IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France.
Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Evang. Huyssens-Stiftung/Knappschaft GmbH, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany.
Surg Endosc. 2020 Mar;34(3):1401-1411. doi: 10.1007/s00464-019-06997-3. Epub 2019 Jul 23.
The posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation. The aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and assessment of intraoperative remnant perfusion for adrenal resection in the posterior retroperitoneoscopic approach.
Six pigs underwent simultaneous (n = 5) or sequential (n = 1) bilateral posterior retroperitoneoscopic adrenalectomy (n = 12). Fluorescence imaging was obtained via intravenous administration of 3 mL of Indocyanine Green (ICG) and by switching the camera systems to near-infrared mode (D-LIGHT P, KARL STORZ; Germany). Fluorescence-based visualization of adrenal glands before vascular division (n = 4), after the main vascular pedicle ligation (negative control, n = 1) or after adrenal resection (n = 7), was followed by completion adrenalectomy. The fluorescence signal intensity dynamics were recorded and analyzed using proprietary software. For each pixel, the slope of fluorescence signal intensity evolution over time was translated into a color-coded perfusion cartography, which was superimposed onto real-time images obtained with the corresponding left and right camera systems. Quantitative fluorescence signal analysis in the regions of interest (ROIs) served to assess adrenal remnant perfusion in divided adrenal glands.
In the retroperitoneum, the vascular anatomy was illuminated in fluorescence imaging first. The adrenal glands were promptly highlighted after primary intravenous ICG administration (n = 9) or showed a fluorescence signal intensity increase upon reinjection (n = 3). Quantitative fluorescence analysis showed a statistically significant difference between perfused and ischemic segments in divided glands (p = 0.0156).
Fluorescence imaging provides real-time guidance during minimally invasive adrenal surgery. Prior to dissection, it allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. After adrenal gland division, ICG injection associated with a computer-assisted quantitative analysis helps to distinguish between well-perfused and ischemic segments. Further studies are underway to establish the correlation between remnant perfusion and viability.
后腹腔镜肾上腺入路在定位和建立工作空间方面具有挑战性。本实验性急性研究的目的是评估计算机辅助定量荧光成像对后腹腔镜入路肾上腺识别和评估肾上腺切除术中残留灌注的影响。
6 头猪同时（n=5）或序贯（n=1）行双侧后腹腔镜肾上腺切除术（n=12）。荧光成像通过静脉注射 3ml 吲哚菁绿（ICG）并将摄像系统切换到近红外模式（D-LIGHT P，KARL STORZ；德国）获得。在血管分离前（n=4）、主要血管蒂结扎后（阴性对照，n=1）或肾上腺切除后（n=7）进行肾上腺荧光可视化，然后完成肾上腺切除术。记录和分析荧光信号强度动态，使用专有软件进行分析。对于每个像素，荧光信号强度随时间的演化斜率被转换为彩色灌注图，并与相应的左、右摄像系统实时图像叠加。对感兴趣区域（ROI）的定量荧光信号分析用于评估分割肾上腺的残留灌注。
在后腹膜，荧光成像首先照亮血管解剖结构。在初次静脉注射 ICG 后（n=9）或再次注射后（n=3），肾上腺迅速被突出显示。定量荧光分析显示，在分割的腺体中，灌注和缺血节段之间存在统计学上的显著差异（p=0.0156）。
荧光成像为微创肾上腺手术提供了实时指导。在解剖之前，它可以轻松地将肾上腺与周围的腹膜后结构区分开来。在肾上腺切除后，ICG 注射联合计算机辅助定量分析有助于区分灌注良好和缺血的节段。正在进行进一步的研究以建立残留灌注与活力之间的相关性。
