Applications of Near Infrared Fluorescence Imaging in Non-Malignant Gynecologic Surgery

Abstract

Study Objective

To review applications of near infrared fluorescence imaging during non-malignant gynecologic surgery.

Design

Educational video.

Setting

Operating room.

Patients or Participants

Series of female patients of reproductive age undergoing non-malignant gynecologic surgery complicated by: (1) endometriosis and large fibroids; (2) obliteration of the posterior cul-de-sac; (3) dense adhesions of the bladder to the lower uterine segment; and (4) a uterine isthmocele.

Interventions

Near infrared fluorescence imaging with indocyanine green (ICG) at a concentration of 2.5mg/mL was used for real-time delineation of the ureters/bladder and vagina. For identification of the ureters/bladder, rigid cystoscopy was performed and 5cc ICG was instilled into each ureter using 5Fr open-ended ureteral stents. For identification of the anterior and posterior vaginal fornix, 10cc ICG was instilled directly into the vagina, after sterile preparation but before placement of a uterine manipulator, and massaged into the vaginal mucosa. Near infrared imaging was also used to intensify the signal from visible light from a hysteroscope, in order to delineate the borders of a lower uterine segment isthmocele.

Measurements and Primary Results

Alternating between standard imaging and near infrared fluorescence imaging during minimally invasive surgery allows for continued visualization of critical structures throughout the case. The strength of fluorescent signals can vary based on the application and the nature of surrounding tissue, including the presence of significant adiposity, retroperitoneal fibrosis, and overlying adhesions.

Conclusion

Near infrared fluorescence imaging is an emerging clinical technology that can provide real-time guidance to surgeons by identifying tissue that needs to be resected or vital structures that need to be avoided, such as the ureters, bladder, and vagina. This technology is routinely used for sentinel lymph node mapping in gynecologic oncology, and can be safely adopted with or without fluorescent contrast agents for numerous applications in non-malignant gynecologic surgery as well.