Real-Time Indocyanine Green Fluorescence Imaging-Guided Complete Mesocolic Excision in Laparoscopic Flexural Colon Cancer Surgery

INTRODUCTION: Laparoscopic surgery for colon cancer located in the hepatic flexure or splenic flexure is not standardized, because lymphatic drainage at this site may vary and the precise site of lymphatic dissection is uncertain. TECHNIQUE: Indocyanine green was injected into the submucosal layer around the tumor at 2 points with a 23-gauge localized injection before lymph node dissection and the lymph flow was observed using a near-infrared camera system 30 minutes after injection. In addition, a complete mesocolic excision with central vascular ligation guided the region where the lymph flow was fluorescently observed. RESULTS: A total of 20 consecutive patients (hepatic flexure, 10 patients; splenic flexure, 10 patients) were enrolled in this study. All of the procedures were safely performed without any complications. The lymph flow was visualized in 19 patients (95%) intraoperatively. Modification of the operative methods was required for 5 patients (modification in the separation line of the mesocolon and vessel selection for central vascular ligation) because the area of lymph flow observed during surgery differed from that of the preoperative diagnosis. CONCLUSION: Intraoperative real-time visualization of the lymph flow using indocyanine green fluorescence imaging during laparoscopic colon cancer surgery, especially flexural colon cancer surgery, is feasible and a helpful technique for identifying appropriate central vessels to be dissected and for determining an appropriate separation line of the mesentery.