Laser Angiography to Assess the Vaginal Cuff During Robotic Hysterectomy

Background and Objectives: 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. Methods: 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. Results: 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 (P = .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 (P = .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 (P = .19). Decreased cuff perfusion was observed with longer instrument activation times in open cuffs (R-2 = 0.3175). Conclusion: 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.