Near-infrared (NIR) perfusion angiography in minimally invasive colorectal surgery

Abstract

Background: Anastomotic leakage is a devastating complication of colorectal surgery. However, there is no technology indicative of in situ perfusion of a laparoscopic colorectal anastomosis.

Methods: We detail the use of near-infrared (NIR) laparoscopy (PinPoint System, NOVADAQ, Canada) in association with fluorophore [indocyanine green (ICG), 2.5 mg/ml] injection in 30 consecutive patients who underwent elective minimally invasive colorectal resection using the simultaneous appearance of the cecum or distal ileum as positive control.

Results: The median (range) age of the patients was 64 (40-81) years with a median (range) BMI of 26.7 (20-35.5) kg/m(2). Twenty-four patients had left-sided resections (including six low anterior resections) and six had right-sided resections. Of the total, 25 operations were cancer resections and five were for benign disease [either diverticular strictures (n = 3) or Crohn's disease (n = 2)]. A high-quality intraoperative ICG angiogram was achieved in 29/30 patients. After ICG injection, median (range) time to perfusion fluorescence was 35 (15-45) s. Median (range) added time for the technique was 5 (3-9) min. Anastomotic perfusion was documented as satisfactory in every successful case and encouraged avoidance of defunctioning stomas in three patients with low anastomoses. There were no postoperative anastomotic leaks.

Conclusion: Perfusion angiography of colorectal anastomosis at the time of their laparoscopic construction is feasible and readily achievable with minimal added intraoperative time. Further work is required to determine optimum sensitivity and threshold levels for assessment of perfusion sufficiency, in particular with regard to anastomotic viability.

Fig. 1

NIR perfusion assessment in laparoscopic right hemicolectomy. a Normal light. b Near-infrared fluorescence. c Superposition of NIR and normal light in green. A Intraoperative photos showing a clear demarcation line after vessel division. B Ileotransverse anastomosis before IDC injection, showing no fluorescence. C Perfusion assessment of the ileotransverse anastomosis

Fig. 2

NIR perfusion assessment in laparoscopic low anterior resection. a Normal light. b Near-infrared fluorescence. c Superposition of NIR and normal light in green. A Colorectal end-to-end anastomosis before IDC injection, showing no fluorescence. B Perfusion assessment of the colorectal anastomosis

Fig. 3

Positive control. a Normal light. b Near-infrared fluorescence. c Superposition of NIR and normal light in green. A Image of the normal cecum after IDC injection