Results of laparoscopic resection in high-risk rectal cancer patients

Preoperative Indocyanine Green Tattooing for Robotic-Assisted Surgery in Rectal Cancer

INTRODUCTION

Preoperative identification of the site of rectal cancer surgery is crucial for ensuring accurate tumor localization and resection. Commonly employed methods include contrast-enhanced enterography and endoscopic marking techniques, such as clipping and India ink tattooing. However, India ink tattooing poses challenges, including obstruction of the surgical field, ink leakage into the abdominal cavity, and potential complications such as peritonitis and adhesive bowel obstruction. Similarly, clipping requires palpation, making minimally invasive procedures, such as laparoscopic or robotic-assisted surgery, impractical.

MATERIALS AND SURGICAL TECHNIQUE

The indocyanine green fluorescence method is employed intraoperatively to monitor blood and lymph flow in the intestinal tract. Here, we discuss the effectiveness of preoperative indocyanine green marking in accurately locating tumors during robot-assisted rectal colorectal surgery.

DISCUSSION

By using the fluorescence properties of indocyanine green, surgeons can precisely identify the tumor site, overcoming the limitations of traditional methods. This technique improves surgical accuracy while minimizing intraoperative risks and achieving optimal oncological outcomes. Preoperative indocyanine green tattooing represents a valuable enhancement to current techniques in rectal cancer surgery, particularly for robot-assisted approaches. Our findings underscore the applicability of preoperative indocyanine green tattooing as a promising alternative in robot-assisted surgery for patients with rectal cancer.

Modified serial techniques "ASTRO" facilitated laparoscopic total mesorectal excision for ultralow-lying rectal cancer in obese male patients: how we do it (with video)

BACKGROUND

Laparoscopic total mesorectal excision (LaTME) is a technically challenging for ultralow-lying rectal cancer in obese male patients. Herein, we introduced modified serial techniques "ASTRO" to facilitate LaTME, and the short-term outcomes were presented.

METHODS

A prospective study (NCT05067413) was conducted between December 2020 and January 2022. The modified serial surgical techniques "ASTRO" included 5 key steps: (1) Anterior peritoneal reflection (APR) dissection at the highest line along with a "n"-shaped membrane bridge; (2) suspending the APR with a purse-string suture through the bladder peritoneum to enlarge the operating space of the anterior rectal wall; (3) traction and counter-traction continuously of the rectum applied with a cotton tape around the rectum; (4) resection of the pelvic rectum on tripartition, followed by the sequence of "posterior > anterior > lateral" principle; and (5) the trans-anterior Obturator nerve gateway was adapted to transect the distal rectum. The operative data and postoperative short-term outcomes were collected.

RESULTS

Twenty-four consecutive patients underwent this procedure successfully. The average body mass index (BMI) was 29.9±1.3. The average of tumor height from anal verge was 4.0 cm (range, 3.0-4.5 cm). The median operating time and blood loss was 217 min (range, 165-420 min) and 50 ml (range, 20-100 ml) respectively. The anterior operation space at the midsagittal plane of the pelvis inlet was increased by 2.0 ± 0.3 cm. The calculated dominant angle was 20 ± 3°. The length of stapling line was 6.8 ± 1.0 cm with 11 cases by one cartridge and 13 cases by 2 cartridges. Eight patients developed postoperative complications including 4 with anastomosis leakage (16.7%), 2 with urinary retention (8.3%), one with anastomotic stenosis (4.2%) and one with ileus (4.2%). All the complications were relatively mild and the patients recovered well.

CONCLUSION

Modified serial techniques "ASTRO" could expand the operating space and facilitate LaTME in obese male patients, thereby reducing the risk of conversion to open and transanal dissection.

Spotlight on Laparoscopy in the Surgical Resection of Locally Advanced Rectal Cancer: Multicenter Propensity Score Match Study

Purpose

This study was aimed to assess the feasibility of laparoscopic rectal surgery, comparing quality of surgical specimen, morbidity, and mortality.

Methods

Prospectively acquired data from consecutive patients undergoing laparoscopic surgery for rectal cancer, at 2 minimally invasive colorectal units, operated by the same team was included. Locally advanced rectal tumors were identified as T3B or T4 with preoperative magnetic resonance imaging scans. All the patients were operated on by the same team. The 1:1 propensity score matching was performed to create a perfect match in terms of tumor height.

Results

Total of 418 laparoscopic resections were performed, out of which 109 patients had locally advanced rectal cancer (LARC) and were propensity score matched with non-LARC (NLARC) patients. Median operation time was higher for the LARC group (270 minutes vs. 250 minutes, P=0.011). However, conversion to open surgery was done in 5 vs. 2 patients (P=0.445), reoperation in 8 vs. 7 (P=0.789), clinical anastomotic leak was found in 3 vs. 2 (P=0.670), and 30-day mortality rates was 2 vs. 1 (P>0.999) between LARC and NLARC, respectively. Readmission rate was higher in the NLARC group (33 patients vs. 19 patients, P=0.026), due to stoma-related issues. There was no statistically significant difference in the R0 resection between the 2 groups (99 patients in LARC vs. 104 patients in NLARC, P=0.284).

Conclusion

This study demonstrates that standardized approach to laparoscopy is safe and feasible in LARC. Comparable postoperative short-term clinical and pathological outcomes were seen between LARC and NLARC groups.