Laser Angiography to Assess the Vaginal Cuff During Robotic Hysterectomy

Abstract

Background and Objectives:Vaginal cuff dehiscence may be a vascular-mediated event, and reports show a higher incidence after robot-assisted total laparoscopic hysterectomy (RATLH), when compared with other surgical routes. This study was conducted to determine the feasibility of using laser angiography to assess vaginal cuff perfusion during RATLH.Methods:This was a pilot feasibility trial incorporating 20 women who underwent RATLH for benign disease. Colpotomy was made with ultrasonic or monopolar instruments, whereas barbed or nonbarbed suture was used for cuff closure. Time of instrument activation during colpotomy was recorded. Images were captured of vaginal cuff perfusion before and after cuff closure. Reviewers evaluated these images and determined areas of adequate cuff perfusion.Results:Indocyanine green (ICG) was visible at the vaginal cuff in all participants. Optimal dosage was determined to be 7.5 mg of ICG per intravenous dose. Mean time to appearance for ICG was 18.4 ± 7.3 s (mean ± SD) before closure and 19.0 ± 8.7 s after closure. No significant difference (P = .19) was noted in judged perfusion in open cuffs after colpotomy with a monopolar (48.9 ± 26.0%; mean ± SD) or ultrasonic (40.2 ± 14.1%) device. No difference was seen after cuff closure (P = .36) when a monopolar (70.9 ± 21.1%) or ultrasonic (70.5 ± 20.5%) device was used. The use of barbed (74.1 ± 20.1%) or nonbarbed (66.4 ± 20.9%) sutures did not significantly affect estimated closed cuff perfusion (P = .19). Decreased cuff perfusion was observed with longer instrument activation times in open cuffs (R2 = 0.3175).Conclusion:Laser angiography during RATLH allows visualization of vascular perfusion of the vaginal cuff. The technology remains limited by the lack of quantifiable fluorescence and knowledge of clinically significant levels of fluorescence.

Vaginal cuff dehiscence after total laparoscopic hysterectomy a case report and brief review of the literature

“…11 The use of laser angiography during robotic hysterectomy to assess the perfusion of the vaginal cuff and guide intraoperative decisions has been assessed in a feasibility trial including 20 women recently with good results. 12 Vaginal atrophy, co-morbidities that influence the healing process, increased age, smoking, radiation treatment, hysterectomy due to malignancy and infection have also been reported as risk factors for VCD. 6 Precipitating causes include early onset of sexual intercourse (commonest precipitating factor for young patients as in present case), and increased intra-abdominal pressure as during defecation/ Valsava Maneuver.…”

The Use of near Infra-Red Radiation Imaging after Injection of Indocyanine Green (NIR–ICG) during Laparoscopic Treatment of Benign Gynecologic Conditions: Towards Minimalized Surgery. A Systematic Review of Literature

“…Of the included studies, one study [19] was a prospective, single-center, randomized within subject clinical trial, while 15 studies were observational: 4 retrospective [14,15,20,21] and 11 prospective [1,2,7,12,16,20,[22][23][24][25][26][27].…”

“…− 2 studies assessed the NIR-ICG capacity to visualize the vascular perfusion of the vaginal cuff after total hysterectomy in order to decrease vaginal cuff dehiscence rate [26,27]. − 1 study assessed if the NIR-ICG was a faceable tool to evaluate intraoperatively ovarian perfusion after detorsion [16] (Table 1).…”

“…Indication for surgery was dysmenorrhea in 43.8% of patients, dyspareunia in 34.5%, dyschezia 27.6%, menorrhagia in 26.7%, rectorrhagia in 3.1%, ovarian cysts in 30%, infertility in 6.8%, pelvic pain and infertility in 20.63%, renal colic in 6.6%, hydroureter in 20%, hydroureteronephrosis in 13.3%, abnormal uterine bleeding (AUB) in 42.5%, cervical dysplasia in 15%, Lynch syndrome in 5%, postmenopausal bleeding in 5% and pelvic pain in 39.3% (Table 2). Laparoscopy was robot-assisted in 5 studies [2,12,20,26,27]. Indocyanine injection was intraurethral in 2 studies [20,23], intravenous in 13 studies and both intraurethral and intravenous in one study [24].…”

Comprehensive Review of Fluorescence Applications in Gynecology

“…The implementation of robotic surgery increased the rate of this complication, with a rate of 0.6% for abdominal hysterectomy and up to 3.16% after robotic hysterectomy [ 56 ]. Vaginal cuff angiography using ICG was performed after robotic hysterectomy in 20 patients [ 57 ]. No difference in terms of vaginal cuff dehiscence prevention was observed for monopolar or ultrasonic devices.…”