O-229 Neck scarf of ureter and Intraoperative ICG-fluorescence for preventing ureters injuries in Da Vinci Robotic deep infiltrating endometriosis excision
Authors: Chuang Y  C , Lu H  F , Chen S  U , Jaafar S  H , Torng P  L 
Published: July 2024

Abstract

Study question
To prevent ureters injury during deep infiltrating endometriosis excision.

Summary answer
Identify the ureter course with ICG and near-infrared fluorescence (NIRF) imaging mode and traction with a vessel loop like neck scarf in white light mode.

What is known already
Deep infiltrating endometriosis is one of the most challenging gynecologic operation due to the distorted anatomy by the fibrosis of endometriosis gland.Identification of ureters through intraurethral ICG instillation and NIRF imaging has been reported to be useful during robotic surgery. However, surgeons cannot do robotic ureterolysis in Firefly NIRF imaging mode. When shift back to the white light mode, surgeons could only try to remember the ureter course during the ureterolysis procedure.When the ureter course was in doubt, the surgeon must shift back to the ICG-NIRF image mode again.

Study design, size, duration
From 2017 Jan1 till 2024 Jan 7, a single surgeon perform 47 consecutive patients with DIE received robotic surgery with ureterolysis from pelvic brim to the level of uterine vessels crossing them. Yellow and blue rubber bands were used to collar the ureters as a neck scarf, with Da Vinci robot system (SI, XI)The third arm as an stable assistant to traction the neck scarf to traction ureter indirectly in different direction when ureterolysis.

Participants/materials, setting, methods
We perform cystoscopy and intraurethral ICG injection with or without ureteral stent placement and Inject ICG-fluorescence with Firefly fluorescence imaging if the ureters were hard to find due to adhesion and fibrosis. Under the Firefly NIRF imaging mode,the location of ureter over the pelvic brim was found and the vessel loops were set up. Then shift back to white light mode to do the ureterolysis.

Main results and the role of chance
47 consecutive patients with deep infiltrating endometriosis were safely operated without fistula, ureter injury, laceration during one month to 5 years period follow up. In them 2 patients need cystoscopy and ICG-NIRF help to setting up the vessel’s loops.

Conclusion
The surgeons could always keep the ureter safety during difficult endometriosis dissection with the vessel loops over the ureter as a neck scarf.There will be an indirect traction force pulled by robotic assistant forceps in the regular robotic laparoscopy light source mode during ureterolysis.
The Firefly NIRF imaging mode could be used to help in setting up the neck scarf of ureters when the adhesion and fibroisis made the ureters course obscure.

Limitations, reasons for caution
Indocyanine Green is a fluorescent substance visible in near-infrared light. It is FDA-approved with IV injection for the identification of anatomical structures.The intra-ureteral ICG injection is off-label use.

Wider implications of the findings
Our techniques could be applied to all pelvic surgeries especially DIE, broad ligament and cervix myoma, scar defect repair and gynecologic cancer surgery, to preventing the ureters injured.
However, further studies will be warranted.

Trial registration number
non-clinical trials