A prospective study of real-time identification of line of transection in robotic colorectal cancer surgery by ICG

Colorectal cancer is the second most common cancer in women and the third most common cancer in men in the world. Surgical resection is the gold standard treatment and minimally invasive surgery remains the standard of care. Anastomotic leakage is one of the most feared postoperative complications in colorectal surgery. Although several factors have been identified as possible causes of anastomotic leakage (i.e., surgical techniques, patient risk factors, suture material or devices), the complete pathogenesis is still unclear. The reported leak rate ranges from 1 to 30% and increases as the anastomosis is more distal. To date the most widely used methods to assess tissue perfusion includes the surgeon intraoperative visual judgement based on the colour; bleeding edges of resected margins; pulsation and temperature, thereby resulting in either excess or insufficient colonic resection. Earlier studies in colorectal surgery have suggested that assessment of tissue perfusion by the clinical judgment of the operating surgeon underestimated the risk of anastomotic leakage. Indocyanine green (ICG) is a intravenous dye which has shown promise in identifying the bowel vascularity real time. Earlier studies on colorectal cancer have shown that ICG based detection of bowel vascularity is technically possible and has reduced the anastomotic leak rates in 16.7% of patients. We conducted a prospective study on patients with ICG guided bowel perfusion during robotic colorectal cancer surgery. The method is technically easy, reproducible and safe. This technique has changed the intraoperative decision in 88% of patients. Larger studies are needed before this can become the standard of care.