Evaluation of Anastomotic Perfusion following Laparoscopic Anterior Resection with Coloanal Anastomosis
A case study by Dr. Cyrus Jahansouz, Dr. Hayim Gilshtein and Dr. Steven D. Wexner, Cleveland Clinic Florida, USA
Summary: A cornerstone of colorectal surgery is the bowel anastomosis. Anastomotic leak is a devastating complication to the patient that can result in infection, sepsis, and even death.1 Healing of the anastomosis depends on both the patient’s general health condition as well as technical factors related to surgery, namely the creation of a well perfused and tension free anastomosis. The evaluation of anastomotic perfusion at the time of surgery remains a significant challenge, even to the most experienced of colorectal surgeons. Ensuring adequate blood flow at the anastomosis has the potential to reduce anastomotic leaks and improve patient outcomes following colorectal
surgery. Real-time visualization of tissue perfusion using the Indocyanine Green (ICG) pharmaceutical enables real-time assessment of anastomotic tissue perfusion allowing for a rapid determination of adequacy of the bowel anastomosis.
Case Details: The following case study Evaluation of Anastomotic Perfusion following Laparoscopic Anterior Resection with Coloanal Anastomosis discusses a patient who underwent laparoscopic anterior resection with coloanal anastomosis for rectal cancer. The patient is a 77 year old female who presented after a rectal mass was discovered during a colonoscopy. Further imaging and biopsy results were consistent with the diagnosis of a Stage 2 (T3, N0, M0) rectal cancer, the distal edge of which was situated approximately 7 cm from the anal verge. After discussion at National Accreditation for Rectal Cancer multidisciplinary tumor board, a laparoscopic anterior resection with coloanal anastomosis was offered to the patient.
Procedure: The procedure began laparoscopically with mobilization of the descending and sigmoid colon and splenic flexure, followed by high ligations of the inferior mesenteric artery and vein. The mesentery was intracorporeally divided to the distal descending colon and a total mesorectal excision was undertaken. A Lone Star retractor® (Cooper Surgical, Trumbull, CT) was placed and a circumferential full thickness incision was made 1 cm above the dentate line. Once dissection was completed, the specimen containing the tumor was carefully delivered though a wound protector placed through the enlarged umbilical port site. After resection of the rectosigmoid, a 5 cm x 5 cm colonic J-pouch was fashioned and delivered to the perineum; 3.5 mL of Indocyanine Green for Injection, USP (ICG) followed by 10 mL of saline solution was administered. Fluorescence angiography
confirmed excellent serosal perfusion of the colonic J pouch (Figure A). A hand-sewn coloanal anastomosis was then fashioned, and an additional 3.5 mL of ICG was administered confirming excellent mucosal perfusion of the anastomosis (Figure B). In addition, a reverse leak test was undertaken.
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