The selection of an optimal site for anastomosis has been dependent on subjective clinical indicators of intestinal viability: color of the bowel wall, bleeding edges of resected margins, and palpable pulsations.
Several intraoperative assessment methods are described in the literature to evaluate bowel perfusion. Indocyanine green fluorescence (ICG) is a relatively new technique. ICG is administered as an intravenous bolus and remains strictly intravascular. Its intensity is correlated with tissue perfusion and bright fluorescence indicates good perfusion. Special camera filters are necessary to visualize it.
Here we show two cases of colorectal anastomosis in which ICG was used to decide the anastomosis site.
In the first case, after sectioning the mesocolon and selecting the anastomosis site, ICG was administered and the colon changed to an intense green. In this case what the eye sees it the same as the ICG. After performing the anastomosis, it was checked again with ICG and no changes were found.
VIDEO 1: The eye and the ICG agree on the differentiation between a well vascularized colon and a poorly vascularized one. The anastomosis was also assessed.
In the second case, after sectioning the mesocolon and preparing the anastomosis colon, ICG was administered. The site initially selected was not the one indicated by ICG. Although the colour of the bowel was correct, ICG showed a better place, so in this case the anastomosis site was changed on the basis of the test.
VIDEO 2: The ICG makes a difference, with the green arrow distinguishing the well vascularized colon (green arrow) from the poorly vascularized one (red arrow). The ICG led us to change the colonic site to perform the anastomosis.
None of these patients presented with anatomosis-derived complications in their postoperative evolution. ICG provides an option to evaluate the perfect site to perform an anastomosis in colorectal surgery, which is especially useful in patients with potential vascularization-related problems.