title: Laser Angiography with Indocyanine Green to Assess Vaginal Cuff Perfusion during Total Laparoscopic Hysterectomy: A Pilot Study.
abstract: To determine feasibility of using laser angiography with indocyanine green (ICG) to assess vaginal cuff vascular perfusion during total laparoscopic hysterectomy (TLH).
  
  
  
  Pilot feasibility trial (Canadian Task Force classification II-2).
  
  
  
  Academic-affiliated hospital.
  
  
  
  Twenty women undergoing TLH for benign disease.
  
  
  
  Participants underwent 1:1 randomization of energy method used for colpotomy (ultrasonic vs monopolar) and vaginal cuff closure suture (barbed vs nonbarbed). After intravenous administration of ICG, laser angiography was used to capture images of the vaginal cuff before and after closure. Three reviewers analyzed fluorescent images of vaginal cuffs to determine percent of cuff perimeter with adequate perfusion when open and length of vaginal cuff adequately perfused when closed.
  
  
  
  ICG fluorescence was visible at the vaginal cuff in all participants. Mean time to appearance of ICG in the pelvis after administration was 19.8 ± 6.8 seconds (mean ± SD) preclosure, and 26.0 ± 22.2 seconds postclosure. With ultrasonic energy 67.5% ± 17.4% of open cuff perimeter and 74.4% ± 20.5% of closed cuff length were adequately perfused, whereas with monopolar energy use 59.1% ± 17.4% of the open cuff perimeter and 66.3% ± 15.4% of closed cuff length were adequately perfused. Cuffs closed with barbed suture showed adequate perfusion along 71.5% ± 15.1% of the length, whereas those closed with nonbarbed suture showed 68.9% ± 20.9% adequate perfusion. When normalized to cervical cup circumference, ultrasonic energy required 1.0 ± .2 s/mm, whereas monopolar energy required .8 ± .3 s/mm (p = .162). Linear regression showed no association of normalized time of energy activation to percentage of perimeter of open cuff (R2= .007) or length of closed cuff (R2= .005) with adequate perfusion. No complications related to intravenous ICG administration occurred.
  
  
  
  Laser angiography with ICG allows evaluation of vascular perfusion at the vaginal cuff during TLH. This technique may facilitate future prospective studies examining causes for vaginal cuff dehiscence, a complication with potential for severe morbidity.
authors.affiliation: Section of Minimally Invasive Gynecology, Department of Gynecology, Cleveland Clinic Florida, Weston, Florida. Electronic address: beranb@ccf.org.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Beran
authors.affiliation: Section of Minimally Invasive Gynecology, Department of Gynecology, Cleveland Clinic Florida, Weston, Florida.
authors.forename: Marie
authors.initials: M
authors.lastname: Shockley
authors.affiliation: Section of Minimally Invasive Gynecology, Department of Gynecology, Cleveland Clinic Florida, Weston, Florida.
authors.forename: Katrin
authors.initials: K
authors.lastname: Arnolds
authors.affiliation: Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Pedro
authors.initials: P
authors.lastname: Escobar
authors.affiliation: Section of Minimally Invasive Gynecology, Department of Gynecology, Cleveland Clinic Florida, Weston, Florida.
authors.forename: Stephen
authors.initials: S
authors.lastname: Zimberg
authors.affiliation: Section of Minimally Invasive Gynecology, Department of Gynecology, Cleveland Clinic Florida, Weston, Florida.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Sprague
mesh_terms: D000328:Adult; D000368:Aged; D000792:Angiography / Q000379:methods*; D020884:Colpotomy; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000009:adverse effects*; D007045:Hysterectomy, Vaginal / Q000379:methods; D007208:Indocyanine Green; D010535:Laparoscopy / Q000009:adverse effects; D007834:Lasers; D008875:Middle Aged; D010865:Pilot Projects; D011446:Prospective Studies; D013537:Sutures; D016896:Treatment Outcome
chemical_list: D007208:Indocyanine Green
keywords: Indocyanine green; Laparoscopic hysterectomy; Laser angiography; Vaginal cuff dehiscence