Itatani Yoshiro, Kawada Kenji, Hida Koya, Deguchi Yasunori, Oshima Nobu, Mizuno Rei, Wada Toshiaki, Okada Tomoaki, Sakai Yoshiharu
Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto, 606-8507 Japan.
Department of Surgery, Osaka Red Cross Hospital, 5 - 30, Fudegasaki-cho, Tennoji-ku, Osaka, Japan.
Int Cancer Conf J. 2020 Jun 16;9(4):170-174. doi: 10.1007/s13691-020-00424-4. eCollection 2020 Oct.
Laparoscopic approaches have become a standard strategy for colon cancer patients who undergo surgical treatment. Complete mesocolic excision (CME) with central vascular ligation (CVL) is the fundamental principle of radical resection of colon cancers. Splenic flexure colon cancer (SFCC) is rare, accounting for less than 4% of all colorectal cancer cases. Moreover, a laparoscopic approach for SFCC following the CME/CVL concept can be challenging because the blood supply of the splenic flexure is derived from either the middle colic artery (MCA) branching from the superior mesenteric artery, the left colic artery (LCA) branching from the inferior mesenteric artery. In addition, approximately one third of SFCC patients have an accessory MCA that can originate from the celiac trunk. Herein, we describe the technical procedure of a laparoscopic left hemicolectomy for SFCC using indocyanine green (ICG) for necessary and sufficient lymphadenectomy followed by intracorporeal anastomosis. Two injections of ICG (0.5 mg/0.2 ml × 2) into the subserosa of the proximal and distal sides of the tumor preceded the surgical procedure after pneumoperitoneum. Near infrared images obtained throughout the laparoscopic procedure helped visualize lymphatic drainage vessels and inform decision making for determining vessels requiring ligation according to the CVL concept: MCA, LCA or accessory MCA. Complete intracorporeal anastomosis following necessary and sufficient lymphadenectomy with ICG can minimize the dissecting area of the laparoscopic left hemicolectomy for SFCC patients. Intravenous ICG injection (2.5 mg) after anastomosis helps confirm blood perfusion at the anastomosis site. Four patients with SFCC underwent a laparoscopic colectomy under ICG navigation in 2019 at our institute. The median operative time was 237 min, the median estimated blood loss was 0 ml, and the median number of dissected lymph nodes was 13. No patients experienced postoperative complications. In conclusion, laparoscopic left hemicolectomy with ICG navigation and intracorporeal anastomosis for SFCC patients may be a feasible option for the radical resection of colon cancer.
腹腔镜手术方法已成为接受手术治疗的结肠癌患者的标准策略。完整结肠系膜切除术（CME）联合中央血管结扎术（CVL）是结肠癌根治性切除的基本原则。脾曲结肠癌（SFCC）较为罕见，占所有结直肠癌病例的比例不到4%。此外，按照CME/CVL理念对SFCC进行腹腔镜手术具有挑战性，因为脾曲的血液供应要么来自肠系膜上动脉分支的中结肠动脉（MCA），要么来自肠系膜下动脉分支的左结肠动脉（LCA）。此外，约三分之一的SFCC患者有副中结肠动脉，其可起源于腹腔干。在此，我们描述了使用吲哚菁绿（ICG）进行腹腔镜左半结肠切除术治疗SFCC的技术步骤，以进行必要且充分的淋巴结清扫，随后进行体内吻合。气腹后手术前，在肿瘤近端和远端的浆膜下注射两次ICG（0.5mg/0.2ml×2）。在整个腹腔镜手术过程中获得的近红外图像有助于可视化淋巴引流血管，并根据CVL理念为确定需要结扎的血管提供决策依据：中结肠动脉、左结肠动脉或副中结肠动脉。对于SFCC患者，在进行必要且充分的ICG淋巴结清扫后进行完整的体内吻合，可将腹腔镜左半结肠切除术的解剖区域降至最低。吻合后静脉注射ICG（2.5mg）有助于确认吻合部位的血液灌注。2019年，我院有4例SFCC患者在ICG导航下接受了腹腔镜结肠切除术。中位手术时间为237分钟，中位估计失血量为0ml，中位清扫淋巴结数为13个。无患者发生术后并发症。总之，对于SFCC患者，采用ICG导航和体内吻合的腹腔镜左半结肠切除术可能是结肠癌根治性切除的一种可行选择。
