Laparoscopic Total Devascularization of the Upper Stomach and Splenectomy (Hassab’s Procedure) Under Indocyanine Green Fluorescence Imaging: Initial Experience

Abstract

The use of surgical treatment for refractory isolated gastric varices has decreased owing to the development of endoscopic and radiologic procedures, although surgeries are sometimes required as the final method. A 75-year-old Japanese woman was diagnosed with solitary gastric varices. Initially, intraoperative splenic artery embolization was performed using the balloon transcatheter technique under general anesthesia. Laparoscopic splenectomy was performed safely owing to preoperative splenic artery embolization. Intraoperative indocyanine green (ICG) fluorescence angiography was performed following the injection of 5 mL of ICG; the remnant stomach was observed using laparoscopic equipment with an ICG imaging system, and blood flow from the remnant gastric artery was confirmed. The blood did not pool or wash out immediately, which confirmed successful devascularization of the stomach. The total operative time was 269 minutes, and the intraoperative blood loss was 500 mL. The patient’s postoperative course was good, and at 21 days after the last operation, she was discharged from our hospital in remission. Real-time fluorescence angiography with ICG is a reliable and objective technique of assessing blood flow of the stomach. Accurate, extensive devascularization in the lower esophagus and upper stomach was performed using Hassab’s procedure in combination with ICG imaging.

Evaluating gastric remnant ischemia by indocyanine green fluorescence-guided surgery after distal gastrectomy in a patient with prior Nissen fundoplication: A case report

“…Although the mortality rate is thought to decrease with improved diagnostic capabilities, gastric remnant ischemia is one of the fatal postoperative complications. The risk of gastric remnant ischemia is high in the DG if the splenic vessels are dissected because the blood supply to the gastric remnant from the splenic artery branch/short gastric artery is no longer available [11] , [12] , [13] , [14] . There are some reports of DG after distal pancreatectomy in a similar situation, and the risk of remnant gastric ischemia after splenic vessels resection was mentioned as well [15] , [16] , [17] , [18] .…”

“…Although ICG fluorescence-guided surgery is beneficial, its application depends upon the subjectivity of the surgeon, and the evaluation method for ICG fluorescence remains unestablished. In addition, from several reports where intraoperative ICG was used to evaluate gastric blood flow, issues with the splenic artery system of patients have been described, which increased the risk of remnant gastric ischemia [12] , [13] , [14] . We performed intraoperative ICG fluorescence-guided surgery for the result from intraoperative endoscopy.…”