HOW I DO IT DIFFERENTLY
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Laparoscopic real-time vessel navigation using indocyanine green fluorescence during laparoscopy-assisted gastric tube reconstruction: First experience
Yuma Ebihara1, Toshiaki Shichinohe2, Yo Kurashima2, Soichi Murakami2, Satoshi Hirano2
1 Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine; Division of Minimally Invasive Surgery, Hokkaido University Hospital, Sapporo, Japan
2 Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
|Date of Submission||07-Sep-2020|
|Date of Decision||23-Nov-2020|
|Date of Acceptance||25-Nov-2020|
|Date of Web Publication||06-May-2021|
Division of Minimally Invasive Surgery, Hokkaido University Hospital, North 15 West 7, Kita-Ku, Sapporo 0608638, Hokkaido
Source of Support: None, Conflict of Interest: None
A considerable percentage of morbidity and mortality after oesophagectomy is due to leakage of oesophagogastrostomy, which is mainly caused by ischaemia of the gastric tube. Therefore, we performed laparoscopic real-time vessel navigation (LRTVN) using indocyanine green fluorescence (ICG) during laparoscopy-assisted gastric tube reconstruction (LAGR) to evaluate gastric tube blood flow and avoid vascular injury. This study included five oesophageal cancer patients who underwent video-assisted thoracoscopic oesophagectomy and LAGR. We confirmed the presence of the left gastroepiploic artery (LGEA) in all cases, and no findings such as post-operative gastric tube ischaemia were observed. In all cases, no vascular injury was observed, and the vascularization of LGEA was confirmed. This report is the first to consider the usefulness of LRTVN using ICG during LAGR. LRTVN using ICG during LAGR was considered to be useful for evaluating gastric tube blood flow and avoiding vascular injury around the splenic hiatus.
Keywords: Indocyanine green, laparoscopic fluorescence angiography, oesophageal cancer, oesophagogastrostomy
|How to cite this URL:|
Ebihara Y, Shichinohe T, Kurashima Y, Murakami S, Hirano S. Laparoscopic real-time vessel navigation using indocyanine green fluorescence during laparoscopy-assisted gastric tube reconstruction: First experience. J Min Access Surg [Epub ahead of print] [cited 2021 Jun 14]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=315532
| ¤ Introduction|| |
Oesophagectomy for oesophageal cancer is the most invasive gastrointestinal surgical procedure, and post-operative complications frequently occur. In particular, the occurrence of anastomotic leakage (AL) not only delays post-operative oral intake and impairs the patient's quality of life (QOL) but also interferes with post-operative therapy and sometimes directly causes death. The occurrence of AL is thought to be related to the blood flow and tension at the anastomotic site. There are many reports that have evaluated the blood flow using indocyanine green (ICG) when determining the anastomosis site at the gastric tube.,, However, AL currently occurs in approximately 10% of cases of oesophagectomy. We believe that it is necessary to confirm the identification of vessels during laparoscopy-assisted gastric tube reconstruction (LAGR) to avoid gastric tube ischaemia. This report is the first to consider the usefulness of laparoscopic real-time vessel navigation (LRTVN) using ICG fluorescence during LAGR.
From March 2019 to May 2019, five consecutive patients who underwent thoracoscopic oesophagectomy and LAGR in the Department of Gastroenterological Surgery II at Hokkaido University Hospital (Sapporo, Japan) were enrolled in this study. All patients gave their informed consent to be included in the study.
Thoracoscopic oesophagectomy (right thoracic approach)
Patients were placed in the prone position under epidural and general anaesthesia, which was achieved using a single-lumen, flexible endotracheal tube for two-lung ventilation as previously reported., First, a 12-mm trocar was carefully inserted into the ninth intercostal space on the scapular angle line, and CO2 was then insufflated at a pressure of 8–10 mmHg. After artificial pneumothorax was achieved at a pressure of 10 mmHg, a laparoscope (Visera Elite II; Olympus Europe SE and Co., KG, Hamburg, Germany) was introduced through the trocar, and three other trocars (one trocar through a 12-mm incision and two others through 5-mm incisions) were positioned. The thoracic oesophagus was completely mobilised circumferentially, and the para-oesophageal lymph nodes were dissected and maintained en bloc with the surgical specimen.
Laparoscopy-assisted gastric tube reconstruction
Patients were repositioned from the prone to the supine position, and gastric tube formation was performed laparoscopically. Patients were placed under general anaesthesia in the supine reverse Trendelenburg position with the legs apart. The first trocar was placed in the umbilicus, and a laparoscope (Visera Elite II; Olympus Europe SE and Co., KG, Hamburg, Germany) was inserted into the peritoneal cavity. The intra-abdominal pressure was set at 10 mmHg. Under direct vision, a 12-mm trocar was inserted at the left para-xiphoid, followed by two 12-mm trocars in the bilateral subcostal areas and a 5-mm trocar along the left anterior axillary line. The surgeon stood between the legs of the patient, with the first assistant standing on the right and the camera operator standing on the left of the operating surgeon. We used laparoscopic coagulation shears for lymph node dissection and vessel coagulation [Figure 1].
|Figure 1: Trocar placement in laparoscopy-assisted gastric tube reconstruction. Four 12-mm trocars are placed in the para-umbilical, bilateral abdominal and epigastric regions. One 5-mm trocar is placed in the left hypochondral area. ○: 12-mm trocar site, △: 5-mm trocar, ×: Umbilicus|
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The right gastric artery, right gastroepiploic artery (GEA) and branches of the left GEA (LGEA) were preserved. The omentum was freed from the transverse colon and divided at the edge adherent to the colon, so vessel communications and a sufficient amount of omentum were fully preserved. We performed LRTVN using ICG fluorescence during LAGR to evaluate gastric tube blood flow and confirm the root of LGEA, using the near-infrared fluorescence laparoscopic system (Visera Elite II; Olympus Europe SE and Co.). ICG dye (Diagnogreen; Dai-Ichi Pharm, Tokyo, Japan) was injected as a 5-mg bolus intravenously to confirm the root of LGEA. ICG fluorescence was detected in all patients about 30–60 s after injection. We ensured that the LGEA was clipped with a hem-o-lock clip and cut using laparoscopic coagulation shears at the root to preserve the branches of the LGEA [Figure 2] and [Figure 3]. A gastric tube of 4-cm wide was made by stapling the lesser curvature of the stomach, and a 5-mg bolus re-injection of ICG dye was administered after forming the gastric tube and we decided the site of anastomosis. The staple lines were over sewn with 4-0 PDS (polyglycolic acid absorbable surgical sutures; Ethicon, Norderstedt, Germany). Gastric tube reconstruction was conducted via the posterior mediastinal route, and hand-sewn anastomosis (posterior wall: Albert-Lembert suture, anterior wall: Gambee suture) was performed.
|Figure 2: Laparoscopic real-time vessel navigation using indocyanine green fluorescence during laparoscopy-assisted gastric tube reconstruction. (a) Intraoperative fluorescence imaging showing the root of left gastroepiploic artery and the arcade of left gastroepiploic artery. (b-d) Intraoperative white light imaging. *White arrow: The arcade of left gastroepiploic artery, White arrowhead: The root of left gastroepiploic artery, Black arrowhead: The stump of left gastroepiploic artery, St.: Stomach, Sp.: Spleen|
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|Figure 3: Laparoscopic real-time vessel navigation using indocyanine green fluorescence during laparoscopy-assisted gastric tube reconstruction. (a) Intraoperative white light imaging showing the root of left gastroepiploic artery and the splenic artery. (b) Intraoperative fluorescence imaging showing the root of left gastroepiploic artery. (c) Intraoperative white light imaging showing the cutting point of left gastroepiploic artery. (d) Intraoperative white light imaging shows preserving vascular around the splenic hiatus. *White arrow: The splenic artery, White arrow head; The root of left gastroepiploic artery, St.: Stomach, Sp.: Spleensplenic artery, White arrow head; The root of left gastroepiploic artery, St.: Stomach, Sp.: Spleen|
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| ¤ Results|| |
The five patients underwent thoracoscopic oesophagectomy using LRTVN during LAGR. The median operating time was 475 min (range 342–565), and the median intraoperative bleeding volume was 95 ml (range 0–540). AL occurred in one case (Grade IIIa on the Clavien–Dindo classification system), but no cases of recurrent nerve palsy or pneumonia were observed. The median length of hospital stay after surgery was 21 days (range 14–37). We could confirm the root of left gastroepiploic artery (LGEA) in all cases, and no findings such as post-operative gastric tube ischaemia were observed. In all cases, no vascular injury around the splenic hiatus was observed during LAGR.
| ¤ Discussion|| |
The anastomoses between the oesophagus and the reconstructed organs in oesophageal reconstruction require that the organs originally in the abdominal cavity be lifted to the neck and anastomosed with the cervical oesophagus; these anastomoses are associated with the highest incidence of AL among all gastrointestinal anastomoses. The stomach is often used for organ reconstruction due to the simplicity of the procedure and stability of anastomotic blood flow. Although the incidence of AL has decreased, suture failure currently occurs in approximately 10% of cases of oesophagectomy. Immediately post-operatively, the occurrence of AL may be accompanied by empyema, mediastinitis and other conditions. In addition, AL may cause delayed oral intake, not only impairing the QOL of the patient but also greatly hindering multidisciplinary therapy such as post-operative chemotherapy or radiation therapy. Many studies have reported that evaluation of gastric tube blood flow by ICG can avoid AL, and Van Daele et al. reported in a systematic review that ICG angiography is a safe, feasible and promising method for perfusion assessment. However, ICG testing is generally performed at the time of gastro-oesophagostomy after gastric tube vascular treatment. There are no previous reports concerning LRTVN using ICG fluorescence during LAGR. Egorov et al. reported that the LGEA is the least described artery in the medical literature, and unusual variations of this artery might lead to vascular injuries causing intraoperative bleeding after surgery. Michels reported that the LGEA took the origin from splenic trunk (72%), inferior polar artery (22%) and superior polar artery (6%). Although the LGEA arises from splenic trunk in more than half of the cases, it is important to know the frequency of the other modalities of its origin. These anatomical vascular variations are to be considered during LAGR. Splenic injury, typically resulting from traction injury, adhesions or direct trauma from instruments during mobilisation of the stomach, is a well-known intraoperative complication during oesophageal cancer surgery, and incidental splenectomy occurs in 3%–8% of oesophagectomies. Rino et al. reported that preservation of this 'splenic hiatal route' would maintain blood flow to the top of the reconstructed stomach and 'splenic hiatal route' was present in 66.7% of the patients and was formed by large vessels or networks of small vessels. In this study, the 'splenic hiatal route' could not be clearly identified by LRTVN. However, we believe that the network of vessels including the 'splenic hiatal route' can be preserved by dissecting the LGEA root. The fluorescence of ICG has been reported to be visible through approximately 0.5–1.0 cm of the soft tissue. Therefore, LRTVN can also be indicated in cases of high visceral fat. In the present study, one patient was found to have one anastomotic leak. Although the blood flow to the gastric tube was good, we believe that it was a technical problem with tension at the anastomosis.
We believe that LRTVN using ICG fluorescence during LAGR is useful for evaluating gastric tube blood flow, identify the vascularization of LGEA and avoiding vascular injury around the splenic hiatus.
However, there is a need for well-designed prospective randomised controlled studies comparing LRTVN with conventional methods concerning post-operative anastomotic-related complication.
| ¤ Conclusion|| |
The results suggest that LRTVN using ICG during LAGR is feasible, and our novel technique could help avoid ischaemia as a cause of anastomotic complication.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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