Robotic low ligation of the inferior mesenteric artery for rectal cancer using the firefly technique

Purpose: By integrating intraoperative near infrared fluorescence imaging into a robotic system, surgeons can identify the vascular anatomy in real-time with the technical advantages of robotics that is useful for meticulous lymphovascular dissection. Herein, we report our initial experience of robotic low ligation of the inferior mesenteric artery (IMA) with real-time identification of the vascular system for rectal cancer using the Firefly technique. Materials and Methods: The study group included 11 patients who underwent a robotic total mesorectal excision with preservation of the left colic artery for rectal cancer using the Firefly technique between July 2013 and December 2013. Results: The procedures included five low anterior resections and six ultra-low anterior resections with loop ileostomy. The median total operation time was 327 min (226‒490). The low ligation time was 10 min (6‒20), and the time interval between indocyanine green injection and division of the sigmoid artery was 5 min (2‒8). The estimated blood loss was 200 mL (100‒500). The median time to soft diet was 4 days (4‒5), and the median length of stay was 7 days (5‒9). Three patients developed postoperative complications; one patients developed anal stricture, one developed ileus, and one developed non-complicated intraabdominal fluid collection. The median total number of lymph nodes harvested was 17 (9‒29). Conclusion: Robotic low ligation of the IMA with real-time identification of the vascular system for rectal cancer using the Firefly technique is safe and feasible. This technique can allow for precise lymph node dissection along the IMA and facilitate the identification of the left colic branch of the IMA.