Robotic real-time vessel navigation using indocyanine green fluorescence for lymph node dissection along the left gastroepiploic vessels during robotic distal gastrectomy - First experience : Journal of Minimal Access Surgery

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Robotic real-time vessel navigation using indocyanine green fluorescence for lymph node dissection along the left gastroepiploic vessels during robotic distal gastrectomy - First experience

Ebihara, Yuma; Kurashima, Yo; Murakami, Soichi; Shichinohe, Toshiaki; Hirano, Satoshi

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Journal of Minimal Access Surgery: Oct–Dec 2022 - Volume 18 - Issue 4 - p 619-621
doi: 10.4103/jmas.jmas_223_21
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Abstract

INTRODUCTION

Lymphatic flow from the greater curvature of the middle third of the stomach reaches the lymph nodes located along the roots of the left gastroepiploic vessels (LGEVs), and lymph node dissection (LND) along the LGEVs in distal gastrectomy for gastric cancer is important. However, it is difficult to identify the left gastroepiploic artery (LGEA) root because the roots of the LGEA at the splenic hilus are obscured intraoperatively by adipose tissue. Egorov et al.[1] reported that 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. Ishikawa et al.[2] reported three branching types of LGEVs according to their origin site (LGEA) and their draining site (left gastroepiploic vein) [Figure 1].

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Figure 1:
Schema of three patterns of the LGEA and LGEV. (a) Three types of LGEA based on the origin site (from SA, 9%; from IPA, 19%; from ITA, 72%). (b) Three types of LGEV based on draining site (into SV, 14%; into IPV, 22%; into ITV, 64%). SA: Splenic artery, ITA: Inferior terminal artery, IPA: Inferior polar artery, SV: Splenic vein, ITV: Inferior terminal vein, IPV: Inferior polar vein, LGEA: Left gastroepiploic artery, LGEV: Left gastroepiploic vein

In the standard procedure, real-time vessel navigation using indocyanine green (ICG) fluorescence is not performed, which can lead to accidental dissection of the short gastric vessels (SGVs) or injury to the splenic artery (SA) because the branching of the LGEA from the SA cannot be identified. Standard procedures may lead to severe complications related to splenic infarction (SI), such as splenic haemorrhage, abscess formation or rupture, which can be fatal due to injury of the SA. Jung et al.[3] demonstrated that 36 of 877 patients (4.1%) had SI after gastrectomy.

SUBJECTS AND METHODS

Between January 2021 and July 2021, we enrolled seven consecutive patients who underwent robotic distal gastrectomy (RDG) with real-time vessel navigation using ICG during LND along LGEVs at our institution. All operations were performed by a single surgeon (Y.E.). The da Vinci robot system (Xi) was used for all procedures. The eligibility criteria were a pre-operative diagnosis of gastric cancer made using endoscopy, computed tomography and endoscopic ultrasound. All patients provided informed consent, and the Hokkaido University Hospital Institutional Review Board approved the data collection and analysis (No. 021-0022).

SETUP FOR ROBOTIC DISTAL GASTRECTOMY

The patients were placed under general anaesthesia in the supine position. The da Vinci Xi® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) was used for all procedures in a standard fashion. For RDG, we typically use a 5-trocar system with a Nathanson hook liver retractor (Yufu Itonaga, Tokyo, Japan). After carbon dioxide pneumoperitoneum was achieved with a pressure of 10 mmHg, an electrolaparoscope was introduced through the umbilical 8-mm trocar, and the other four trocars were positioned as shown in Figure 2. The robotic second and fourth arms were docked on the 8-mm left upper and umbilical trocars, respectively. The first and third arms were docked on the 12-mm right upper and left lower trocar, respectively, and the assistant surgeon used the right lower trocar (12-mm). The lymph node regions and dissection were defined according to the Japanese Classification of Gastric Carcinoma (JCGC).[4]

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Figure 2:
Positions of surgical trocars. The robotic second and fourth arms were docked on the 8-mm left upper and umbilical trocars, respectively. The first and third arms were docked on the 12-mm right upper and left lower trocar, respectively, and the assistant surgeon used the right lower trocar (12 mm). (○: 12-mm trocar, △: 8-mm trocar, ▮: Nathanson hook liver retractor, ×: Umbilicus)

In robotic real-time vessel navigation using ICG fluorescence, Firefly™ fluorescence imaging technology of the Da Vinci Xi® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) was applied. ICG dye (Diagnogreen; Dai-Ichi Pharm, Tokyo, Japan) was injected intravenously as a 5-mg bolus. We verified that the root of LGEA is clipped and cut to preserve SA and the preservation of the connection around the SGVs as much as possible [Figure 3]. The basic extent of LND was D1+ (D1 + No. 7, 8a and 9 lymph nodes) or D2, and LND was performed. Regions of lymph nodes and LNDs were defined according to the JCGC.[4] The specimen was retrieved in an endoscopic bag and extracted through an enlarged umbilical incision.

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Figure 3:
Robotic real-time vessel navigation using indocyanine green fluorescence for lymph node dissection along the left gastroepiploic vessels during the robotic distal gastrectomy. (a) Exposing the roots of LGEVs. Dotted line: LND along the LGEVs. (b) Real-time vessel imaging visualised the fluorescence of the SA, LGEVs and IPA. Dividing the LGEA while preserving the IPA. Dotted line: LND along the LGEVs. (c) Final view of LND along LGEVs preserving the IPA. (d) Final view of LND along LGEVs confirming the blood supply of the SGVs, IPA and spleen. LN: Lymph nodes, LND: Lymph node dissection, SA: Splenic artery, LGEVs: Left gastroepiploic vessels, IPA: Inferior polar artery, SGVs, Short gastric vessels

All seven patients underwent RDG using real-time ICG fluorescence angiography, and it was possible to identify the root of the LGEA. There were no complications (Clavien–Dindo classification II). There were no cases of post-operative SI or spleen-related complications. We confirmed the LGEA and connecting tissue, including vessels around the splenic hiatus and SGVs in all cases, and there were no findings such as post-operative SI or abscess formation. We believe that real-time vessel navigation using ICG fluorescence during LND along LGEVs is a useful technique that preserves the blood supply to the spleen and reduces post-operative spleen-related complications. ICG fluorescence has been reported to be visible through approximately 0.5–1.0 cm of soft tissue.[5] Therefore, real-time vessel navigation using ICG fluorescence is also appropriate in patients with high amounts of visceral fat.

This is the first report on the avoidance of post-operative complications related to splenic ischaemia by confirming the location of LGEVs and SGVs and conservation of the connecting tissue including vessels (inferior terminal artery, inferior polar artery, etc.) around the splenic hilum, validating the utility of Firefly™ fluorescence imaging technology with the Da Vinci Xi® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing.

REFERENCES

1. Egorov VI, Yashina NI, Zhurenkova TV, Petukhova MV, Starostina NS, Zarinskaya SA, et al Spleen-preserving distal pancreatectomy with resection of the splenic vessels.Should one rely on the short gastric arteries? JOP. 2011;12:445–57
2. Ishikawa Y, Ehara K, Yamada T, Matsuzawa N, Arai S, Ban D, et al Three-dimensional computed tomography analysis of the vascular anatomy of the splenic hilum for gastric cancer surgery Surg Today. 2018;48:841–7
3. Jung YJ, Seo HS, Lee HH, Kim JH, Song KY, Choi MH, et al Splenic infarction as a delayed febrile complication following radical gastrectomy for gastric cancer patients: Computed tomography-based analysis World J Surg. 2018;42:1826–32
4. Japanese Gastric Cancer Association. . Japanese gastric cancer treatment guidelines 2014 (ver.4) Gastric Cancer. 2017;20:1–19
5. Tanaka R, Nakashima K, Fujimoto W. Sentinel lymph node detection in skin cancer using fluorescence navigation with indocyanine green J Dermatol. 2009;36:468–70
Keywords:

Left gastroepiploic vessels; post-operative complications; robotic distal gastrectomy; splenic infarction

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