Fluorescence‐guided D3 lymphadenectomy in robotic right colectomy with complete mesocolic excision

Abstract

Background In robotic right hemicolectomy for cancer, appropriate lymphadenectomy is essential. Visualization of draining lymph nodes and blood flow with near‐infrared (NIR) fluorescence DaVinci® imaging system is a recent development. We present the technique of robotic right colectomy with complete mesocolic excision (CME) and D3 lymphadenectomy using Indocyanine Green (ICG) endoscopic submucosal injection to intraoperatively identify tumour lymphatic basin. Methods The day before surgery, in patients scheduled for robotic right colectomy an endoscopic submucosal injection of 3 mg of ICG solution around the tumor is realized. Robotic right hemicolectomy is performed with suprapubic trocars layout and “bottom to up dissection”, realizing a CME with central vessel ligation and D3 lymphadenectomy. Site of primary tumor and lymphatic basin are visible with the FireflyTM camera modality. Results From July 2016 to July 2020, 85 patients received a robotic right colectomy with CME and D3 lymphadenectomy. In 50 patients, ICG submucosal injection was performed: visualisation of the site of primary tumour and of LN in the D3 area was possible in all cases; in 17/50 patients (34%), LN out from anatomical lymphatic basin were identified. No side effects were observed. Conclusions In this series, submucosal ICG injection showed to be feasible and safe. The accuracy in identification of D3 lymphatic basin was high, thus permitting an image‐guided radical lymphadenectomy. Fluorescent technology represents an interesting innovation to ameliorate surgery of colon cancer.

Updates on Robotic CME for Right Colon Cancer: A Qualitative Systematic Review

“…After duplicate censoring, fourteen studies were included in this review [22][23][24][25][26][27][28][29][30][31][32][33][34][35], and the publication dates ranged from 2013 to 2021.…”

“…There are ten retrospective non comparative case series [22,23,[27][28][29][30][31][33][34][35] and four comparative studies (three retrospective and one prospective) of robotic versus laparoscopic CME for right colectomy [24][25][26]32]; the patient number ranges from 20 to 202.…”

“…The da Vinci Xi robotic platform has been utilized in nine of the fourteen studies [23,25,28,30,31,33,35], the Si platform in two [22,24], the X platform in one [35] and both the Si and the Xi in the remaining two [29,32].…”

“…Four different approaches to colonic dissection, CME and lymphadenectomy are reported, the difference essentially residing in the sequence of surgical steps and the direction of detachment of the mesocolon from the retroperitoneum: a "medial-to-lateral" approach [22,24,30,32], a "bottom-to-up" approach [23,25,28,29,31,35], a "top-to-down" approach [26] and a "superior mesenteric vein first" approach [27,33,34].…”

“…The ileo-colic anastomosis was performed intracorporeally in ten out of the fourteen studies [22][23][24][25]29,[31][32][33][34][35] and extracorporeally in two [28,30]; both the techniques have been utilized in two studies [26,27], in which, however, the number of patients receiving intracorporeal or extracorporeal anastomosis is not specified.…”