Optimal indocyanine green dosage for lymphatic collector mapping during fluorescence-guided laparoscopic D3 lymph node dissection in patients with right colon cancertients with right colon cancer

Introduction. The standard approach to treating patients with right colon cancer (RCC) is complete mesocolic excision (CME), the main criteria of which include consequent surgical separation by sharp dissection of the visceral fascia layer from the parietal one and high ligation of blood vessels. However, the extent of lymph node dissection is currently not standardized. In European countries, D2 lymph node dissection is more often performed, while in many Asian countries, D3 lymph node dissection, based on the removal of the apical lymph nodes, is widely used. The lack of precise landmarks and insuffcient visualization of the lymphatic system do not allow the surgeon to reliably judge the radicality of the resection of the lymphatic drainage zone without specialized dyes.
The aim of the study was to evaluate the immediate results of regional lymphatic collector mapping in patients with RCC using individual dose calculation of indocyanine green (ICG).
Material and Methods. The study included 63 patients with RCC who underwent laparoscopic right hemicolectomy (LRH) with CME and D3 lymph node dissection between January 2023 and October 2024. All patients underwent colonoscopy with submucosal administration of ICG 1 cm proximal and distal to the tumor on the day before surgery or on the day of surgery at least 3 hours before. In 27 patients (group 1), the ICG dose was determined empirically (0.5–7.5 mg, median 2.0 mg). In 36 patients (group 2), the dose was calculated individually based on the visceral fat area (VFA) determined by abdominal computed tomography (CT). The total ICG dose was 1 mg per 100 cm² of VFA. All cases were evaluated according to a fve-level scale, with levels 1 and 5 considered as failed mapping and levels 2–4 as a positive result (successful mapping).
Results. Successful mapping was recorded in 22 (81.5 %) of 27 patients in group 1 and in all 36 (100 %) patients in group 2. Moreover, optimal mapping (good visualization of the regional lymph collector in the NIR mode) was obtained in 11 (40.7 %) of 27 and 31 (86.1 %) of 36 patients, respectively (p<0.001). The complication rates were 37.0 % and 19.4 %, respectively (p=0.156), with complications of grade ≥3 according to Clavien–Dindo classifcation in 7.2 % and 2.8 % of patients (p=0.156). During the pathomorphological evaluation of the removed specimen, the median number of examined lymph nodes (LN) was 46 (12–119) and 53 (33–139) (p=0.054), and the median of metastatic LNs was 3 and 4 nodes, respectively (p=0.992).
Conclusion. When mapping the regional lymphatic collector using ICG in RCC, it is advisable to use an individual calculation of the ICG dose based on VFA, which allows achieving the maximum frequency of successful mapping (100 %) and optimal mapping in 86.1 % of cases.

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