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L. Lipetskaia et al.
plex anatomical spaces. ICG can be used intraoperatively in laparoscopic sigmoid vaginoplasty to determine sigmoid segment
perfusion and viability prior to committing to neovagina construction. In the study of ve patients, ICG green demonstrated poor
viability of sigmoid segment in one patient and procedure was
aborted [27]. In another study, ICG green was helpful in identifying upper urinary tract anatomy, thus guiding safer and faster dissection during Vecchietti procedure [28].
Imaging technique: Cystoscopic intraureteral ICG injection
lasted 3.4min, improving the anatomic identication of the ureters, with the additional benet of having the bladder highlighted
in case of congenital anomaly.
Revisions ofPrior Reconstructive Surgeries
Frequently pelvic reconstructive procedures use permanent grafts
(polypropylene mesh or Gore-Tex sutures) to increase longevity
of the repair and prevent prolapse or incontinence recurrence.
Although the risks of complications associated with graft use are
low, occasionally excision of permanent materials from pelvic
structures is required to treat graft related complications. In case
of erosion or infections due to foreign body, it is important to
minimize the damage to adjacent organs while dissecting implant
away from vagina. The tissue planes are frequently distorted due
to inammation and scarring, and highlighting adjacent structures
with the ICG helps to delineate the tissue planes and prevent
injury (Fig.16.6).
Fig. 16.6 Revision of prior pelvic reconstructive surgery complicated by
Gore-Tex suture erosion (Parts a–c) (a) Attempt to remove Gore-Tex stitch
eroding in vagina. Stitch is located in the area of vagina adjacent to left ureterovesical junction. (b) Foley balloon lled with ICG mix enhances bladder
visualization. (c) Foley balloon manipulated with robotic instruments into the
area of left ureterovesical junction allows to safely continue dissection avoiding injury to bladder and ureter
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a
b
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c
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Imaging technique: 100cc of intralipid TPN solution mixed
with 0.5 mL of ICG green (2.5 mg/mL in distilled water) and
30cc instilled in 18F Foly balloon inserted into bladder.
L. Lipetskaia et al.
Fluorescent Angiography
Vaginal Cu Angiography inanAttempt toAssess
Devascularization DuetoThermal Injury After Total
Robotic Hysterectomy
Minimally invasive hysterectomy compares favorably to laparotomy in overall complication rate but is notorious for increased
vaginal cuff dehiscence. Both energy used during colpotomy and
suturing techniques for cuff closure were implicated in higher
dehiscence rate [29]. Vascular perfusion plays a role in cuff healing along with other factors. Developing techniques for quantication of thermal damage impact on perfusion can come in handy
while we are attempting to nd solutions for this problem. ICG
angiography represents an emerging technology for real-time
evaluation of the vaginal cuff during laparoscopic hysterectomy
with potential to limit the incidence of vaginal cuff dehiscence
through design of further research studies.
Imaging technique: 2.5–5mg ICG IV bolus followed by 10mL
saline ash. ICG dye appeared in surgical eld in 11s. Repeated
administration was required in 11 min. Most participants show
uorescence all the way to the cuff edge, but the width of thermal
injury brim varies around the cuff. The calculation of cuff perimeter percentage with adequate perfusion is required to assess the
extent of devascularized zone [30] (Fig.16.7).
Ovarian Artery Perfusion toAssess Ovarian Torsion
Ovarian torsion is dened as partial or complete rotation of the
ovarian vascular pedicle and causes obstruction to venous outow
and arterial inow. It presents as acute abdominal pain and
diagnosed during surgical exploration. The ultimate goal of sur-
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a
b
Fig. 16.7 Samples of images used for perfusion analysis (a, b) with repre-
sentative markings demonstrating adequate perfusion (c, d) at the cuff. The
short perpendicular bars delineate transition from perfused to nonperfused
regions. The parallel curve demonstrates areas with adequate perfusion. The
long perpendicular bars in D delineate the total length of the closed vaginal
cuff (Beran etal Laser Angiography with Indocyanine Green to Assess Vagi-
nal Cuff Perfusion during Total Laparoscopic Hysterectomy: A Pilot Study. J
Minim Invasive Gynecol. 2017 Mar-Apr;24 (3):432–437. doi: 10.1016/j.
jmig.2016.12.021. Epub 2017 Jan 4. PMID: 28063908)
c
d
gery is restoration of blood ow to the ovary and ovarian preservation whenever possible. Potential viability of torsed ovary is
traditionally assessed visually by observing twisted and blackand-blue adnexa, and decision on surgical removal needs to be
made in real time. One study assessed feasibility of ICG use in
diagnosis of detorsed adnexa viability. Perfusion was achieved in
ten patients (83%) in a median time of 1min, resulting in ovarian
conservation. Perfusion was absent in two cases, and postoophorectomy histologic necrosis was conrmed in one case [31].
Imaging technique: A loading dose of 8cc of ICG dye was
injected IV and untwisted ovary was observed for 10min after
ICG dye administration. Perfusion was dened as visualization of
ICG dye in the involved ovary and/or fallopian tube, causing the
structures to turn green. If no perfusion was visualized 10min
after the initial bolus injection, an additional 4cc bolus of ICG
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dye could be administered, and the ovary was observed for another
10min. This process could be repeated an additional three times,
if necessary, resulting in a maximum volume of 20cc of ICG dye.
L. Lipetskaia et al.
Fluorescence Imaging-Guided Surgical
Navigation
Ureter Visualization
Iatrogenic bladder injuries are the most frequent urologic injuries,
but they are usually recognized and repaired immediately, and
potential complications are typically minor. In contrast, 50–70%
of iatrogenic ureteral injuries are diagnosed postoperatively with
gynecologic surgery accounting for 52% to 82% of those injuries
[32]. The ureter is injured in roughly 0.5–2% of all hysterectomies and routine gynecologic pelvic operations [33, 34]. The lack
of precise haptic feedback in robotic and laparoscopic surgery has
previously been associated with increasing rates of inadvertent
ureteral injuries across various surgical specialties [35]. Clear
identication of the pelvic ureter can be difcult but remains
essential to avoid inadvertent iatrogenic ureteral injury. The preventative ureteral stents placement is controversial in gynecological surgery due to the lack of clear evidence of efcacy.
Illuminating catheters have been designed to improve visualization of ureters intraoperatively but did not gain popularity [36].
Injection technique: Three techniques involving NIR entail IV
use of NIR dye, direct instillation of NIR solution into ureteral
orice via cystoscopy, and use of ureteral catheter with NIR properties in construction material.
(a) 0.06mg/kg of nerindocianine sodium administered IV.Ureter
is imaged at 10 and 30min post-infusion. Lower (0.042mg/
kg) and higher (0.12mg/kg) doses perform poorer by diminishing visualization time or decreasing the efcacy [37]
(Fig.16.8).
(b) Cystoscopy is performed at the beginning of the surgery to
insert the tip of a 6-Fr ureteral catheter and instill 8mL of
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Fig. 16.8 A. Intraoperative ureteral identication by nerindocianine sodium
use via IV administration (Huh etal. Fluorescence Imaging of the Ureter in
Minimally Invasive Pelvic Surgery. J Minim Invasive Gynecol. 2021
Feb;28(2):332–341.e14. doi: 10.1016/j.jmig.2020.06.022. Epub 2020 Jun 29.
PMID: 32615331)
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ICG (1.25mg/mL solution). Finally, the catheters are removed
because the uorescence remains in the ureters up to 6h. This
method can be applied retroactively if injury is suspected at
the end of surgery. Ureteral injury is identied by observing
extravasation of the dye after instillation (Fig.16.9).
(c) The ureteral catheter constructed with near-infrared dye simi-
lar to ICG embedded in its wall does not require intraoperative dye administration. This technique is user- friendly and
can be utilized by the novice surgeons with little experience
in laparoscopic surgery [38] (Fig.16.10).
Fluorescent Medical Devices
By creating medical and surgical devices that uoresce under NIR
imaging, the number of patients beneting from uorescence
assisted surgery will increase. There are a few medical device
companies (EndoGlow, Rochester, NY.) that have been innovative
in developing surgical devices that uoresce under NIR imaging
(Fig.16.11). For instance, uorescent imbedded rectal and vaginal manipulators take the place of traditional bougies or end-toend anastomosis sizers in pelvic surgeries. Pilot studies have
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Fig. 16.9 Intraoperative ureteral identication by indocyanine green use via
catheter infusion (Shibata R et al. Intraoperative dyes, uorescence and
enhanced imaging in benign gynaecologic surgery. Cu Opin Obstet Gynecol.
2022 Aug 1;34 (4):237–243. doi: 10.1097/GCO.0000000000000793. PMID:
35895966)
L. Lipetskaia et al.
Fig. 16.10 Intraoperative ureteral identication by indocyanine green use
via NIR-embedded novel ureteral catheter infusion (Fujita H, etal. Use of a
Novel Fluorescent Catheter to Locate the Ureters during Total Laparoscopic
Hysterectomy. J Minim Invasive Gynecol. 2021 Jul;28 (7):1420–1424. doi:
10.1016/j.jmig.2021.04.004. Epub 2021 Apr 19. PMID: 33887490)
demonstrated several benets to the transillumination effect of
using a uorescent manipulator [39]. Surgeons were able to identify deep inltrating rectal endometriosis, better recognize surgical planes in complex anatomy, and visualize relative tissue depth.
The ability to transilluminate vaginal tissue aided in post-
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hysterectomy bladder dissections during sacrocolpopexies and
rectopexies. An unexpected benet was the increased communication between the attending surgeon and surgical learners
(fellows/residents) or surgical assists. The enhanced visualization
allowed the surgical learner or rst-assist to see and understand
the intricacies of the dissection more easily.
The manipulator can be placed in the vagina (Fig.16.11) or
rectum (Fig. 16.12) to manipulate tissue and highlight tissue
plains, therefore guiding dissection.
Fig. 16.11 EndoGlow device placed into vagina to guide dissection between
vagina and bladder (regular light view on left and infrared view on the right)
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L. Lipetskaia et al.
Fig. 16.11 (continued)
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Fig. 16.12 EndoGlow device placed into rectum to guide dissection between
rectum and closed vaginal cuff after hysterectomy (regular light view on left
and infrared view on the right)
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Conclusion
FGS has numerous clinical applications in gynecological surgery
from SLN mapping, anatomic visualization of ureters or tissue
planes, and perfusion assessment of anastomoses or specic arteries. These tools aid surgeons intraoperatively in real time and provide essential visual feedback that has previously been inaccessible.
FGS continues to rapidly evolve and improve surgical care; however, further well-powered studies are needed to establish the value
of uorescence guidance in gynecologic surgery.
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AOG.0b013e3181f38599.
2. Gupta S, Maghsoudlou P, Ajao M, Einarsson JI, King LP.Very low rates
of ureteral injury in laparoscopic hysterectomy performed by fellowshiptrained minimally invasive gynecologic surgeons. J Minim Invasive
Gynecol. 2022;29(9):1099–103.
3. Towner M, Kim JJ, Simon MA, Matei D, Roque D.Disparities in gynecologic cancer incidence, treatment, and survival: a naative review of outcomes among black and white women in the United States. Int J Gynecol
Cancer. 2022;32(7):931–8. Published 2022 Jul 4.
4. Onstad MA, Schmandt RE, Lu KH. Addressing the role of obesity in
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5. Stewart HL, Birch DJS. Fluorescence guided surgery methods. Appl
Fluoresc. 2021;9:4. https://doi.org/10.1088/2050- 6120/ac1dbb.
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