Indocyanine Green Fluorescence Identification of Ureters in Robotic Hartmann Reversal

Abstract

Introduction: Hartmann reversal is a complex surgical procedure associated with significant morbidity. Injuries of the urinary tract can occur in 10% to 15% of primary colorectal resections and complex reconstructive surgeries. Indocyanine green (ICG) intraureteral injection has been advocated recently for ureteral identification during pelvic surgery. Decreasing the rate of ureteral injuries directly impacts length of stay, costs, morbidity, and mortality rate. This video illustrates the utility of intraureteral ICG during a Hartmann reversal procedure in a complex pelvis. Materials and Methods: Intraureteral injection of ICG was used in five patients, three Hartmann reversals and two rectal bulky tumors. All patients underwent robotic procedures except one patient with a bulky and perforated rectal tumor combined with a left pelvic kidney. This specific video highlights a patient who underwent a laparoscopic Hartmann procedure for pelvic abscess caused by a perforated sigmoid diverticula. A Hartmann reversal was performed 2 months later. A robot-assisted Hartmann reversal was carried out and off-label bilateral intraureteral infusion of ICG was performed. A 5F ureteral catheter was inserted in both ureters before surgery, 10 cm beyond the ureteral orifice and then retracted back to 2 cm. When requested, 25 mg of ICG were dissolved in 10 mL of saline and injected into both ureters. ICG reversibly binds to proteins of the urothelial layer. ICG is a fluorescent dye, made of hydrophobic molecules that usually is injected intravenously and binds to plasma proteins and is excreted by liver. It becomes fluorescent when excited by the robotic laser light (Firefly Fluorescence Endoscope System; Intuitive Surgical, Inc., Silicon Valley in Sunnyvale, CA). Injection time was 15 minutes and ICG helped identify the right ureter that was slightly medialized and adherent to the rectal stump. A peristomal hernia was present and treated by direct suture after an adhesiolysis. After dissecting the rectal stump from the right ureter and pelvic wall, the rectal stump was re-transected and a colorectal end-to-end mechanical anastomosis was performed. A perianastomotic suction drainage was placed in the pelvis. Both ureteral catheters were removed at the end of the procedure. Results: Neither ureteral injuries nor ICG-related intraoperative and/or postoperative adverse events, nor renal failures were experienced in all the treated cases. A transient hematuria was observed in two patients. Conclusions: Use of intraureteral ICG may be a safe and helpful procedure to identify ureters in complex pelvic and colorectal surgery. It can serve as a valid tool in preventing iatrogenic ureteral injuries. No competing financial interests exist. Runtime of video: 7 mins 52 secs