Management of postoperative complications after laparoscopic left hemicolectomy: An approach in modern times after incorporation of indocyanine green and full mobilization of the splenic flexure

BACKGROUND: The aim of this study was to report our experience in the management of complications after laparoscopic left hemicolectomy (LLH) after the incorporation in our clinical practice of intraoperative indocyanine green (ICG) fluorescence angiography (FA). METHODS: In our last period after incorporation of ICG-FA, 277 unselected consecutive patients underwent laparoscopic colorectal surgery with this technology. Ninety-seven (35%) right hemicolectomy, 19 segmental resection of the splenic flexure (6.9%), 54 anterior resection of the rectum (19.5%) and 107 LLH (38.6%) were performed. Complications were graded according to Clavien-Dindo classification, and anastomotic leakages (AL) were graded according to Clavien-Dindo classification and to International Study Group of Rectal Cancer (ISGRC) classification. RESULTS: Eight surgical and one medical complications (8.4%) were observed. Two AL occurred (1.9%). One drained spontaneously by drainage placed intraoperatively (Clavien-Dindo I, ISGRC A) and one treated by laparoscopic peritoneal lavage, leakage suture and ileostomy (Clavien-Dindo III-b, ISGRC C). Other complications were: wound infection (Clavien-Dindo II) (2); postoperative anemia caused by rectorrhagia (Clavien-Dindo II) (2); pelvic abscess between bladder and uterus (Clavien-Dindo III-a) (1); hemoperitoneum secondary to inferior mesenteric artery bleeding treated with peritoneal lavage and hemostasis (Clavien-Dindo III-b) (1); atrial fibrillation (Clavien-Dindo II) (1). All complications have been resolved. CONCLUSIONS: The complication rate after LLH after the incorporation of ICG-FA is low, since the number of AL have dramatically decreased in comparison to our previous experience. The management of these patients proved to be safe and effective due to in all cases the complication has been resolved. Further studies are required to standardize the management of these patients

Fluorescence angiography with indocyanine green (ICG) to evaluate anastomosis in colorectal surgery: where does it have more value?

Background Indocyanine green (ICG) fluorescence angiography (FA) was introduced to provide the real-time intraoperative evaluation of the vascular supply of anastomosis. However, further studies are required to evaluate its advantages in colorectal surgery and to know in which procedure this technology has more value. The aim of the present study is to assess the usefulness of the ICG-FA in the colorectal anastomosis evaluation and to evaluate where it is most useful depending on type of resection performed in terms of change of section line based on the ICG-FA and anastomotic leakage (AL) rates. Methods This is a prospective study. From September 2014 to November 2018, all patients who underwent any colorectal surgical procedure with ICG-FA in our center were enrolled in the study. Based on the type of surgery, patients were grouped in 4 categories: Group A, right hemicolectomy; Group B, segmental resection of the splenic flexure; Group C, left hemicolectomy; and Group D, anterior resection of the rectum. Results One-hundred-ninety-two unselected consecutive patients were enrolled: 67 in group A, 9 in B, 81 in C, and 35 in D. Change of section line based on ICG-FA occurred in 35 cases (18.2%): 4 in group A (6%), 1 in group B (11.1%), 21 in group C (25.9%), and 9 in group D (25.7%). ALs occurred in 5 patients (2.6%): 2 in group A (3%), 1 in C (1.2%), and 2 in D (5.7%). Conclusions ICG-FA leads to significantly more changes in the resection line in case of left hemicolectomy followed by anterior resection. FA is a promising optical imaging technique to reduce the AL incidence after colorectal procedures. To confirm this data, further studies with wider sample size and with an objective evaluation of the anastomotic perfusion are required