Indocyanine Green tattoo in localising low rectal lesions and intracorporeal anastomosis.

Abstract

Aim: We present an alternative technique to traditional endoscopic tattooing for localising rectal tumours, with intra-operative use of Indocyanine Green (ICG) delivered endoscopically without the adverse effects that deter colorectal surgeons. Methods: We describe a case of a 40-year-old female who underwent a laparoscopic ultra-low anterior resection, following a colonoscopy that revealed a malignant appearing hemi-circumferential 5cm polyp, 8cm from the anal verge. Preoperative imaging staged the lesion as a T2N0 rectal cancer. For intra-operative tumour localisation, endoscopic ICG was used instead of endoscopic ink to avoid distorting the mesorectal plane through local fibrotic reaction or hindering total mesorectal excision (TME). Results: The technique used is described as follows: 1)TME dissection and preparation for rectal division 2)Tumour localisation via flexible sigmoidoscopy using a Stryker® 1588 system 3)Preparation of endoscopic ICG and drawing up to endoscopic tattoo syringe 4)With camera in infrared mode, injection of ICG Tattoo into anterior wall of rectum 10mm distal from tumour (away from mesorectum). To reduce ICG diffusion, a maximum 1.5mL volume was infiltrated 5)Ultra-low distal resection performed using a Signia® purple 60mm stapler 6)Perfusion check of conduit with intravenous ICG administration, visibly distinct from intramucosal tattoo ICG 7)Formation of intracorporeal, side-to-end (Baker type) anastomosis. Flexible sigmoidoscopy confirmed a negative leak test and widely patent anastomosis The patient had an uncomplicated post-operative course and was discharged day 3 post-op. The histopathology resection margins were clear and final staging was T1N0M0. Conclusion: This case demonstrated an alternate use of ICG successfully. Its administration both endoscopically and intravenously allowed for rectal tumour localisation and perfusion check of the anastomosis. This reduced distortion of the TME plane, giving visual reassurance in appropriate resection margin and anastomotic perfusion.