Robotic-Assisted Resection of Pelvic Arteriovenous Malformation Utilising Intraoperative Video Angiography with Indocyanine Green

Abstract

<h3>Study Objective</h3> Surgical resection of pelvic arteriovenous malformations (AVM) can be challenging, and pre-operative imaging may not clearly identify feeding vessels. We describe a case of pelvic AVM in a young woman and demonstrate the robotic surgical resection utilising video angiography with indocyanine green (ICG). <h3>Design</h3> Case report and surgical video. <h3>Setting</h3> Four-arm robotic assisted laparoscopy. <h3>Patients or Participants</h3> A nullipara with pelvic AVM. <h3>Interventions</h3> Robotic-assisted resection of pelvic AVM guided by intraoperative ICG angiography. <h3>Measurements and Main Results</h3> A 22-year-old woman presented with progressively worsening left pelvic pain. Pelvic ultrasound demonstrated a 7cm left adnexal vascular mass and magnetic resonance angiogram confirmed a left pelvic AVM. The patient was counselled regarding the risks of embolization versus surgery and decided on the latter. Using a robotic surgical system, the left pelvic side wall was opened at the pelvic brim and careful dissection of the retroperitoneal alveolar tissue was performed. 3mL of a 2.5mg/mL solution of ICG was injected peripherally, followed by 10mL bolus of normal saline. Using the near infra-red imaging of the robotic system, the ICG demonstrates small efferent vessels arising from the left ovarian vessels and a large vein communicating with the left external iliac vein. Vascular clips were applied to the aberrant vein prior to ligation. The AVM was carefully dissected away from the surrounding tissues, with use of bipolar diathermy for coagulation of smaller vessels. A further dose of ICG was injected after resection to ensure haemostasis and to confirm the perfusion of remaining organs. Mesosalpinx and pelvic side wall peritoneum were closed with 2-0 barbed suture. The patient was discharged the following day with complete resolution of left pelvic pain and normal pelvic ultrasound scan 6 weeks later. <h3>Conclusion</h3> Robotic surgical resection of pelvic AVM is enhanced with guidance from intraoperative ICG video angiography to ensure haemostasis and complete excision.