#290 Fluorescence guided Selective Autonomic Nerve preserving Robotic TME-Dr. Nishtha Midha

This is one of the 2023 KS International Innovation Awards videos selected for inclusion in the Vattikuti Foundation – ORSI Humans on the Cutting Edge of Robotic Surgery Conference, October 6, 7 & 8, 2023 in Ghent, Belgium. Posting does not imply that is has been selected as a Finalist, just that the content will be discussed at the Conference.

From the entry: Fluorescence guided Selective Autonomic Nerve preserving Robotic TME Introduction Since the adoption of Total Mesorectal excision (TME), oncological outcome has improved. However, functional outcomes such as sexual and urinary dysfunction are still concerning. Autonomic nerve preservation (ANP) with adherence to TME principles is challenging in a narrow or deep pelvis due to poor visualization, lack of anatomical knowledge and neoadjuvant treatment induced tissue edema.

Methodology 0.5mg/kg body weight of Indocyanine green (ICG) is administered intravenously 12hr prior to the surgery. Unlike adjacent structures, autonomic nerves do not take up ICG and are distinctively visualized as white structures on a bottle green background under firefly mode. This facilitates identification and selective nerve preservation at critical zones of nerve injury.

Case snippet 52-year-old lady, status post chemoradiation for a non-metastatic adenocarcinoma, 2cm from the anal verge with levator ani involvement.

Salient points

1. Standardized and reproducible step by step approach to ANP TME procedure

2. Identification and navigation of autonomic nerve dissection in real time at critical zones of injury during TME

Surgical technique After standard positioning and port placement, abdominal phase begins by incising the Right pararectal peritoneal fold at sacral promontory, in proximity to Superior rectal artery to safeguard the Hypogastric nerves. At the cranial aspect of IMA, para-aortic plexus is preserved by adapting to Intra-sheath nerve separation technique under Fluorescence guidance.

During standardized pelvic phase of TME hypogastric nerves and its branches are selectively safeguarded under Fluorescence navigation.

Conclusion Fluorescence navigation accentuates autonomic nerve dissection, thus improving genitourinary functional outcome.

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