Accurate intraoperative real-time blood flow assessment of the remnant stomach during robot-assisted distal pancreatectomy with celiac axis resection using indocyanine green fluorescence imaging and da Vinci Firefly technology

Abstract

Background: Ischemic gastropathy is one of the unique postoperative complications associated with distal pancreatectomy with celiac axis resection for locally advanced pancreatic cancer. Therefore, it is essential to evaluate blood flow to the stomach following a resection; however, no intraoperative procedures have been established to assess this issue. Herein we describe two cases in which intraoperative evaluation of real-time blood flow in the residual stomach was performed using indocyanine green fluorescence and da Vinci Firefly technology during a robot-assisted distal pancreatectomy with celiac axis resection. Methods: Robot-assisted distal pancreatectomy with celiac axis resection was performed using a da Vinci Xi surgical system on two patients with locally advanced pancreatic cancer and suspected invasion of the celiac artery. ICG (0.5 mg/kg) was injected intravenously after resection to evaluate real-time blood flow of the stomach using a da Vinci Firefly system. Blood flow of the stomach was evaluated 60 seconds after the intravenous injection of ICG. Results: Case 1 was confirmed that there was sufficient blood flow in the residual stomach. Therefore, reconstruction of the left gastric artery was not performed, and the surgery was completed with preservation of the entire stomach. Case 2 was performed a proximal gastrectomy at first because the tumor directly involved the gastric lesser curvature and the left gastric artery. Next, ICG was injected intravenously, and after confirming good blood flow in the residual stomach and stomach stump, an esophageal residual gastric anastomosis was performed. Good postoperative outcomes were achieved and there was no evidence of ischemic gastropathy and delayed gastric emptying in both two cases. Conclusions: This method is very useful in determining whether or not to perform reconstruction of the left gastric artery and/or additional resection of the remnant stomach during a robot-assisted distal pancreatectomy with celiac axis resection.