Surgical Endoscopy (2023) 37:4088–4096 and Other Interventional Techniques

https://doi.org/10.1007/s00464-023-10033-w

DYNAMIC MANUSCRIPT

Lateral pelvic sentinel lymph node biopsy using indocyanine green

fluorescence navigation: can it be a powerful supplement tool
for predicting the status of lateral pelvic lymph nodes in advanced
lower rectal cancer
Hao Su1 · Zheng Xu2 · Mandula Bao3 · Shou Luo2 · Jianwei Liang2 · Wei Pei2 · Xu Guan2 · Zheng Liu2 · Zheng Jiang2 ·
Mingguang Zhang2 · Zhixun Zhao2 · Weisen Jin4 · Haitao Zhou2

Received: 20 June 2022 / Accepted: 12 March 2023 / Published online: 30 March 2023
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023

Abstract
Background An innovative instrument for laparoscopy using indocyanine green (ICG) allows easy detection of sentinel
lymph nodes (SLNs) in lateral pelvic lymph nodes (LPLNs). Here, we investigated the safety and efficacy of lateral pelvic
SLN biopsy (SLNB) using ICG fluorescence navigation in advanced lower rectal cancer and evaluated the sensitivity and
specificity of this technique to predict the status of LPLN.
Methods From April 1, 2017 to December 1, 2020, we conducted lateral pelvic SLNB using ICG fluorescence navigation
during laparoscopic total mesorectal excision and lateral pelvic lymph node dissection (LLND) in 23 patients with advanced
low rectal cancer who presented with LPLN but without LPLN enlargement. Data regarding clinical characteristics, surgical
and pathological outcomes, lymph node findings, and postoperative complications were collected and analyzed.
Results We successfully performed the surgery using fluorescence navigation. One patient underwent bilateral LLND and
22 patients underwent unilateral LLND. The lateral pelvic SLN were clearly fluorescent before dissection in 21 patients.
Lateral pelvic SLN metastasis was diagnosed in 3 patients and negative in 18 patients by frozen pathological examination.
Among the 21 patients in whom lateral pelvic SLN was detected, the dissected lateral pelvic non-SLNs were all negative.
All dissected LPLNs were negative in two patients without fluorescent lateral pelvic SLN.
Conclusion This study indicated that lateral pelvic SLNB using ICG fluorescence navigation shows promise as a safe and
feasible procedure for advanced lower rectal cancer with good accuracy, and no false-negative cases were found. No metas-
tasis in SLNB seemed to reflect all negative LPLN metastases, and this technique can replace preventive LLND for advanced
lower rectal cancer.

Keywords Rectal cancer · Sentinel lymph node · Lateral pelvic lymph node dissection · Indocyanine green · Laparoscopic
surgery

Hao Su and Zheng Xu are the first authors who contributed equally
to this work.

* Weisen Jin Hospital, Chinese Academy of Medical Science and Peking

shwhalan@yeah.net Union Medical College, Beijing 100021, China
3
* Haitao Zhou Department of Pancreatic and Gastric Surgery, National
zhouhaitao01745@163.com Cancer Center, National Clinical Research Center
for Cancer/Cancer Hospital, Chinese Academy of Medical
1
Department of Gastrointestinal Surgery, Key Laboratory Science and Peking Union Medical College, Beijing 100021,
of Carcinogenesis and Translational Research (Ministry China
of Education/Beijing), Peking University Cancer Hospital & 4
Department of Anorectal Diseases, Third Medical Center
Institute, Beijing 100142, China
of Chinese PLA General Hospital, Haidian District,
2
Department of Colorectal Surgery, National Cancer Center, Beijing 100039, People’s Republic of China
National Clinical Research Center for Cancer/Cancer

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Surgical Endoscopy (2023) 37:4088–4096
Surgery remains the standard treatment for colorectal can-
cer with curative intent. Total mesorectal excision (TME)
is the standard surgical procedure [1]. However, patients
with advanced lower rectal cancer at or below the perito-
neal reflection occasionally develop metastases to the lat-
eral pelvic lymph nodes (LPLNs), which are considered a
major site for postoperative local recurrence [2, 3]. Patients
with LPLN metastasis present a particular challenge for both
diagnosis and treatment. In Eastern countries, principally in
Japan, LPLN metastasis is considered a local disease and is
treated with lateral pelvic lymph node dissection (LLND)
in addition to TME [4]. The potential surgical risks and
morbidity associated with LLND, as well as the uncertainty
of oncological outcomes, have made LLND controversial
and limited, especially in patients with pathologically nega-
tive LPLN [5]. Preoperative radiological examinations have
helped detect LPLN metastasis in 14%–20% of cases with
locally advanced low rectal cancer on initial assessment,
but these remain insufficient, and some patients with LPLN
metastasis cannot be detected [6].
The sentinel lymph node (SLN) is the first lymph node to
receive lymphatic flow from the tumor. SLN biopsy (SLNB)
has been widely performed in breast cancer, malignant mela-
noma, and some gastrointestinal cancers [7–9]. SLN naviga-
tion surgery using indocyanine green (ICG) for gastric can-
cer has the potential to improve patient treatment selection
[10]. ICG is a sterile, anionic, and water-soluble solution
that acts as a fluorophore in response to near-infrared (NIR)
irradiation and is considered an ideal agent for the acquisi-
tion of high-quality images of both the circulatory and lym-
phatic systems [11]. Therefore, to address these concerns,
we attempted to use this innovative technique in surgery for
patients who presented with advanced lower rectal cancer
with LPLN but without LPLN enlargement based on mag-
netic resonance imaging (MRI) evaluation (i.e., lymph nodes
with a short-axis diameter < 10 mm, as seen on MR images,
are not regarded as lymph node enlargement) and evaluated
the sensitivity and specificity of lateral pelvic SLNB using
ICG fluorescence navigation for the accurate diagnosis of
LPLN metastasis. In this article, we described this technique
and investigated its safety and efficacy.
Methods
Patients
From April 1, 2017 to December 1, 2020, consecutive
patients diagnosed with advanced lower rectal cancer who
underwent lateral pelvic SLNB using ICG fluorescence
navigation during laparoscopic TME and LLND by a single
surgeon in our hospital were enrolled retrospectively.
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Eligible patients were 18–80 years of age, with a body
mass index (BMI) between 18.5 and 30 kg/m2, a pathologi-
cal diagnosis of rectal adenocarcinoma, and a tumor at or
below the peritoneal reflection, diagnosed with stage II or
III preoperatively according to the UICC-TNM classifica-
tion, and presented with LPLN but without LPLN enlarge-
ment based on MRI evaluation. Patients with a history of
colorectal surgery, multiple primary colorectal carcinomas,
and distant metastases were excluded. Moreover, those with
allergic hypersensitivity to ICG were excluded. In princi-
ple, all patients received neoadjuvant chemoradiotherapy
(NACRT) or neoadjuvant chemotherapy (NACT) in prin-
ciple. Patients who received neoadjuvant therapy under-
went surgery 6–8 weeks after radiotherapy or 4 weeks after
chemotherapy. This study was conducted in accordance with
the principles of the Declaration of Helsinki. All patients
received a detailed explanation of the procedures and pro-
vided informed consent, and this study was approved by the
institutional review board.
The LPLN, including the internal iliac, external iliac,
and obturator nodes, was evaluated independently by the
surgeon and the radiologist before surgery. The LPLN was
considered present based on the maximum short axis of the
LPLN ≥ 5 mm and enlarged based on the maximum short
axis of the LPLN ≥ 10 mm before neoadjuvant treatment or
before surgery (if the patient did not receive neoadjuvant
treatment).
Surgical procedures
The fluorescence system used in this study was an Opto-
Cam 2100 (OptoMedic, Guangdong, China). This device
can be used in standard laparoscopic visible imaging mode
and can be switched to NIR fluorescence mode by means of
button control on the camera head, on the stack console, or
via the foot pedal.
Under general anesthesia, all patients were placed in a
supine lithotomy position with a 15° tilt toward the left and
the head bent downward. Then, the five-port technique was
used for abdominal performance: a 10-mm supra-umbilical
port was used as the observation port, a 12-mm port in the
right lower quadrant was used as the primary operating port,
and three 5-mm ports in the right upper quadrant, left upper
quadrant, and left lower quadrant were used as the secondary
operating ports. After confirming the absence of abdominal
metastasis, the perineal performance was started with finger
dilatation, followed by the application of an anal dilator to
clearly observe the lower margin of the tumor. ICG (25 mg;
Eisai, Tokyo, JP) was diluted with 10 mL of distilled water.
Approximately 0.5 mL of the prepared solution, containing
1.25 mg of ICG, was injected into the submucosal layer of
the rectum at three points around the primary tumor, for a
total volume of 1.5 mL (Fig. 1).
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4090
Fig. 1  The injection of ICG around the rectal tumor
Fig. 2  The resected SLN under ICG-enhanced NIR fluorescence-
guided imaging
First, lateral pelvic SLNB was started using ICG fluores-
cence navigation (Fig. 2). The direction of the lateral lymph
node drainage was determined through overall scanning
under the guidance of ICG-enhanced NIR fluorescence-
guided imaging (Fig. 3A), and the first LPLN or the LPLNs
receiving ICG that had a shining fluorescent spot in the
image as an SLN were defined. All SLNs were resected
if they were discovered and sent separately for frozen
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Surgical Endoscopy (2023) 37:4088–4096
pathological examination. Following the TME principle,
the rectum and mesorectum were dissected, and the pelvic
autonomic nerves were protected carefully.
After completion of the laparoscopic TME, the remain-
ing LLND using ICG fluorescence navigation was per-
formed as follows. First, a dissection was made along the
ureter–hypogastric fascia close to the bladder to reveal the
lateral pelvic region, and the ureters and hypogastric nerve
were protected carefully. The peritoneum was opened along
the edge of the external iliac vessels close to the deep ingui-
nal ring (Fig. 3B). The fatty tissue outside the external iliac
vessels was removed along the edge of the iliopsoas and
internal obturator muscle. Second, after identification of the
obturator nerve, a dissection was made along the vesico-
hypogastric fascia to separate the fatty tissue around the
bladder and lateral pelvic space (Fig. 3C). The common
internal iliac vessels and obturator nerve were completely
cleared from the lymphatic tissue down to the inferior vesi-
cal vessels and obturator fossa. Third, a fluorescence system
was used to observe the residual soft tissues of the lateral
pelvic region to prevent the omission of lymph nodes during
dissection (Fig. 3D). All dissected specimens, including the
SLN, were subjected to paraffin pathological examination.
Perioperative management
From 2 to 6 PM on the day before surgery, 70 mg of polyeth-
ylene glycol (macrogol) per 1 L of water was administered to
all patients four times (1 L each hour). Preventive antibiotics
were administered by intravenous drip 30 min preoperatively
and on the first day postoperatively. All patients were admin-
istered nonsteroidal anti-inflammatory drugs intravenously.
Oral intake was initiated in the first postoperative morning.
Evaluations
The clinical characteristics collected included the patient’s
age, sex, BMI, American Society of Anesthesiologists
(ASA) score, tumor location, previous abdominal opera-
tion history, and preoperative therapy. Surgical outcomes
included operative time, estimated blood loss, and type of
operation. The resected specimens were reviewed by two
pathologists, and the pathological outcomes included the
resection margin, tumor size, and pathological TNM stage.
The lymph nodes included navigation visibility, fluorescence
findings, and number of harvested lymph nodes and meta-
static lymph nodes. Data on postoperative complications,
including anastomotic leak, lymphatic leak, anastomotic
stenosis, bleeding, urinary retention, bowel obstruction,
incisional infection, and ICG allergy were also collected.
Reoperation and readmission rates were also measured.
Surgical Endoscopy (2023) 37:4088–4096
Fig. 3  The laparoscopic LLND procedure using ICG fluorescence
navigation. A Overall scanning under ICG-enhanced NIR fluores-
cence-guided imaging, B lymph node dissection in the external iliac
region, C lymph node dissection in the internal iliac region, and D
Follow‑up
The first postoperative day marked the beginning of the
follow-up period. After discharge, doctors contacted
patients via telephone or outpatient services to evalu-
ate the tumor state. Patients were routinely followed up
at outpatient clinics 2 weeks after discharge and every
3 months after the operation. No patient was lost during
follow-up, and the deadline of the follow-up period was
March 1, 2022.
Statistical analysis
Statistical analysis was performed using the SPSS software
version 20.0 for Windows (SPSS Inc., Chicago, IL, USA).
Quantitative variables are presented as means and standard
deviations and qualitative data as numbers and percentages.
Quantitative variables were compared using the Student t
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residual soft tissues of the lateral pelvic region (EIA external iliac
artery, EIV external iliac vein, IIA internal iliac artery, ON obturator
nerve)
test, and qualitative variables were compared using the χ2 test.
P-values < 0.05 were considered statistically significant.
Results
General data
Laparoscopic TME and LLND using ICG fluorescence
navigation were successfully performed in 23 patients with
advanced lower rectal cancer. During surgery, 2 patients
had no identified lateral pelvic SLN which had a shining
fluorescent spot in the image, therefore 21 patients under-
went lateral pelvic SLNB. The patients included 15 men
(65.2%) and 8 women (34.8%). Five patients (21.7%) had a
history of abdominal surgery; however, none of the surger-
ies were converted to open surgery. The patients’ mean age
was 58.0 years (range 3.6.0–76.0 years) and mean BMI was
23.6 kg/m2 (range 18.0–29.4 kg/m2). A total of 16 (69.6%),
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4092 Surgical Endoscopy (2023) 37:4088–4096

Table 1  Clinical characteristics of patients Surgical and pathological outcomes

Parameter Data
Nineteen patients (82.6%) underwent laparoscopic low
Gender, n (%) anterior resection, and four patients (17.4%) underwent
Male 15 (65.2) laparoscopic abdominoperineal resection. One patient
Female 8 (34.8) (4.3%) underwent bilateral LLND and 22 patients (95.7%)
Age, year, mean (range) 58.0 (36–76) underwent unilateral LLND. The mean time required for
BMI, kg/m2, mean (range) 23.6 (18.0–29.4) the surgery was 257.6 min (range 180.0–335.0 min) and
ASA score, n (%) the mean estimated intraoperative blood loss was 174.5 mL
1 16 (69.6) (range 50.0–270.0 mL). The mean time and blood loss for
2 7 (30.4) LLND were 98.4 min (range 59.4–200.0 min) and 71.8 mL
3 0 (range 30.0–115.0 mL), respectively. Pathological diagno-
Previous abdominal operation, n (%) sis revealed a negative resection margin in all patients. The
Yes 5 (21.7) length of the tumor presented the tumor size, and the mean
No 18(88.3) length was 3.2 cm (range 1.2–6.5 cm). The pathological
Preoperative neoadjuvant therapy, n (%) stages of TNM are provided in Table 2.
NACRT​ 18 (78.3)
NACT​ 3 (13.0) Lymph node findings
No 2 (8.7)
Distance of tumor from anal verge, cm, mean 4.3 (1.0–8.0) Lateral pelvic SLNs were successfully identified in 21
(range)
(76.2%) patients, and the mean time from injection to when
BMI body mass index, ASA American Society of Anesthesiologists, fluorescence of the lateral pelvic SLN could be observed
NACRT​ neoadjuvant chemoradiotherapy, NACT​ neoadjuvant chemo- was 9.1 min (range 4.0–19.0 min) after ICG injection. Two
therapy
patients had no fluorescence in the lateral pelvic lymph
nodes throughout the surgery. Among the different LPLN
7 (30.4%), and 0 patients had ASA scores 1, 2, and 3, respec- locations, the most commonly detected lateral pelvic SLN
tively. NACRT was performed in 18 patients (78.3%) and was the obturator region.
NACT in 3 patients (13.0%). Two patients refused neoadju- The mean number of lateral pelvic SLN retrieved was 2.3
vant treatment and underwent surgery. The mean distance of (range 1–4), and unilateral LPLN dissected was 10.2 (range
the tumor from the anal verge on digital rectal examination 3–18). Lateral pelvic SLN metastasis was diagnosed in 3
was 4.3 cm (range 1.0–8.0 cm) (Table 1). patients and negative in 18 patients by frozen pathological

Table 2  Surgical and Parameter Data

pathological outcomes of
patients Type of operation, n (%)
Laparoscopic low anterior resection 19 (82.6)
Laparoscopic abdominoperineal resection 4 (17.4)
Type of LLND, n (%)
Bilateral LLND 1 (4.3)
Unilateral LLND 22 (95.7)
Operation time, min, mean (range) 257.6 (180.0–335.0)
Intraoperative blood loss, ml, mean (range) 174.5 (50.0–270.0)
Time for LLND, min, mean (range) 98.4 (59.0–200.0)
Blood loss for LLND, ml, mean (range) 71.8 (30.0–115.0)
The length of tumor, cm, mean (range) 3.2 (1.2–6.5)
pTNM stage, n (%)
I 2 (8.7)
II 6 (26.1)
III 15 (65.2)
Postoperative hospitalization, days, mean (range) 7.3 (4.0–13.0)
Hospitalization cost, CNY, mean (range) 46,917.2 (40,022.0–55,657.0)

LLND lateral pelvic lymph node dissection

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Surgical Endoscopy (2023) 37:4088–4096
Table 3  Lymph node findings
of patients with lateral pelvic
SLN detected
Paraffin pathological results of lateral
pelvic SLN (+)
Paraffin pathological results of lateral
pelvic SLN (−)
Lateral pelvic non-SLNs (+)
Lateral pelvic non-SLNs (−)
LPLN (+)
LPLN (−)
SLN sentinel lymph node, LPLN lateral pelvic lymph node, + metastasis, − no metastasis
examination. Simultaneously, the paraffin pathological
results of the lateral pelvic SLN were the same as those of
the frozen pathological examination. Among the 21 patients
in whom lateral pelvic SLN was detected, the dissected lat-
eral pelvic non-SLNs were all negative. All dissected LPLNs
were negative in two patients without fluorescent lateral pel-
vic SLN tumors (Table 3).
Postoperative complications
The mean time of postoperative hospitalization was 7 days
(range 4–13 days), and the mean hospitalization cost was
46,917.2 CNY (range 40,022.0–55,657.0 CNY) (Table 2).
During follow-up, one patient (4.3%) experienced anasto-
motic leakage on postoperative day 6 and recovered after
transverse colostomy. One patient (4.3%) had lymphatic
leakage, which was cured by fasting and adequate drainage.
One patient (4.3%) had urinary retention that was replaced
with a catheter for a month. No side effects or allergic reac-
tions related to the ICG injections were observed. None of
the patients experienced symptoms that were indicative of
anastomotic stenosis, incisional infection, or bowel obstruc-
tion. No patient was lost to follow-up and experienced recur-
rence during the follow-up period. All complications were
resolved successfully.
Discussion
Substantial evidence has shown that the development of
comprehensive therapy for rectal cancer, including chemo-
therapy, radiotherapy, immunotherapy, targeted therapy, and
surgery, improved the prognosis and survival of patients
with rectal cancer. However, it has been reported that the
local recurrence rate of rectal cancer is as high as 21–46%
[12], which has become a challenging issue in the treatment
of rectal cancer. Among them, local recurrence caused by
LPLN metastasis is of concern, with rates ranging from 10.6
to 25.5% [13–15]. Usually, treatment for clinical stage II or
III locally advanced rectal cancer includes NACRT followed
4093
Frozen pathological results of lateral Frozen pathological results
pelvic SLNB (+) of lateral pelvic SLNB (−)
3 0
0 18
0 0
3 18
3 0
0 18
by TME and postoperative adjuvant chemotherapy with fluo-
rouracil and oxaliplatin. However, recent studies have shown
that TME and NACRT may not adequately address the man-
agement of LPLN metastasis [16, 17]. Therefore, in Eastern
countries, it is suggested that LPLN metastasis should be
treated with LLND in addition to TME. However, LLND is
relatively difficult due to increased surgical time, blood loss,
and a higher risk of urinary and sexual dysfunction.
It has been reported that ICG-enhanced NIR fluores-
cence-guided imaging is a feasible and convenient tech-
nique to assist LLND, and this novel technique can make
the surgery much easier and shorten the learning curve for
surgeons who are not familiar with LLND [18]. The ICG
fluorescence technique has been used to identify vessels and
lymph nodes in digestive surgery for several years. Ryu et al.
[19] found that fluorescence navigation of the ureter is feasi-
ble in laparoscopic LLND and has the potential to increase
safety. Moreover, SLN fluorescence navigation surgery has
been performed for gastric cancer to detect SLN by inject-
ing ICG around the tumor and finding lymph nodes with the
earliest tracer spreading. SLN fluorescence navigation for
early gastric cancer has shown acceptable SN detection rates
and accuracy of lymph node status determination. Kim et al.
[20] used the ICG fluorescent method for SLN detection in
early gastric cancer and found that using the near-infrared
ICG method, the sensitivity was 98.9%, the specificity was
76.0%, and the false-positive rate was 25.4%. Okubo et. al
[21]. also believed that the evaluation of fluorescence inten-
sity is useful for selected SLNs, and if fluorescence intensity
is measurable in surgery, an infrared fluorescence method
using ICG may be useful and safe for the detection of SLN in
early gastric cancer. Therefore, the SLN fluorescence navi-
gation method may revolutionize SLN mapping procedures
in gastric cancer. Moreover, the distribution and pathological
status of SLN would be useful in determining the extent of
gastric resection.
Yasui et al. [22] used ICG method to detect SLN in lapa-
roscopic rectal cancer surgery and found that laparoscopic
ICG-guided SLN strategy may be a low-risk and time-sav-
ing method to prevent laparoscopic LLND in cases with
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4094
negative lateral pelvic lymph nodes. But in their study, they
did not include the patients after NCRT. In fact, the fluores-
cent presentation of lymph nodes in patients after NCRT was
different from those without NCRT. They enrolled patients
only without LPLN enlargement (the maximum short axis
of the LPLN < 10 mm). But for patients without LPLN pres-
entation (the maximum short axis of the LPLN < 5 mm),
the metastasis rate was very low and LLND was consid-
ered overtreatment [23]. They performed TME at first and
then completed SLNB and LLND. The long time between
the injection of ICG and SLNB may affect the detection of
SLN and the lymph nodes receiving ICG that had a shining
fluorescent spot may be not limited to the first lymph node
to receive lymphatic flow from the tumor. Moreover, frozen
pathological examination of SLN was important procedure
in SLNB, but they did not perform it.
Based on these studies, lateral pelvic SLNB using ICG
fluorescence navigation was applied in patients who pre-
sented with advanced lower rectal cancer with LPLN but
without LPLN enlargement and received NCRT in prin-
ciple. Different from previous study, we performed lateral
pelvic SLNB using ICG fluorescence navigation at first in
the surgical procedures and the resected SLN were sent for
frozen pathological examination. Some studies have found
that ICG-enhanced NIR fluorescence-guided imaging helped
decrease intraoperative blood loss and increased the number
of LPLNs harvested [18]. Although no significant differ-
ence was found in the operative time compared to that of
patients without fluorescence-guided imaging, it is believed
that fluorescence-guided imaging can help the surgeon
distinguish lymph nodes from non-lymphatic soft tissues
to protect the vessels and nerves. In the present study, the
mean time required for the surgery was 257.6 min (range
180.0–335.0 min), which is significantly shorter than the
time of conventional LLND reported before, and this dif-
ference was attributed to the fast and accurate judgment of
LPLN. Moreover, in this study, it did not take much time
from ICG injection to fluorescence detection. Therefore, we
believe that the overall operation time was not prolonged due
to the injection of ICG, which conversely shortened the total
time due to the quick detection of the resection zone. In fact,
during LLND, we found that fluorescence-guided imaging
was easy to implement with a short learning curve due to the
simplicity of the LPLN detection.
The mean number of LPLN harvested in this study was
10.2 (range 5–18), which is significantly higher than that
of conventional LLND and is thought to improve the intra-
operative surgical staging and ultimately lead to a better
oncological outcome [24]. Finally, a lateral pelvic SLN was
identified in 21 (91.3%) patients, which suggests that fluo-
rescence-guided imaging can provide better sensitivity for
LLND, in which many people may benefit from. Moreover,
among the 21 patients with pelvic lateral SLN detected, 3
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Surgical Endoscopy (2023) 37:4088–4096
patients exhibited metastasis in the pelvic lateral SLN and 18
patients were metastasis negative. In addition, all dissected
LPLNs of the 18 patients with metastasis-negative lateral
pelvic SLNs were negative. Therefore, the false-negative rate
of pelvic lateral SLNB was 0, and the negative predictive
value of the pelvic lateral SLN fluorescence navigation was
100% (18/18) in this group of patients. Meanwhile, of the
20 patients with no metastasis in the LPLN, all 20 patients
showed no metastasis in the lateral pelvic SLN (including 2
patients with no lateral pelvic SLN). Therefore, the negative
specificity of the lateral pelvic SLN fluorescence naviga-
tion was 100% (20/20). Moreover, the paraffin pathological
results of the lateral pelvic SLN were the same as those
of the frozen pathological examination. As a consequence,
we believe that lateral pelvic SLNB using ICG fluorescence
navigation could replace LLND in patients with advanced
rectal cancer with LPLN but without LPLN enlargement.
In those without metastasis in lateral pelvic SLNB using
fluorescence navigation, LLND may not be necessary.
The reported incidence of urinary dysfunction ranges
from 11 to 50%, and the risk of sexual dysfunction is 16%
and 40% in conventional LLND [25]. With the increasing
use of laparoscopic, robotic, and transanal robotic equipment
in LLND, we attempted to refine this surgical technique.
However, whether any of these developments will lead to
a reduction in morbidity remains to be proven. The protec-
tive value of fluorescence-guided imaging of the ureter and
nerves has been demonstrated in several studies. Kim et.
al [26] believed that fluorescence-guided imaging can pro-
vide an exact understanding of the LPLN position in LLND,
reduce the possibility of incomplete resection of metastatic
LPLN, and avoid unnecessary injury to other neurovascular
structures. We also found that only one patient had lym-
phatic leakage, and only one patient had urinary dysfunction.
Both of the patients were treated conservatively. Side effects
or allergic reactions related to ICG injection during or after
surgery were not observed.
This study had several limitations. First, this was a retro-
spective study based on preliminary results, and the present
outcomes were from a single surgeon and a relatively small
number of patients. Prospective randomized controlled trials
from multiple centers with larger sample sizes and longer
follow-up periods are required to confirm our results. Sec-
ond, postoperative survival data were not analyzed, and fur-
ther long-term oncological outcomes are required to deter-
mine the actual impact of lateral pelvic SLN fluorescence
navigation in laparoscopic LLND.
In conclusion, our results suggest that ICG fluorescence
navigation can provide clear visualization of the LPLN
and no metastasis in SLNB may reflect all negative LPLN
metastases. The simplicity and safety of this method led
us to believe that lateral pelvic SLNB using ICG fluores-
cence navigation would be an ideal technique for selected
Surgical Endoscopy (2023) 37:4088–4096
advanced rectal cancer patients presenting with LPLN but
without LPLN enlargement. However, further studies with
long-term follow-up are required to confirm the efficacy of
this technique in patients with lateral pelvic SLNB.
Supplementary Information The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00464-0​ 23-1​ 0033-w.
Acknowledgements This work was funded by the 2021 research pro-
ject on clinical application norms of minimally invasive surgery by
the medical and health science and technology development research
center of the National Health Commission (No: wa2021rw13), Scien-
tific research foundation of Peking University Cancer Hospital (No:
2022-9), and Chinese Academy of Medical Sciences Initiative for Inno-
vative Medicine (No: CAMS-2017-I2M-4-002).
Declarations
Disclosures Hao Su, Zheng Xu, Mandula Bao, Shou Luo, Jianwei
Liang, Wei Pei, Xu Guan, Zheng Liu, Zheng Jiang, Mingguang Zhang,
Zhixun Zhao, Weisen Jin, and Haitao Zhou have no conflicts of interest
or financial ties to disclose.
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for patients with recurrent lateral pelvic lymph nodes after rectal Publisher's Note Springer Nature remains neutral with regard to
cancer surgery: a novel technique-M TEP LLND. Surg Today jurisdictional claims in published maps and institutional affiliations.
49:981–984
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lymph node dissection in the management of lower rectal cancer. exclusive rights to this article under a publishing agreement with the
Langenbecks Arch Surg 397:353–361 author(s) or other rightsholder(s); author self-archiving of the accepted
25. Kim MJ, Oh JH (2018) Lateral lymph node dissection with the manuscript version of this article is solely governed by the terms of
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