Live surgeryApril 29, 20231:46:246 speakersAvailable in: EN / IT
Clinical Round: ICG-guided right hemicolectomy in a young woman with ascending colon cancer
Clinical case of ICG-guided laparoscopic right hemicolectomy in a 49-year-old woman with ascending colon cancer: multidisciplinary discussion with residents from Bologna and Trieste.
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Clinical case
Adenocarcinoma del colon ascendente/flessura epatica (preoperatorio: displasia di alto grado su adenoma tubulare)
DiagnosisAdenocarcinoma del colon ascendente/flessura epatica (preoperatorio: displasia di alto grado su adenoma tubulare)
Prior treatmentLegature elastiche e scleroterapia emorroidaria
Clinical historyAnemia sintomatica (Hb 7,6), pregressa diagnosi di emorroidi trattate con legature/scleroterapia; sorella operata a 32 anni per ca renale; rilievo di fibroma uterino sottosieroso e angioma epatico VII segmento
NotesHostess Alitalia, ottime condizioni generali; ICG iniettato intra-operatoriamente per via sottosierosa peritumorale
Overview
Episode of the Permanent School on ICG Surgery dedicated to right colon surgery, hosted by Gian Luca Baiocchi with senior faculty Paolo Del Rio (Naples) and Stefano Scabini (Genoa) and the resident teams from Bologna (tutor: Matteo Rotoli) and Trieste (tutor: Marina Bortul). The episode opens with a how-I-do-it on the use of indocyanine green in right colon surgery: assessment of stump perfusion before anastomosis and lymph node navigation, with details on injection technique (subserosal with spinal needle), progressively reduced dilutions (down to 0.125 mg) and variable timing from injection to observation.\\n\\nThe clinical case concerns a 49-year-old woman, an Alitalia flight attendant, with severe anemia (Hb 7.6) and a 4 cm lesion of the ascending colon/hepatic flexure with biopsy showing high-grade dysplasia. The multidisciplinary discussion covers all steps of the pathway: surgical indication vs endoscopic treatment, management of the segment VII liver lesion (hemangioma), role of neoadjuvant therapy in the presence of suspicious lymph nodes, genetic counseling considering the patient's age and family history (sister with renal cancer at 32), pre-operative preparation (Impact, oral antibiotics, ERAS), trocar set-up and induction of pneumoperitoneum.\\n\\nThe intra-operative video shows peritumoral ICG injection, complete mobilization of the parietocolic gutter, Kocher maneuver and dissection of the transverse mesocolon with fluorescence visualization of unexpected lymph nodes along the gastroepiploic arcade (station 6). Del Rio shares his personal experience of routine gastroepiploic lymphadenectomy for hepatic flexure tumors with 8% positivity. The boundaries of CME, intra- vs extracorporeal anastomosis, use of drainage, and post-operative monitoring are discussed. Final histology reveals a G2 mucinous adenocarcinoma pT3N0 (0/23) with MLH1/MSH2 deficiency, prompting reflection on the risk of fluorescence-driven over-treatment.
Topics
Use of ICG in right colon surgery: perfusion and lymph node navigation
Subserosal ICG injection technique with spinal needle
Surgical indication vs endoscopic treatment for high-grade dysplasia lesions
Multidisciplinary management and medico-legal implications
Characterization of incidental liver lesions (CEUS, MRI, intraoperative ultrasound)
Neoadjuvant chemotherapy in right colon cancer (FOxTROT)
Genetic counseling and microsatellite instability (MSI)
Pre-operative preparation, ERAS and immunonutrition (Impact)
Laparoscopy vs robotics for right hemicolectomy
CME and D3 lymphadenectomy in right colon cancer
Station 6 (gastroepiploic) lymphadenectomy for hepatic flexure tumors
Intra- vs extracorporeal anastomosis
Post-operative drainage and monitoring with CRP/procalcitonin
Vessel navigation and GPS surgery (future perspectives)
Tools used
ICG (verde di indocianina)Stryker (sistema di imaging fluorescente)PINPOINT/1688 cameraAgo da spinaleVLOC (sutura barbed)Suturatrici meccaniche lineariImpact (immunonutrizione)TC con mezzo di contrastoCEUSRisonanza magnetica epatica
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