Laparoscopic abdominoperineal resection (APR) with total mesorectal excision (TME) for low rectal cancer has been shown to be safe and effective and is associated with advantages over open techniques. However, laparoscopy has some limitations secondary to the anatomical structure of pelvis, rigid visualization system, instrument length, and articulation. The da Vinci robot has the potential to overcome some of the limitations of laparoscopy, and early experiences with robotic rectal resection highlight the potential advantages compared to conventional laparoscopy. Robotic APR can be performed utilizing a fully robotic technique or a hybrid laparoscopic–robotic technique whereby the robot is docked after mobilizing the sigmoid colon and dividing the vessels with conventional laparoscopic techniques.

Background

Decreased blood perfusion at an intestinal anastomosis may contribute to postoperative anastomotic leak (AL) resulting in substantial morbidity and mortality. Near-infrared (NIR) laparoscopy in conjunction with indocyanine green (ICG) allows for visualization of the microcirculation before formation of the anastomosis, thereby allowing the surgeon to choose the point of transection at an optimally perfused area.

Methods

This is a retrospective case-control analysis examining the effectiveness of NIR + ICG in reducing the rate of AL after low anterior resection (LAR) for rectal cancer. Records of patients undergoing robot-assisted LAR for rectal cancer with and without ICG were analyzed for the years 2011 and 2012.

Results

Among the 40 patients who underwent robotic LAR, NIR + ICG was used in 16 cases (41 %). Male patients accounted for the majority of cases in both groups (74 %). The median level of the anastomosis was 3.5 cm in the NIR + ICG group and 5.5 cm in the control group. There was no difference in the use of diverting ileostomy. In 3 patients (19 %), the use of NIR + ICG resulted in revision of the proximal bowel (colonic) transection point before formation of the anastomosis. The distal transection point was never revised. The rate of AL in the NIR + ICG group was 6 % versus 18 % in control group.

Conclusions

ICG fluorescence may play a role in anastomotic tissue perfusion assessment and affect the AL rate. Larger prospective studies are needed to further validate this novel technology.