Conversion to open surgery in obese patients undergoing minimally invasive distal pancreatectomy: results from a multicenter analysis.

BACKGROUND: Although minimally invasive distal pancreatectomy (MIDP) is considered a standard approach it still presents a non-negligible rate of conversion to open that is mainly related to some difficulty factors, as obesity. The aim of this study is to analyze the preoperative factors associated with conversion in obese patients with MIDP. METHODS: In this multicenter study, all obese patients who underwent MIDP at 18 international expert centers were included. The preoperative factors associated with conversion to open surgery were analyzed. RESULTS: Out of 436 patients, 91 (20.9%) underwent conversion to open, presenting higher blood loss, longer operative time and similar rate of major complications. Twenty (22%) patients received emergent conversion. At univariate analysis, the type of approach, radiological invasion of adjacent organs, preoperative enlarged lymphnodes and ASA ≥ III were significantly associated with conversion to open. At multivariate analysis, robotic approach showed a significantly lower conversion rate (14.6 % vs 27.3%, OR = 2.380, p = 0.001). ASA ≥ III (OR = 2.391, p = 0.002) and preoperative enlarged lymphnodes (OR = 3.836, p = 0.003) were also independently associated with conversion. CONCLUSION: Conversion rate is significantly lower in patients undergoing robotic approach. Radiological enlarged lymphnodes and ASA ≥ III are also associated with conversion to open. Conversion is associated with poorer perioperative outcomes, especially in case of intraoperative hemorrhage.

Robotic Distal Pancreatectomy: A Novel Standard of Care? Benchmark Values for Surgical Outcomes From 16 International Expert Centers.

BACKGROUND AND OBJECTIVE: Robotic distal pancreatectomy (DP) is an emerging attractive approach, but its role compared with laparoscopic or open surgery remains unclear. Benchmark values are novel and objective tools for such comparisons. The aim of this study was to identify benchmark cutoffs for many outcome parameters for DP with or without splenectomy beyond the learning curve. METHODS: This study analyzed outcomes from international expert centers from patients undergoing robotic DP for malignant or benign lesions. After excluding the first 10 cases in each center to reduce the effect of the learning curve, consecutive patients were included from the start of robotic DP up to June 2020. Benchmark patients had no significant comorbidities. Benchmark cutoff values were derived from the 75th or the 25th percentile of the median values of all benchmark centers. Benchmark values were compared with a laparoscopic control group from 4 high-volume centers and published open DP landmark series. RESULTS: Sixteen centers contributed 755 cases, whereof 345 benchmark patients (46%) were included the analysis. Benchmark cutoffs included: operation time ≤300 minutes, conversion rate ≤3%, clinically relevant postoperative pancreatic fistula ≤32%, 3 months major complication rate ≤26.7%, and lymph node retrieval ≥9. The comprehensive complication index at 3 months was ≤8.7 without deterioration thereafter. Compared with robotic DP, laparoscopy had significantly higher conversion rates (5×) and overall complications, while open DP was associated with more blood loss and longer hospital stay. CONCLUSION: This first benchmark study demonstrates that robotic DP provides superior postoperative outcomes compared with laparoscopic and open DP. Robotic DP may be expected to become the approach of choice in minimally invasive DP.

Robotic versus laparoscopic distal pancreatectomy in obese patients.

BACKGROUND: Although robotic distal pancreatectomy (RDP) has a lower conversion rate to open surgery and causes less blood loss than laparoscopic distal pancreatectomy (LDP), clear evidence on the impact of the surgical approach on morbidity is lacking. Prior studies have shown a higher rate of complications among obese patients undergoing pancreatectomy. The primary aim of this study is to compare short-term outcomes of RDP vs. LDP in patients with a BMI ≥ 30. METHODS: In this multicenter study, all obese patients who underwent RDP or LDP for any indication between 2012 and 2022 at 18 international expert centers were included. The baseline characteristics underwent inverse probability treatment weighting to minimize allocation bias. RESULTS: Of 446 patients, 219 (50.2%) patients underwent RDP. The median age was 60 years, the median BMI was 33 (31-36), and the preoperative diagnosis was ductal adenocarcinoma in 21% of cases. The conversion rate was 19.9%, the overall complication rate was 57.8%, and the 90-day mortality rate was 0.7% (3 patients). RDP was associated with a lower complication rate (OR 0.68, 95% CI 0.52-0.89; p = 0.005), less blood loss (150 vs. 200 ml; p < 0.001), fewer blood transfusion requirements (OR 0.28, 95% CI 0.15-0.50; p < 0.001) and a lower Comprehensive Complications Index (8.7 vs. 8.9, p < 0.001) than LPD. RPD had a lower conversion rate (OR 0.27, 95% CI 0.19-0.39; p < 0.001) and achieved better spleen preservation rate (OR 1.96, 95% CI 1.13-3.39; p = 0.016) than LPD. CONCLUSIONS: In obese patients, RDP is associated with a lower conversion rate, fewer complications and better short-term outcomes than LPD.

Robotic redo Heller myotomy: how I do it?

BACKGROUND: Despite the high success rate associated with Heller myotomy in the treatment of primary achalasia, symptom persistence or relapse occurs in approximately 10-20% of patients. Unfortunately, the ideal treatment after failed myotomy is not well established yet. We present a didactical video with a stepwise technique to perform a robotic revisional procedure after failed Heller myotomy. METHODS: In this report, each surgical step is thoroughly described and visually represented with useful technical tips that might help in improving surgical results of revisional Heller myotomy. RESULTS: In patients with previous surgical myotomy, the robotic platform with its high-definition magnified view and EndoWrist instruments allow for a safe and precise redo surgical myotomy. CONCLUSIONS: Despite its improved surgical capabilities, the role of robotic redo Heller myotomy in the treatment algorithm of patients with recurrent symptoms after failed surgical myotomy should be further explored.

Robotic kidney transplantation in the obese patient: 10-year experience from a single center.

Despite increasing obesity rates in the dialysis population, obese kidney transplant candidates are still denied transplantation by many centers. We performed a single-center retrospective analysis of a robotic-assisted kidney transplant (RAKT) cohort from January 2009 to December 2018. A total of 239 patients were included in this analysis. The median BMI was 41.4 kg/m2 , with the majority (53.1%) of patients being African American and 69.4% of organs sourced from living donors. The median surgery duration and warm ischemia times were 4.8 hours and 45 minutes respectively. Wound complications (mostly seromas and hematomas) occurred in 3.8% of patients, with 1 patient developing a surgical site infection (SSI). Seventeen (7.1%) graft failures, mostly due to acute rejection, were reported during follow-up. Patient survival was 98% and 95%, whereas graft survival was 98% and 93%, at 1 and 3 years respectively. Similar survival statistics were obtained from patients undergoing open transplant over the same time period from the UNOS database. In conclusion, RAKT can be safely performed in obese patients with minimal SSI risk, excellent graft function, and patient outcomes comparable to national data. RAKT could improve access to kidney transplantation in obese patients due to the low surgical complication rate.

The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection.

OBJECTIVE: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). SUMMARY BACKGROUND DATA: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. METHODS: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology. RESULTS: After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety. CONCLUSION: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

Educational step-by-step surgical video about operative technique in robotic pancreaticoduodenectomy (RPD) at University of Illinois at Chicago (UIC): 17 steps standardized technique-Lessons learned since the first worldwide RPD performed in the year 2001.

BACKGROUND: RPD (Robotic pancreatoduodenectomy) was first performed by P. C. Giulianotti in 2001 (Arch Surg 138(7):777-784, 2003). Since then, the complexity and lack of technique standardization has slowed down its widespread utilization. RPD has been increasingly adopted worldwide and in few centres is the preferred apporached approach by certain surgeons. Some large retrospective series are available and data seem to indicate that RPD is safe/feasible, and a valid alternative to the classic open Whipple. Our group has recently described a standardized 17 steps approach to RPD (Giulianotti et al. Surg Endosc 32(10): 4329-4336, 2018). Herin, we present an educational step-by-step surgical video with short technical/operative description to visually exemplify the RPD 17 steps technique. METHODS: The current project has been approved by our local Institutional Review Board (IRB). We edited a step-by-step video guidance of our RPD standardized technique. The data/video images were collected from a retrospective analysis of a prospectively collected database (IRB approved). The narration and the images describe hands-on operative "tips and tricks" to facilitate the learning/teaching/evaluation process. RESULTS: Each of the 17 surgical steps is visually represented and explained to help the in-depth understanding of the relevant surgical anatomy and the specific operative technique. CONCLUSIONS: Educational videos descriptions like the one herein presented are a valid learning/teaching tool to implement standardized surgical approaches. Standardization is a crucial component of the learning curve. This approach can create more objective and reproducible data which might be more reliably assessed/compared across institutions and by different surgeons. Promising results are arising from several centers about RPD. However, RPD as gold standard-approach is still a matter of debate. Randomized-controlled studies (RCT) are required to better validate the precise role of RPD.

Applying the Delphi process for development of a hepatopancreaticobiliary robotic surgery training curriculum.

BACKGROUND: Robotic hepatopancreaticobiliary (HPB) procedures are performed worldwide and establishing processes for safe adoption of this technology is essential for patient benefit. We report results of the Delphi process to define and optimize robotic training procedures for HPB surgeons. METHODS: In 2019, a robotic HPB surgery panel with an interest in surgical training from the Americas and Europe was created and met. An e-consensus-finding exercise using the Delphi process was applied and consensus was defined as 80% agreement on each question. Iterations of anonymous voting continued over three rounds. RESULTS: Members agreed on several points: there was need for a standardized robotic training curriculum for HPB surgery that considers experience of surgeons and based on a robotic hepatectomy includes a common approach for "basic robotic skills" training (e-learning module, including hardware description, patient selection, port placement, docking, troubleshooting, fundamentals of robotic surgery, team training and efficiency, and emergencies) and an "advanced technical skills curriculum" (e-learning, including patient selection information, cognitive skills, and recommended operative equipment lists). A modular approach to index procedures should be used with video demonstrations, port placement for index procedure, troubleshooting, and emergency scenario management information. Inexperienced surgeons should undergo training in basic robotic skills and console proficiency, transitioning to full procedure training of e-learning (video demonstration, simulation training, case observation, and final evaluation). Experienced surgeons should undergo basic training when using a new system (e-learning, dry lab, and operating room (OR) team training, virtual reality modules, and wet lab; case observations were unnecessary for basic training) and should complete the advanced index procedural robotic curriculum with assessment by wet lab, case observation, and OR team training. CONCLUSIONS: Optimization and standardization of training and education of HPB surgeons in robotic procedures was agreed upon. Results are being incorporated into future curriculum for education in robotic surgery.

Robotic hepaticojejunostomy: surgical technique and risk factor analysis for anastomotic leak and stenosis.

BACKGROUND: A variety of techniques have been described for the construction of the HJ (hepaticojejunostomy). Due to its technical challenges, HJ is rarely performed in a pure laparoscopic setting. In stark contrast, the increasing availability of the robotic platform has sparked new interest in pursuing this procedure in a minimally invasive fashion. The aim of our study was to describe our surgical technique and to identify risk factors for anastomotic leak and stenosis following robotic surgery. METHODS: We performed a retrospective analysis of a prospectively collected database, including all consecutive HJ carried out for different indications over a 10 year period. RESULTS: One hundred fifty-two patients undergoing robotic HJ performed by the same surgeon were analyzed. Bile leak occurred in 2.6% of the patients. Stricture rate was 3.3%. The median follow up was 25.5 months. There was no mortality related to anastomotic complications. On univariate analysis, patient's age less than 65 years was the only risk factor for anastomotic stricture. On multivariate analysis, no predictor factors for leak or stenosis were identified. CONCLUSION: HJs carried out in a robotic fashion allow highly satisfactory results. No independent risk factors for bile leak of stenosis were identified on multivariate analysis.

Near-Infrared Indocyanine Green-Enhanced Fluorescence and Evaluation of the Bowel Microperfusion During Robotic Colorectal Surgery: a Retrospective Original Paper.

BACKGROUND: Leakage of the anastomosis after colorectal surgery is a severe complication, and one of the most important causes is poor vascular supply. However, a microvascular deficit is often not detectable during surgery under white light. Near-infrared indocyanine green (ICG)-enhanced fluorescence may be useful for assessing microvascular deficits and conceivably preventing anastomotic leakage. OBJECTIVES: This paper presents a preliminary retrospective case series on robotic colorectal surgery. The aim is to evaluate the feasibility, safety and role of near-infrared ICG-enhanced ?uorescence for the intraoperative assessment of peri-anastomotic tissue vascular perfusion. MATERIALS AND METHODS: From among more than 164 robotic colorectal cases performed, we retrospectively analyzed 28 that were all performed by the same surgeon (PCG) using near-infrared ICG-enhanced fluorescence technology: 16 left colectomies (57.1%), 8 rectal resections (28.6%), 3 right colectomies (10.8%) and 1 pancolectomy (3.6%). RESULTS: The rates of conversion, intraoperative complications, dye allergic reaction and mortality were all 0%. In two cases (7.1%)-1 left and 1 right colectomy-the level of the anastomosis was changed intraoperatively after ICG showed ischemic tissues. Despite the application of ICG, one anastomotic leak (after left colectomy for a chronic recurrent sigmoid diverticulitis with pericolic abscess) was observed. CONCLUSIONS: ICG technology may help to determine when to intraoperatively change the anastomotic level to a safer location. In our case series, ICG results led to a change in the level of the anastomosis in 7.1% of the cases. Despite the use of ICG, we observed one leak. This may have been related to vascularization-independent causes (e.g., infection in this case) or may reflect a need for better standardization of this ICG technology. In particular, we need a way to objectively assess the ICG signal and the related risk of leakage. More randomized, prospective, well-powered trials are needed to unveil the full potential of this innovative surgical technology.

Reconstruction/Repair of Iatrogenic Biliary Injuries: Is the Robot Offering a New Option? Short Clinical Report.

OBJECTIVE: The aim of this study is to analyze perioperative outcomes of robotic reconstruction of iatrogenic biliary injuries and describe the surgical technique in detail. BACKGROUND: Iatrogenic bile duct injuries (BDIs) continue to be a major concern in open and laparoscopic cholecystectomy. In the past decade, robotic surgery has been applied to many different procedures showing technical advantages, especially in microsurgical fields. Few cases of robotic BDI reconstructions have been described in the literature so far. This is the first clinical series of consecutive patients undergoing robotic BDI reconstructions. METHODS: This study is a single-surgeon retrospective review of a prospectively maintained database including 14 patients who underwent robot-assisted biliary reconstruction due to iatrogenic BDIs. RESULTS: In all, 14 patients underwent robot-assisted BDI reconstructions. The mean operative time, blood loss, and length of hospitalization were 280.6 min (SD = 132.0), 135.0 mL (SD = 169.7), and 8.4 days (SD = 6.7), respectively. The conversion rate to open surgery was 0%. Long-term follow-up was available in 85.7% (12 out of 14 patients) with a mean follow-up of 36.1 months (SD = 28.1). The >30-day complication rate was 14.3% (n = 2). These 2 patients presented with recurrent episodes of cholangitis due to hepatico-jejunostomy mild stenosis, which were successfully treated with transhepatic percutaneous biliary drainage and multiple dilatations. CONCLUSIONS: Robot-assisted BDI reconstruction is feasible, safe, and may represent an interesting option in expert hands. It maintains all the benefits of minimally invasive surgery and seems to have technical advantages in fine dissection and microsuturing in the liver hilum (magnified microsuturing). In this series, 14 patients with major BDIs were repaired with the robotic approach, with conversion and reoperation rates of 0%. Long-term outcome evaluation requires a longer follow up and larger series, but the initial results are promising.

Minimally invasive, robot-assisted procedure for kidney transplantation among morbidly obese: Positive outcomes at 5 years post-transplant.

The pre-transplant weight loss required of end-stage renal disease patients is often unachievable. Though robot-assisted procedures among extremely obese have shown minimal complication, long-term outcomes are understudied. Previously, we reported no difference in 6-month patient and graft survival among 28 robot-assisted transplant cases (2009-2013) and 28 open controls (2004-2010). Groups were frequency-matched on age, sex, race, donor compatibility, disease, and dialysis history. Cases had greater median pre-transplant body mass index (BMI; 42.3 (31.1-64.3) vs 36.8 (30.0-51.1)). Here, we compared patient and graft survival through 5 years post-transplant. Infection, wound complications, and significant re-hospitalizations were collected. One-, three-, and five-year graft survival were 100%, 100%, and 89.3% among cases, and 96.4%, 85.7%, and 78.6% among controls. Rejection within 1 year was greater among cases (11 vs 8). Five-year rates were similar (P = 0.54). Post-transplant BMI remained comparable. No cases and eight controls experienced surgical site infection (SSI). Two cases and one control experienced hernias. Post-transplant diabetes was documented among five cases and six controls. Three deaths occurred among cases, two among controls. This is the most extensive known follow-up of such obese recipients of robot-assisted transplant. Our procedure is a promising pathway to transplant and decreased mortality for those deemed too high risk for conventional surgery.

Trans-gastric pancreaticogastrostomy reconstruction after pylorus-preserving robotic Whipple: a proposal for a standardized technique.

BACKGROUND: A number of technical improvements regarding the pancreatic anastomosis have decreased the morbidity and mortality after pancreaticoduodenectomy. However, postoperative pancreatic fistula (POPF) remains is the most feared complication, and the ideal technique for pancreatic reconstruction is undetermined. MATERIALS AND METHODS: This study is a retrospective review of a prospectively maintained database. Data were collected from all consecutive robot-assisted pancreaticoduodenectomies (RAPD), performed by a single surgeon, at the University of Illinois Hospital & Health Sciences System, between September 2007 and January 2016. RESULTS: A total of 28 consecutive patients (16 male and 12 female) who underwent a RAPD were included in this study. Patients had a mean age and mean BMI of 61.5 years (SD = 12.3) and 27 kg/m2 (SD = 4.9), respectively. The mean operative time was 468.2 min (SD = 73.7) and the average estimated blood loss was 216.1 ml (SD = 113.1). The mean length of hospitalization was 13.1 days (SD = 5.4). There was no clinically significant POPF registered. CONCLUSION: Trans-gastric pancreaticogastrostomy (TPG) represents a valid and feasible option as a pancreatic digestive reconstruction during RAPD. Initial results showed decreased incidence of POPF with an increased risk of postoperative bleeding. Our experience suggests that TPG might be safer than pancreaticojejunostomy (PJ); further studies are needed in order to confirm.

Operative technique in robotic pancreaticoduodenectomy (RPD) at University of Illinois at Chicago (UIC): 17 steps standardized technique : Lessons learned since the first worldwide RPD performed in the year 2001.

BACKGROUND: Minimally invasive pancreaticoduodenectomy (MIPD) was introduced in the attempt to improve the outcomes of the open approach. Laparoscopic pancreaticoduodenectomy (LPD) was first reported by Gagner and Pomp (Surg Endosc 8:408-410, 1994). Unfortunately, due to its complexity and technical demand, LPD never reached widespread popularity. Since it was first performed by P. C. Giulianotti in 2001, Robotic PD (RPD) has been gaining ground among surgeons. MIPD is included as a surgical option in the latest NCCN Guidelines. However, lack of surgical standardization, however, has limited the reproducibility of MIPD and made the acquisition of the technique by other surgeons difficult. We provide an accurate description of our standardized step-by-step RDP technique. METHODS: We took advantage of our 15-year long experience and > 150 cases performed to provide a step-by-step guidance of our RPD standardized technique. The description includes practical "tips and tricks" to facilitate the learning curve and assist with the teaching/evaluation process. RESULTS: 17 surgical steps were identified as key components of the RPD procedure. The steps reflect the subdivision of the RPD into several parts which help to understand a strategy that takes into accounts specific anatomical landmarks and the demands of the robotic platform. CONCLUSIONS: Standardization is a key element of the learning curve of RPD. It can potentially provide consistent, reproducible results that can be more easily evaluated. Despite promising results, full acceptance of RPD as the 'gold standard' is still work in progress. Randomized-controlled trials with the application of a standardized technique are necessary to better define the role of RPD.

Virtual Reality Simulator Systems in Robotic Surgical Training.

The number of robotic surgical procedures has been increasing worldwide. It is important to maximize the cost-effectiveness of robotic surgical training and safely reduce the time needed for trainees to reach proficiency. The use of preliminary lab training in robotic skills is a good strategy for the rapid acquisition of further, standardized robotic skills. Such training can be done either by using a simulator or by exercises in a dry or wet lab. While the use of an actual robotic surgical system for training may be problematic (high cost, lack of availability), virtual reality (VR) simulators can overcome many of these obstacles. However, there is still a lack of standardization. Although VR training systems have improved, they cannot yet replace experience in a wet lab. In particular, simulated scenarios are not yet close enough to a real operative experience. Indeed, there is a difference between technical skills (i.e., mechanical ability to perform a simulated task) and surgical competence (i.e., ability to perform a real surgical operation). Thus, while a VR simulator can replace a dry lab, it cannot yet replace training in a wet lab or operative training in actual patients. However, in the near future, it is expected that VR surgical simulators will be able to provide total reality simulation and replace training in a wet lab. More research is needed to produce more wide-ranging, trans-specialty robotic curricula.

Indocyanine Green (Icg)-Enhanced Fluorescence for Intraoperative Assessment of Bowel Microperfusion During Laparoscopic and Robotic Colorectal Surgery: The Quest for Evidence-Based Results.

Anastomotic leakage is a severe complication after colonic/rectal surgery. One of the most important causes of anastomotic leakage is poor vascular supply. However, microvascular impairment at the anastomotic site is very often not detected intraoperatively by observation under white light. Indocyanine green (ICG)-enhanced fluorescence is a technology that may be useful for detecting microvascular alterations and potentially preventing anastomotic leakage. The aim of this Editorial-Minireview is to briefly and critically assess the literature evidence regarding the feasibility of using an ICG ?uorescent tracer for detecting microvascular changes in the perianastomotic tissue and its potential role in preventing anastomotic leakage. We focused on minimally invasive (robotic and laparoscopic) colorectal surgery. Intraoperative ICG angiography and the quantification of ICG kinetics can be used to intraoperatively reveal the tissue-perfusion status during colorectal surgery. This may be useful for intraoperatively changing a previously planned resection/anastomotic level, and conceivably decreasing the degree of anastomotic leakage. At this stage, even though ICG technology appears to be very promising and some preliminary clinical studies have suggested that certain ICG pharmacokinetic parameters may be used to predict leakage, more reliable scoring and grading tools are needed. Furthermore, in minimally invasive colorectal surgery, more randomized prospective well-powered trials are needed to properly standardize this surgical technology.

Near-Infrared Indocyanine Green-Enhanced Fluorescence and Minimally Invasive Colorectal Surgery: Review of the Literature.

BACKGROUND: Leakage of the anastomosis after colonic/rectal surgery is a serious complication. One of the most important causes of anastomotic leakage is impaired vascularization. A microvascular tissue deficit is very often not intraoperatively de visu detectable under white light. Near-infrared indocyanine green (ICG)-enhanced fluorescence is a cutting-edge technology that may be useful for detecting microvascular impairment and potentially preventing anastomotic leakage. AIM: The aim of this narrative review was to evaluate the feasibility and the usefulness of intraoperative assessment of vascular anastomotic perfusion in colorectal surgery using an indocyanine green (ICG) fluorescent tracer. MATERIAL AND METHODS: A PubMed/MedLine, Embase, and Scopus narrative literature review was performed, in which "colorectal surgery" and "indocyanine green" were used as key words. The inclusion criteria were 1) manuscripts written in English; 2) full text is available; 3) topic related to the use of ICG fluorescence for the assessment of tissue perfusion during laparoscopic or robotic colorectal surgery; and 4) sample: adult patients, benign or malignant disease. Exclusion criteria included 1) case reports; 2) topic not related to the use of ICG fluorescence for the evaluation of tissue perfusion during laparoscopic or robotic colorectal surgery; 3) manuscripts that focused solely on other applications of ICG technology; and 4) any study type not showing original data. Results and Critical Discussion: The intraoperative visual assessment of tissue viability under white light may lead to an underestimation of microvascular blood flow impairment. ICG can be safely used in cases of minimally invasive colonic surgery and also low anterior resections. This technology may be useful when deciding whether to intraoperatively change a previously planned resection/anastomotic level, which could decrease theoretically the occurrence of anastomotic leakage. CONCLUSIONS: Near-infrared ICG technology is a very useful approach. Multiple preliminary studies suggest that this technique may be used to predict anastomotic leakage. However, evaluation of the ICG signal is still too subjective. Some reliable scoring/grading parameters related to the ICG signal need to be defined. Additionally, more prospective, randomized, and adequately powered studies are required to completely reveal the true potential of this surgical technological innovation.