Indocyanine Green–Guided Robotic Low Anterior Resection for Rectal Cancer: A Step-by-Step approach

Abstract

The treatment of locally advanced rectal adenocarcinoma is based on a multimodal approach, including total mesorectal excision¹. Robotic surgery provides a three-dimensional visualization, a stable image, and greater precision in pelvic dissection, allowing better control over critical structures². The use of indocyanine green fluorescence enables real-time assessment of anastomotic perfusion, enhancing anastomotic safety³.

This video highlights the essential technical steps of robotic low anterior resection, including mesorectal dissection, anastomosis construction, and strategies to minimize complications, demonstrating the advantages of the robotic approach.

We present a 37-year-old female patient with no relevant medical history, reporting rectal bleeding and tenesmus. Endoscopic evaluation revealed a vegetative lesion in the mid-rectum, confirmed as moderately differentiated adenocarcinoma. Thoraco-abdomino-pelvic CT showed thickening of the rectal wall with small locoregional lymph nodes, without other suspicious lesions; pelvic MRI allowed staging of cT2–3N+.

After well-tolerated total neoadjuvant therapy, the patient underwent robotic low anterior resection with indocyanine green fluorescence, including protective colostomy. Postoperative recovery was uneventful. Pathological examination revealed complete mesorectum and adenocarcinoma G2 ypT1(Sm3)N0(0/14)R0, reflecting an almost complete pathological response. At six months, the patient shows regular bowel transit without abdominal pain.

Robotic surgery with indocyanine green fluorescence allows precise pelvic dissection and safe assessment of anastomotic perfusion, facilitating the execution of complex technical steps and demonstrating the efficacy of the multimodal approach in rectal cancer.