Initial report of near-infrared fluorescence imaging as an intraoperative adjunct for lymph node harvesting during robot-assisted laparoscopic gastrectomy

Abstract

Introduction: Adequate lymphadenectomy is a fundamental aspect of oncologically sound gastrectomies. Robot-assisted laparoscopic gastrectomy is a minimally invasive alternative that allows functional imaging to be easily integrated to the surgical field and may aid in intraoperative identification of lymphovascular bundles.

Methods: Indocyanine green application and near-infrared fluorescence imaging were used during robot-assisted laparoscopic gastrectomy as an adjunct for the identification of relevant lymph node basins in real time.

Results: A total of 31 patients were included. Twenty-nine gastrectomies were performed for adenocarcinoma and two wedge resections for neuroendocrine tumors. The mean lymph node retrieval was twenty-nine (range 17-61) for adenocarcinoma and five for neuroendocrine tumors. In all cases, at least five lymph nodes were seen along the main nodal basins, which provided real time intraoperative feedback regarding lymph node identification. Average time for indocyanine green application and functional imaging was less than 10 min.

Conclusions: Near-infrared fluorescent imaging may provide an improved method to help visualize lymph nodes intraoperatively during robot-assisted laparoscopic gastrectomy, thus adding a potentially valuable adjunct for lymphadenectomy and overall lymph node retrieval. J. Surg. Oncol. 2016;113:768-770. © 2016 Wiley Periodicals, Inc.

Keywords: fluorescence; indocyanine green; lymph node; robotic surgical procedure; stomach neoplasm.

© 2016 Wiley Periodicals, Inc.

Figures

Figure 1. Typical port placement for robot-assisted gastrectomy

Figure 2. Endoscope-guided application of ICG to the tumor site

An arrowhead demonstrates the endoscope used for tumor identification. Injection site surrounding tumor marked in the gastric surface by stitches.

Figure 3. Primary tumor and draining lymph nodes and channels identified by NIFI-ICG

A white arrow head indicates the primary tumor site marked with ICG. Blue arrowheads indicate ICG uptake by draining lymph nodes and channels.

Figure 4. Right gastroepiploic lymph node bundle identified with NIFI-ICG application

A. Arrowhead shows the right gastroepiploic artery, vein and lymph node package. B. Near-infrared image. The arrowhead indicates ICG uptake by the right gastroepiploic lymph node bundle. No NIFI-ICG lymph nodes are noted below the level of ligation.

Figure 5. Left gastric lymph node bundle identified with NIFI-ICG application

A. The arrowhead shows the left gastric artery, vein and lymph node package. B. Near-infrared image. The arrowhead indicates the ICG uptake by the left gastric lymph node bundle. No NIFI-ICG lymph nodes are noted below the level of ligation.