Category: Robotic Surgery: Lower Tract - Benign
Introduction & Objective :
Separating the bladder and vaginal cuff sutures lines is a key principle of vesicovaginal fistula (VVF) repair. Although omentum may be used for interposition, fashioning a pedicle of adequate length to reach the deep pelvis and ensuring pedicle perfusion may be difficult. We describe our technique of using intravenous indocyanine green (ICG) to assess omental pedicle perfusion during robotic VVF repair.
A 61-year-old woman was found to have a VVF two days after undergoing a laparoscopic radical hysterectomy for cervical cancer. Preoperative cystoscopy demonstrated a 4 cm erythematous area at the posterior bladder wall that extended into the trigone at the midline, while bilateral retrograde pyelograms did not demonstrate evidence of any ureteral abnormalities. Intraoperatively, the bladder and vaginal cuff defects were isolated and repaired, and an omental pedicle based on the left gastroepiploic artery was formed. Three milliliters of ICG (10 milligrams ICG in 10 milliliters distilled water) was administered intravenously, and the omental pedicle was inspected under near-infrared fluorescence imaging.
Under near-infrared fluorescence, the entirety of the omental pedicle fluoresced green, confirming perfusion from its broad base to its distal end. The omental pedicle was then interposed between the bladder and vaginal cuff suture lines. Estimated blood loss was 300 milliliters, and total operative time was 205 minutes. Length of stay was 2 days, and there were no postoperative complications. The Foley catheter was removed on postoperative day 11. At 13 months follow up, there was no clinical evidence of fistula recurrence.
Intravenous ICG is a simple and efficient method to assess omental pedicle perfusion. This technique may be particularly useful during robotic VVF repair, which may require a long omental pedicle to separate the bladder and vaginal cuff suture lines.