Purpose: This video aims to describe the use of
Indocyanine green (ICG) fluorescence technology to
delineate bowel perfusion and to describe the technical
aspects of transanal extraction with single stapling
technique of the colorectal anastomosis for low anterior
resection.
Methods: This is a 50 year-old male with T2N0 rectal
cancer who is taken to the operating room for robotic-assisted
laparoscopic low anterior resection with transanal
extraction and the use of Indocynine Green fluorescence
(ICG).
Results: Patient is positioned is in modified lithotomy.
A laparoscopic medial to lateral dissection of the
descending colon and rectum is performed. After high
ligation of the inferior mesenteric vein and lateral and
splenic mobilization of the colon, the four-arm Da Vinici
robot is docked. The inferior mesenteric artery is divided.
A total mesorectal excision of the rectum down to the
anal canal is performed. The optimal point of transection
is then marked by the surgeon under white (visible) light
followed by intravenous injection of 6-8 mg of ICG. The
bowel is then visualized via near infrared laparoscopy and
the point of transection of the proximal is revised based on
optimal bowel perfusion. The specimen is extracted via a
wound protector through the anus and divided extracorporeally.
An anvil is secured to the descending colon and
is returned to the abdomen. A purse string is then secured
to the rectal stump and tied around the open spike of the
end to end stapler. An end-to-end colorectal anastomosis
is performed. Flexible sigmoidoscopy reveals pink mucosa
and a negative air-leak test.
Conclusions: This video demonstrates the feasibility
and advantages of the use of fluorescence imaging during
creation of anastomosis; the advantages of endoscopic
imaging to delineate integrity of the anastomosis as well
the technique with regards to creating a single staple anastomosis
and transanal extraction during a low anterior
resection.