Effectiveness of fluorescence-guided methods using near-infrared fluorescent clips of robotic colorectal surgery: a case report

In robotic colorectal surgery, fluorescent guidance with firefly technology offers two advantages. First, it is advantageous, because the Da Vinci-compatible NIRFCs allow accurate, real-time monitoring of lesion location and sufficient intestinal resection by grasping the lesion precisely. The ideal length of the distal RM (DRM) is an essential factor that regulates the elimination of lymph node metastasis in the mesentery and distal intramural spread in the intestinal wall [6, 8]. Especially, in rectal cancer cases like the present case, a shorter DRM increases the risk of local recurrence and decreases the overall survival rate [9, 10]. Thus, the tumor should be localized accurately. Unlike the conventional tattoo marking method, the Da Vinci-compatible NIRFC does not result in ink scattering. Moreover, the firefly technology makes localizing the tumor easier. The Da Vinci-compatible NIRFC is useful in the management of rectal cancer cases.

Second, it reduces the risk of postoperative complications. ICG evaluation with firefly technology prevents postoperative AL, a severe complication of colorectal cancer. AL occurs in 1–20% of patients. It has been associated with less favorable short-term outcomes, such as a high reoperation rate and prolonged hospital stay, as well as long-term outcomes, such as a high local recurrence rate and low concurrent cancer-specific survival [11]. In laparoscopic surgery, a dedicated ICG camera is used. The number of facilities capable of performing ICG evaluation remains limited. However, the demand for ICG increased in 2018 when it became covered by insurance. The camera, used in the Da Vinci surgery, resulted in an easy ICG evaluation and safe anastomosis [12]. Based on these advantages, robotic surgery can be viewed in real-time.

The optimal placement, intensity, and clarity for the Da Vinci-compatible NIRFCs will be reviewed by gathering-related cases. In the future, the application of this method in the management of patients with lower rectal cancer should be investigated. In lower rectal cancer, the circumferential RM (CRM) influences the local recurrence rate, like the DRM. After preoperative treatment, the 5-year local recurrence rate for a CRM measuring > 1 mm was significantly lower than those ≤ 1 mm [13]. Total mesorectal excision (TME) surgery is the standard treatment for patients with lower rectal cancer [14]. To achieve a complete TME and ensure a sufficient CRM, tumor site marking with NIRFC may be used instead of tattoo marking, which results in ink scattering. The scattered ink during tattoo marking makes it difficult to recognize the TME layers (Fig. 6). Thus, it is not suitable for patients undergoing TME. The NIRFCs marking method is useful for cases of lower rectal cancer.

Fig. 6figure 6

Scattered ink makes it difficult to distinguish the TME layers

Aside from TME, chemoradiation therapy and total neoadjuvant therapy are also standard treatment options for patients with lower rectal cancer [14]. These modalities reduce the size of the primary lesion. Consequently, the intestinal resection length is shortened, and the anal function is preserved. Tumor site marking with NIRFC allows a more accurate localization of the lesion.

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