Beran Benjamin D, Shockley Marie, Padilla Pamela Frazzini, Farag Sara, Escobar Pedro, Zimberg Stephen, Sprague Michael L
Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
Department of Gynecology and Obstetrics, Gynecologic Specialties, Emory University School of Medicine, Atlanta, Georgia, USA.
JSLS. 2018 Apr-Jun;22(2). doi: 10.4293/JSLS.2018.00001.
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.
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.
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 ( = .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 ( = .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 ( = .19). Decreased cuff perfusion was observed with longer instrument activation times in open cuffs ( = 0.3175).
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.
阴道断端裂开可能是血管介导的事件，报告显示与其他手术途径相比，机器人辅助全腹腔镜子宫切除术（RATLH）后阴道断端裂开的发生率更高。本研究旨在确定在RATLH期间使用激光血管造影评估阴道断端灌注的可行性。
这是一项纳入20例因良性疾病接受RATLH的女性的初步可行性试验。阴道切开术采用超声或单极器械进行，而倒刺或非倒刺缝线用于断端闭合。记录阴道切开术期间器械激活的时间。在断端闭合前后拍摄阴道断端灌注的图像。评估人员对这些图像进行评估并确定断端灌注充足的区域。
所有参与者的阴道断端均可见吲哚菁绿（ICG）。确定最佳剂量为静脉注射每次7.5 mg ICG。ICG出现的平均时间在闭合前为18.4±7.3秒（平均值±标准差），闭合后为19.0±8.7秒。使用单极（48.9±26.0%；平均值±标准差）或超声（40.2±14.1%）器械进行阴道切开术后，开放断端的判断灌注无显著差异（P = 0.19）。使用单极（70.9±21.1%）或超声（70.5±20.5%）器械闭合断端后无差异（P = 0.36）。使用倒刺（74.1±20.1%）或非倒刺（66.4±20.9%）缝线对估计的闭合断端灌注无显著影响（P = 0.19）。开放断端中，器械激活时间越长，断端灌注降低（P = 0.3175）。
RATLH期间的激光血管造影可使阴道断端的血管灌注可视化。该技术仍受限于缺乏可量化的荧光以及对具有临床意义的荧光水平的了解。
