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Colorectal anastomoses after anterior resection for cancer carry a high risk of leakage. Different factors might influence the correct healing of anastomosis, but adequate perfusion of the bowel is highlighted as one of the most important elements. Fluorescence angiography (FA) is a new technique that allows the surgeon to perform real-time intraoperative angiography to evaluate the perfusion of the anastomosis and hence, potentially, reduce leak rate. The aim of this study was to evaluate the impact of FA of the bowel on postoperative complications and anastomotic leakage after laparoscopic anterior resection with total mesorectal excision (TME). FA was performed in all patients undergoing laparoscopic anterior resection with TME for cancer followed by colorectal or coloanal anastomosis. Results were compared to a historical controls group of 38 patients previously operated by the same surgeon for the same indication but without the use of FA. From October 2014 to November 2015, 42 patients underwent laparoscopic anterior resection with TME and FA of the bowel. The surgeon subjectively decided to change the planned anastomotic level of the descending colon due to hypoperfused distal segment in two out of 42 patients in the FA group (4.7 %). Anastomotic leakage, confirmed by postoperative CT scan and water-soluble contrast enema, was found in two cases of a historical controls group and none in the FA group. No adverse events (side effects or allergic reaction) related to FA were recorded. All the other postoperative complications were comparable between the two groups. In our experience, ICG FA was safe and effective in low rectal cancer resection, possibly leading to a reduction in the anastomotic leakage rate after TME.

Anastomotic leakage after colorectal surgery is a severe complication. One possible cause of anastomotic leakage is insufficient vascular supply. The aim of this study was to evaluate the feasibility and the usefulness of intraoperative assessment of vascular anastomotic perfusion in colorectal surgery using indocyanine green (ICG)-enhanced fluorescence. Between May 2013 and October 2014, all anastomosis and resection margins in colorectal surgery were investigated using fluorescence angiography (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany) intraoperatively to assess colonic perfusion prior to and after completion of the anastomosis, both in right and left colectomies. A total of 107 patients undergoing colorectal laparoscopic resections were enrolled: 40 right colectomies, 10 splenic flexure segmental resections, 35 left colectomies, and 22 anterior resections. In 90 % of cases, the indication for surgery was cancer and high ligation of vessels was performed. Based on the fluorescence intensity, the surgical team judged the distal part of the proximal bowel to be anastomosed insufficiently perfused in 4/107 patients (two anterior, one sigmoid and one segmental splenic flexure resections for cancer), and consequently, further proximal “re-resection” up to a “fluorescent” portion was performed. None of these patients had a clinical leak. The overall morbidity rate was 30 %; one patient undergoing right colectomy had an anastomotic leakage, apparently unrelated to ischemia; there were no clinical evident anastomotic leakages in colorectal resections including all low anterior resections. ICG-enhanced fluorescent angiography provides useful intraoperative information about the vascular perfusion during colorectal surgery and may lead to change the site of resection and/or anastomosis, possibly affecting the anastomotic leak rate. Larger further randomized prospective trials are needed to validate this new technique.

The short-term results of a retrospective consecutive series of multidisciplinary laparoscopic approach to deep infiltrating endometriosis with intestinal involvement requiring segmental bowel resection procedures are presented. Patients with radiologically or intraoperative-confirmed endometriosis, who underwent a combined laparoscopic segmental bowel resection by a team of gynecologists and colorectal surgeons, were retrospectively reviewed. The postoperative data were collected in a specific database and analyzed for short-term (30 days) postoperative outcomes with the comparison between two specimen’s extraction methods. Forty-one patients (median age of 36 years, range 25–44) have been operated by a combined team of gynecologist and colorectal surgeons. The median operative time was 247.5 min (range 155–375), and median estimated blood loss was 300 ml (range 100–1300). In 20 patients, the surgical specimens were extracted transvaginally, while in 21 cases, a sovrapubic transverse Pfannenstiel minilaparotomy was used. No intraoperative complications or conversion to laparotomy were reported. An acceptable cumulative rate of postoperative morbidity was observed (6/41, 15 %), without any postoperative deaths. Comparing the two subgroups of patients with different modalities of specimen retrieval, postoperative pain (assessed by visual analog scale) was significantly reduced in the transvaginal extraction group (median: 1 and range: 0–2 vs median: 3, 5 and range: 1–6; p= 0.002), without any statistically significant differences in terms of complications. Laparoscopic bowel segmental resection combined with gynecologic surgery for deep infiltrating endometriosis with intestinal involvement is a valid treatment option with a low rate of postoperative complications. Transvaginal specimen extraction allows the same results of minilaparotomic incision, minimizing surgical trauma and warranting a clear benefit in terms of reduction of postoperative pain.

Recently major developments in video imaging have been achieved: among these, the use of high definition and 3D imaging systems, and more recently indocyanine green (ICG) fluorescence imaging are emerging as major contributions to intraoperative decision making during surgical procedures. The aim of this study was to present our experience with different laparoscopic procedures using ICG fluorescence imaging. 108 ICG-enhanced fluorescence-guided laparoscopic procedures were performed: 52 laparoscopic cholecystectomies, 38 colorectal resections, 8 living-donor nephrectomies, 1 laparoscopic kidney autotransplantation, 3 inguino-iliac/obturator lymph node dissections for melanoma, and 6 miscellanea procedures. Visualization of structures was provided by a high definition stereoscopic camera connected to a 30° 10 mm scope equipped with a specific lens and light source emitting both visible and near infra-red (NIR) light (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany). After injection of ICG, the system projected high-resolution NIR real-time images of blood flow in vessels and organs as well as highlighted biliary excretion . No intraoperataive or injection-related adverse effects were reported, and the biliary/vascular anatomy was always clearly identified. The imaging system provided invaluable information to conduct a safe cholecystectomy and ensure adequate vascular supply for colectomy, nephrectomy, or find lymph nodes. There were no bile duct injuries or anastomotic leaks. In our experience, the ICG fluorescence imaging system seems to be simple, safe, and useful. The technique may well become a standard in the near future in view of its different diagnostic and oncological capabilities. Larger studies and more specific evaluations are needed to confirm its role and to address its disadvantages.

Abstract: Background: The incidence of wound morbidity (WM) after conventional thyroidectomy (CT) is 2 to 7%. This study evaluated the rate of WM after video-assisted thyroidectomy (VAT), with emphasis on surgical-site infections (SSIs). Methods: A total of 112 patients were recruited for this prospective, randomized surveillance analysis. The eligibility criteria included nodule smaller than 30 mm, gland volume less than 30 ml, and no previous neck surgery or advanced cancer. The exclusion criteria specified coexistent infection, immunosuppressive treatment, and pathologies requiring antibiotic prophylaxis. The patients were randomized for VAT or CT. Neither antibiotic prophylaxis nor a drain was used. The patients were followed after surgery for WM. Results: Both groups consisted of 56 patients. The rate for WM was significantly lower in the VAT group (n = 1) than in the CT group (n = 8) (p < 0.05). The incidence of SSI was 5.3% after CT and 0% after VAT (p < 0.05), and the most common pathogenic organism was Staphylococcus aureus. All WMs became evident after patient discharge. Wound infection was associated with prolonged ambulatory dressings. Conclusions: No previous studies have compared the rates for WM associated with endoscopic versus open surgery in the cervical area. Wound morbidity was significantly reduced after VAT relative to CT. The authors underscore the important effect of the minor surgical trauma associated with VAT on the development of SSIs.