Where is the cord? An ICG Overview in Laparoscopic Varicocele Ligation
EAES Academy. Dharmadhikari S. 07/05/22; 363144; P189
Shalmali Dharmadhikari
Contributions
Contributions
Abstract
Background:
Varicocele, the abnormal dilatation of the pampiniform plexus, can be treated by microsurgical subinguinal (Goldstein), inguinal (Ivanissevich), abdominal (Palomo, nonartery sparing) and endoscopic approach. Laparoscopic varicocele ligation is a long tried and tested treatment modality for varicocele. Indocyanine green (ICG) is a water-soluble dye which has the property of fluorescence enabling it to emit fluorescent radiation when excited by a laser beam or when exposed to near-infrared light (NIR) at about 820 nm and longer wavelengths. The difficulty in identifying the testicular vessels, which should be spared, can be reduced by the use of intraoperative indocyanine green angiography (ICGA).
Method:
A prospective study was conducted in a tertiary care hospital. 60 cases with varicocele of grade 3 and above were selected. Through randomisation, using clinstat, 30 cases (Group B) were taken up for intraoperative ICGA after a subdermal test dose was given a day prior to surgery. The remaining 30 cases(Group A) underwent laparoscopic varicocele ligation without ICGA visualisation. Ports placed in the supraumbilical, suprapubic and on the ipsilateral side of the varicocele, lateral to epigastric vessels. After exposing the testicular vessels, ICG was injected intravenously in 30 of the 60 cases and both artery and vein visualised with fluoroscopic guidance. Vein was ligated with preservation of the artery and lymphatics.
Result:
The testicular artery was clearly identified by ICGA and the veins were ligated, while preserving a few lymphatic vessels and the spermatic duct. The preserved arteries were confirmed by repeated ICGA at the end of operation. The mean time to the arterial phase (AP) from the ICG injection was 30.2 seconds and the mean time to the venous phase was 42.6 seconds. The mean interval from the arterial phase to the venous phase was 23.3 seconds. This time interval was utilised in proper identification. With no dye related complication, there was infection at operated site seen in 10% cases in Group A and 6.6% in Group B. Hydrocoele was seen in 1.4% cases who underwent with laparoscopic varicocele ligation. There was a decrease in post-operative complications such as recurrence and hydrocoele in the cases that were operated with ICGA.
Conclusion:
ICG angiography is a safe and convenient modality that allows easier identification of vascular anatomy and provides and overall heightened surgical performance in difficult cases. It helps in reducing postoperative complications that could occur due to unaware injury to the testicular vessels and lymphatics.
Varicocele, the abnormal dilatation of the pampiniform plexus, can be treated by microsurgical subinguinal (Goldstein), inguinal (Ivanissevich), abdominal (Palomo, nonartery sparing) and endoscopic approach. Laparoscopic varicocele ligation is a long tried and tested treatment modality for varicocele. Indocyanine green (ICG) is a water-soluble dye which has the property of fluorescence enabling it to emit fluorescent radiation when excited by a laser beam or when exposed to near-infrared light (NIR) at about 820 nm and longer wavelengths. The difficulty in identifying the testicular vessels, which should be spared, can be reduced by the use of intraoperative indocyanine green angiography (ICGA).
Method:
A prospective study was conducted in a tertiary care hospital. 60 cases with varicocele of grade 3 and above were selected. Through randomisation, using clinstat, 30 cases (Group B) were taken up for intraoperative ICGA after a subdermal test dose was given a day prior to surgery. The remaining 30 cases(Group A) underwent laparoscopic varicocele ligation without ICGA visualisation. Ports placed in the supraumbilical, suprapubic and on the ipsilateral side of the varicocele, lateral to epigastric vessels. After exposing the testicular vessels, ICG was injected intravenously in 30 of the 60 cases and both artery and vein visualised with fluoroscopic guidance. Vein was ligated with preservation of the artery and lymphatics.
Result:
The testicular artery was clearly identified by ICGA and the veins were ligated, while preserving a few lymphatic vessels and the spermatic duct. The preserved arteries were confirmed by repeated ICGA at the end of operation. The mean time to the arterial phase (AP) from the ICG injection was 30.2 seconds and the mean time to the venous phase was 42.6 seconds. The mean interval from the arterial phase to the venous phase was 23.3 seconds. This time interval was utilised in proper identification. With no dye related complication, there was infection at operated site seen in 10% cases in Group A and 6.6% in Group B. Hydrocoele was seen in 1.4% cases who underwent with laparoscopic varicocele ligation. There was a decrease in post-operative complications such as recurrence and hydrocoele in the cases that were operated with ICGA.
Conclusion:
ICG angiography is a safe and convenient modality that allows easier identification of vascular anatomy and provides and overall heightened surgical performance in difficult cases. It helps in reducing postoperative complications that could occur due to unaware injury to the testicular vessels and lymphatics.
Background:
Varicocele, the abnormal dilatation of the pampiniform plexus, can be treated by microsurgical subinguinal (Goldstein), inguinal (Ivanissevich), abdominal (Palomo, nonartery sparing) and endoscopic approach. Laparoscopic varicocele ligation is a long tried and tested treatment modality for varicocele. Indocyanine green (ICG) is a water-soluble dye which has the property of fluorescence enabling it to emit fluorescent radiation when excited by a laser beam or when exposed to near-infrared light (NIR) at about 820 nm and longer wavelengths. The difficulty in identifying the testicular vessels, which should be spared, can be reduced by the use of intraoperative indocyanine green angiography (ICGA).
Method:
A prospective study was conducted in a tertiary care hospital. 60 cases with varicocele of grade 3 and above were selected. Through randomisation, using clinstat, 30 cases (Group B) were taken up for intraoperative ICGA after a subdermal test dose was given a day prior to surgery. The remaining 30 cases(Group A) underwent laparoscopic varicocele ligation without ICGA visualisation. Ports placed in the supraumbilical, suprapubic and on the ipsilateral side of the varicocele, lateral to epigastric vessels. After exposing the testicular vessels, ICG was injected intravenously in 30 of the 60 cases and both artery and vein visualised with fluoroscopic guidance. Vein was ligated with preservation of the artery and lymphatics.
Result:
The testicular artery was clearly identified by ICGA and the veins were ligated, while preserving a few lymphatic vessels and the spermatic duct. The preserved arteries were confirmed by repeated ICGA at the end of operation. The mean time to the arterial phase (AP) from the ICG injection was 30.2 seconds and the mean time to the venous phase was 42.6 seconds. The mean interval from the arterial phase to the venous phase was 23.3 seconds. This time interval was utilised in proper identification. With no dye related complication, there was infection at operated site seen in 10% cases in Group A and 6.6% in Group B. Hydrocoele was seen in 1.4% cases who underwent with laparoscopic varicocele ligation. There was a decrease in post-operative complications such as recurrence and hydrocoele in the cases that were operated with ICGA.
Conclusion:
ICG angiography is a safe and convenient modality that allows easier identification of vascular anatomy and provides and overall heightened surgical performance in difficult cases. It helps in reducing postoperative complications that could occur due to unaware injury to the testicular vessels and lymphatics.
Varicocele, the abnormal dilatation of the pampiniform plexus, can be treated by microsurgical subinguinal (Goldstein), inguinal (Ivanissevich), abdominal (Palomo, nonartery sparing) and endoscopic approach. Laparoscopic varicocele ligation is a long tried and tested treatment modality for varicocele. Indocyanine green (ICG) is a water-soluble dye which has the property of fluorescence enabling it to emit fluorescent radiation when excited by a laser beam or when exposed to near-infrared light (NIR) at about 820 nm and longer wavelengths. The difficulty in identifying the testicular vessels, which should be spared, can be reduced by the use of intraoperative indocyanine green angiography (ICGA).
Method:
A prospective study was conducted in a tertiary care hospital. 60 cases with varicocele of grade 3 and above were selected. Through randomisation, using clinstat, 30 cases (Group B) were taken up for intraoperative ICGA after a subdermal test dose was given a day prior to surgery. The remaining 30 cases(Group A) underwent laparoscopic varicocele ligation without ICGA visualisation. Ports placed in the supraumbilical, suprapubic and on the ipsilateral side of the varicocele, lateral to epigastric vessels. After exposing the testicular vessels, ICG was injected intravenously in 30 of the 60 cases and both artery and vein visualised with fluoroscopic guidance. Vein was ligated with preservation of the artery and lymphatics.
Result:
The testicular artery was clearly identified by ICGA and the veins were ligated, while preserving a few lymphatic vessels and the spermatic duct. The preserved arteries were confirmed by repeated ICGA at the end of operation. The mean time to the arterial phase (AP) from the ICG injection was 30.2 seconds and the mean time to the venous phase was 42.6 seconds. The mean interval from the arterial phase to the venous phase was 23.3 seconds. This time interval was utilised in proper identification. With no dye related complication, there was infection at operated site seen in 10% cases in Group A and 6.6% in Group B. Hydrocoele was seen in 1.4% cases who underwent with laparoscopic varicocele ligation. There was a decrease in post-operative complications such as recurrence and hydrocoele in the cases that were operated with ICGA.
Conclusion:
ICG angiography is a safe and convenient modality that allows easier identification of vascular anatomy and provides and overall heightened surgical performance in difficult cases. It helps in reducing postoperative complications that could occur due to unaware injury to the testicular vessels and lymphatics.
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