may be challenging due to the involvement of other visceral organs and also cost consuming due to the use of multiple endo-staplers.Video S1 demonstrates a step by step approach to laparoscopic extended colectomy with complete mesocolic excision for a hepatic flexure tumour involving the jejunum with emphasis on radicality of the surgery and cost reduction.
Purpose
Identifying tumor location is important in colorectal tumor resection. Preoperative endoscopic India ink marking is a widespread practice, but local injection of ink is an unstable procedure. Although it is often invisible, the ink may be sprayed into the peritoneal cavity and contaminate the surgical field. At our hospital, we introduced fluorescent clip marking (FCM) using the Zeoclip FS®, an endoscopic clip developed using near-infrared fluorescent resin. We tested the usefulness of FCM by retrospectively comparing cases in which FCM was used with cases in which conventional ink marking was used.
Methods
We enrolled 305 patients with colorectal tumors who underwent colorectal surgery after preoperative marking from January 2017 to April 2022. We classified the patients into the FCM group (86 patients) and the India ink tattoo group (219 patients). Endoscopic marking was completed in the FCM group by the day before surgery, and fluorescence was evaluated during surgery with a fluorescent laparoscopic system. Patient backgrounds, marking visibility, adverse effects, and early postoperative results were retrospectively compared between groups.
Results
Marking was visually confirmed in 80 patients in the FCM group (93.02%) and in 166 patients in the India ink tattoo group (75.80%) (p = 0.0006). In the group with India ink tattoos, contamination of the surgical field was observed in seven cases (3.20%). No adverse events were observed in the FCM group.
Conclusion
In colorectal surgery, FCM provides better visibility than the conventional India ink tattooing method and is a simple and safe marking method.
Clinical trial registration
Examination of fluorescence navigation for laparoscopic colorectal cancer surgery.
Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2020-3. https://kawaguchi-mmc.org/wp-content/uploads/clinicalresearch-r02.pdf.
omplete mesocolic excision and central vascular ligation (CVL) have been debated and gradually accepted by colorectal surgeons. [1][2][3] CVL is especially recommended in Japanese guidelines. 4 Colon cancer of the splenic flexure represents approximately 1% to 8% of all colon cancers, and complete mesocolic excision and CVL using the laparoscopic approach are still considered difficult because of the many blood vessel variations. [5][6][7][8][9] However, 3-dimensional (3D) CT angiography can show the details of vascular branching. [10][11][12][13][14] In this study, 3D images of the vascular anatomy created from CT scans were downloaded to wearable glasses, which were then used for virtual and mixed reality, using the Holoeyes MD system (Holoeyes, Inc., Tokyo, Japan).Preoperative navigation was performed using Meta Quest 2 (nontransmissive glasses; Meta Platforms, Inc., Menlo Park, CA; approximately $500), and intraoperative navigation was performed using HoloLens2 (transmissive glasses; Microsoft, Inc., Redmond, WA; approximately $3000). Magic Leap 1 (Magic Leap, Inc., Plantation, FL, approximately $1800) is another type of glasses that can be used for this navigation.Lymph node dissection and blood vessel resection were performed by viewing a hologram similar to
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