KARL STORZ Advanced Imaging Technologies in Laparoscopic Colorectal Surgery simposio

The most challenging situation for a surgical surgeon would be operating laparoscopically

upon patients with narrow pelvis, male patients with very obese patients as well.

Sometimes we also do laparoscopic surgery on reduced surgery, so sometimes we would

be facing with the difficulty of the dissection with adhesions in the pelvic cavity yeah since

here our institution bangkok phuket colorectal disease institute is actually located in phuket

Thailand we are an international institution we have patients from around the world flying in

from all the continents including domestic patients as well come coming from every part

of Thailand countries and then we have all kind of cases challenge cases referral cases

cases, difficult cases, cases that no other places could do or correct the surgical issues.

So all those cases would be flying in, gathering, coming to our institution.

Among all those difficult cases, of course, there might be some very, very or extremely

difficult cases as well.

let's say for example the combination of all the typical factors combined in one patient with

high expectation of having anastomosis rather than ended up with the permanent colostomy

for example redo cases male patient obese patient narrow pelvis very

very dense adhesion from radiations and chemotherapy prior to this surgery.

Based on the literature reported, I think in the past 10 years, we all know that there

are many reliable indications for using the ICG for assessing particular conditions.

For instance, we do check the vascularity, the blood supply before doing the anastomosis

to make sure that the anastomosis would be intact and would be healed up nicely without

any complications.

That's the first indication with it's very common use nowadays.

nowadays. And the other two or three complications is that the ECG can also identify occult malignancies

during the surgery. I'm talking about lymph node lymphatic mapping and in the situation

that we would need to identify peritoneal implantation of the tumor, particularly colorectal

for colorectal cancers.

Using the ICG would be much more easier

to identify retinal seeding

once we would like to remove completely all of them

and aim for cure for the patient.

The last but not least indication

that's quite common for using the ICG

and very useful as to prevent the complication

during the surgery and after the surgery as well

is that we can use the ICG

to identify ureter particularly difficult cases with densification resurgery once again.

So identification of intraoperative ureter would be very crucial to prevent ureter injury

and prevent post-operative complications related to the injury.

In my experience, as mentioned earlier, that there are varieties of medication for using

the ICG during the surgery for safe surgery, more precise surgery and as to prevent intraoperative

complications and post-operative complications as well.

well. Normally, and commonly as well, we use overlay mode of the ICG in order to check

the vascularity twice for the anastomosis. First, as to decide the position of the proximal

colon as to make sure that the the decision is correct to dissect the part that have a very

good vascularization but blood supply and the second point that we would use the overlay mode

is to check after the anastomosis formed in order to make sure once again that the anastomosis is

well vascularized or have having a good blood supply and the other mode that we also using is

the monochromatic mode most of the time monochromatic mode would be using in combination

with overlay mode to make sure that we have a good and the right position right vascular supply

to recheck the overlay mode using monochromatic mode and the other indications for using the ICG

the intensity mode is becoming more and more important as we would like to do the complete

resection not only to the tumor nowadays the complete resection of the lymphatic metastases

disease, sentinel lymph nodes for colon and rectal cancers would be one of the key for

a good long-term oncology outcomes as well.

So we also use that particular mode to identify or mapping the sentinel lymph nodes during

the surgery as to plan for a complete resection for the patient in order to have the best

possible outcomes yeah i think fluorescence imaging adding on laparoscopic surgery is

very very useful particularly when we use the three-dimensional

imaging laparoscopic surgery as well as that to make it easier and a shorter operation with

less complication because the dissection is more precise the icg procedure would not consume a lot

of timing for or during the surgery normally in literature it would be reported that that

particular procedure would add about four to five minutes but the advantages of doing so would be

vary our weight of what we would gain from spending just four to five minutes for this

kind of procedure. Normally it would be very easy to ask the anesthetist to help us to

inject the ICG. Normally the ICG would come in vial with 25 milligrams and we would be

adding a steroid water of 10 cc mix mix it well and make sure we would have to use it within six

hours after the mixture each of particular dosage for one time using of the ict would be recommended

at about three cc's that would make it 7.5 milligram for each particular dosage

and we can also repeat using it during the same cases of the maximal dosage of

two milligram per kilo kilogram of the patient's body weight so it's quite safe

and sound for using the ACG the only contraindication for using the ACG is

is that if the patient had history of iodide allergy,

so we should carefully select the patient

and ask the patient if the patient

have a history of iodide allergy.

So if so, then we should avoid injecting the ICG

to this particular group of patients

to prevent severe anaphylaxis.

So when we talked about the learning curve

of using the ICG during the surgery.

I would say you would not need any special skills.

You just need a special equipment or tools

from a certain reliable source or company

and make sure that that particular company

would have a very friendly and good services

from the technicians and representative

to assist you during the operation of the surgery and make it much easier and smooth during procedure.

I think, in my opinion, the advantages of ICG is way more than the investment.

For example, if we have one patient with leakage of the DNA osmosis, that would be a miserable

complication.

And that complication may lead to the mortality of 15%.

And adding on top of that, this group of particular patients with leakage may have to be ended

up with permanent colostomy at about 50%.

So, talking about these, only one indication for using the ICG is quite clear.

And another advantages or benefits of using ICG is that we can do more clear resection

on cancer patients both to see the occult malignancies including peritoneal

seedings and lymph node metastasis during the surgery using the mapping

from ICG and these advantages would be for the patient for the long run as to

to be cancer-free for life.

So that would be priceless for the patient,

because it means one or many patients' life

with cancer-free condition.

And to avoid a major complication to the ureter,

to avoid the ureter injury during the surgery,

surgery is one of the advantages of using the ECG because we would have to spend a lot

of time repairing and a lot of money to spend on repairing and then doing the follow-up

with the patients with urethra injury and sometimes patients would need many, many subsequent

sequence surgery in order to correct the particular uretic injury so in conclusion with I think

in my personal experience and based on international literature ICG is very very useful and it's

the future for all the surgeons around the world not only for those mentioned advantages

but nowadays that we all know that medical legal issues would be one of the headache issue if any

patient would have any complication after surgery. ICG would be one of the way to prevent all the

complications and it would be a good evidence as to show that we have done the best for the

patient not only subjectively but objectively as well from the icg imaging talking about

three-dimensional imaging nowadays that very very friendly to the surgeons this technology should be

out years ago i've been waiting for this kind of technology because we have been suffering using

using two-dimensional laparoscopic surgery

because it's not as the natural eye view of everybody.

We surgeons would love to see during the surgery

as the normal vision having three-dimensional

because the depth of the view would make it,

would make it different during the surgery,

make it easier to identify the different planes with the depth of the three-dimensional technology.

And that would be translating to more precision of the dissection,

and more precision of the dissection would be leading to less complication,

information, safe intraoperative timing for the surgery and another important advantage

of three-dimensional technology is to reduce the learning curve of doing laparoscopic surgery

for those beginners or young surgeons that would be working in the future for us as well.

and the combination of the three-dimensional technology of scopic surgery and the icg

would be just a perfect would be just a perfect match for good technology advanced technology

as to help not only the surgeon but very importantly the patients to have a good surgery

surgery with less complication, less operative time, fast and rapid recovery, and better

long-term outcome, particularly the oncologic outcomes.

Once we have difficult cases, challenge cases, or some cases seem not to be so difficult,

but once we put the camera in we would think that oh this case would be one of

the challenge cases so it's I'm trying to say that it's very important to have

a well equipped tool and operating room just to be used in real time where we

we really needed just to proceed successfully

with the laparoscopic surgery,

do not need to convert to an open surgery.

If the surgeons feel more comfortable

with the additional technology

to help us identify what we don't know,

identify the right anatomy,

identify the right structures that we would be dissecting

that would make it the best real-time decision on particular patients, sometimes surprising

patients after just putting the camera in.

So I think all this technology would be very useful and very beneficial for the patient

as to do the difficult cases.

But once again, if we do have other new technology

adding on, for instance, three-dimensional technology

and then the ICG technology with us doing the orthoscopic surgery,

that would be very helpful as to be more confident

evidence, using the evidence base of the findings during the surgery, make it easier, make it

understandable during the surgery and hopefully this technology could lower the rate of conversion

of the scopic surgery to open surgery.

This is the example of the real case using ICG and three-dimensional technology of the

patient female patient with rectal sigmoid cancer actually she's got a history of

cyclic pelvic pain once she had menstruation we use both three-dimensional camera and and the

two-dimensional icg technology for this case as you can see from the videos just now that the

The surprise is that we saw lots of dense adhesion within the pelvic cavity with the spot of endometriosis.

Luckily, we have three-dimensional technology that we can overcome the dissection of the dense adhesion

of the pelvic cavity of the small intestine to the pelvic cavity as you can see, that's the endometriosis foci.

side yes so you can see that using the technology of three-dimensional imaging we could confidently

dissect the dense adhesion within the pelvic cavity causing by endometriosis safely for the

patient then we eventually could proceed with the routine oncologic dissection of the rectal sigmoid

cancer, high ligation of the IMV and IMA and the mesorectal dissections as well.

This part of the surgery as you can see that we asked the anesthetist to inject the ICG

of three cc's into the patient's circulator and flush with 10 cc's of noosaline as you can see

that the imaging would turn green to the blood vessels and to the colon proximal colon once we

now planning to do the proximal dissection ready for anastomosis you can see that the

The first decision was to make the proximal dissection

at the spot of the pickup.

Once we inject the ACG,

we could see that the perfusion

of the proximal colon for anastomosis is more proximal.

I think it's about two or three centimeter more proximal

to the first decision.

So we had to change the decision of the dissection

more approximately to ensure that the blood supply is good enough for the

intact anastomosis without complication. Second injection of the ICG regarding

anterosection as you can see from these videos that we inject the ICG of 3

milliliters asking the anesthetist to do so. We can see and recheck the intact

anastomosis with good blood supply of the icg as you can see that the proximal

colon which is anastomosing with the distal rectum turn green after five seconds of injection of the

I see