Live surgeryOctober 16, 20234:27:2511 speakersAvailable in: EN / IT
Live Surgery 3 - ICG-Guided Laparoscopic Extended Right Hemicolectomy for Transverse Colon Cancer
Live surgery of laparoscopic extended right hemicolectomy with ICG in a 75-year-old patient with stenosing adenocarcinoma of the transverse colon, in a format dedicated to surgical residents.
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Clinical case
Adenocarcinoma infiltrante stenosante del colon trasverso medio
Patient framing as discussed at case introduction
SexM
Age75 anni
StagecT3-T4 N0 M0
DiagnosisAdenocarcinoma infiltrante stenosante del colon trasverso medio
Prior treatmentNessuno
Clinical historyPaziente in buone condizioni generali, BMI 26-27, ipertensione arteriosa e ipertrofia prostatica. Anemia sideropenica e perniciosa al check-up annuale, SOF positivo su tre campioni, colonoscopia con riscontro di lesione stenosante non valicabile e due adenomi sigmoidei.
NotesPaziente con esiti di appendicectomia (cieco fissato in pelvi) e aderenze multiple; lesione non marcata endoscopicamente per assenza di preparazione completa; ICG iniettato per via sottosierosa intraoperatoriamente.
Overview
Third session of the 2023 edition of ICG-School, dedicated to a case of laparoscopic extended right hemicolectomy with indocyanine green-guided lymphadenectomy. The workshop has an original format: the main faculty is composed of resident-chairmen from various Italian centers (San Raffaele, Brescia, Verona, Florence) who discuss the clinical case in all its steps, supported by four senior surgeons (Davide Cavaliere, Luigi Boni, Gian Andrea Baldazzi, Edoardo Rosso) who intervene on specific topics. The case is that of Attilio, a 75-year-old patient with a stenosing adenocarcinoma of the mid-transverse colon (cT3-T4 N0 M0), identified by Dr. Paola Carrai (general practitioner) through a blood check-up showing iron-deficiency anemia, then confirmed by FOBT and colonoscopy.
The preoperative discussion thoroughly addresses diagnostics (the usefulness of CT colonography, liver MRI, PET, CEA markers, microsatellite instability and mismatch repair on biopsies), endoscopic tumor marking, the study of mesenteric vascularization, and surgical timing. Davide Cavaliere delivers a structured presentation on prehabilitation, ERAS protocols, and bowel preparation, while the debate highlights the enormous variability among centers (mechanical preparation with Plenvu vs no preparation, oral antibiotics Miracle protocol, probiotics). Luigi Boni gives a critical lecture on Complete Mesocolic Excision (CME) with the concept of 'mesopages', emphasizing how the literature does not standardize the control arm and questioning the actual oncological advantage of 3 cm² of additional mesocolon compared to the risk of vascular complications.
The live surgery in Cremona shows the technical steps: induction of pneumoperitoneum with Veress needle, trocar placement, lysis of adhesions (patient with prior appendectomy and cecum fixed in the pelvis), subserosal injection of ICG, isolation of the ileocolic vessels and the right branch of the middle colic artery, performance of the embryological plane between mesocolon and Toldt's fascia. Gian Andrea Baldazzi presents in detail the technique of intracorporeal ileocolic anastomosis (mechanical with mustard-colored cartridge and double-layer hand-sewn in frail patients). The case proves complex due to high BMI, abundant adhesions, and a colon distended with feces; drainage is discussed (ultimately placed near the subhepatic space), as is the use of the extraction bag and management of the postoperative course.
Topics
Colorectal cancer screening and the role of the general practitioner
