Treatment of an Inguinal Lymphatic Fistula with Indocyanine Green

Abstract

<h3>Study Objective</h3> To address iatrogenic lymphocele after inguinal lymphadenectomy for vulvar cancer with a minimally invasive intervention, by localizing the disrupted lymphatic duct with real-time NIR/ICG fluorescent imaging. <h3>Design</h3> Narrated video footage. <h3>Setting</h3> Department of Gynecologic Oncology, Bern University Hospital. <h3>Patients or Participants</h3> Patient A underwent hemivulvectomy with homolateral inguinal sentinel lymphadenectomy for a squamous cell carcinoma of the right vulva, FIGO Ib. Two weeks later she reported a wound dehiscence in her right groin with abundant yellowish discharges, persisting over time and leading to a remarkable progression of the dehiscence. Patient B was seen after R1 resection of a relapsing FIGO II, already treated with combined chemoradiotherapy one year before. She underwent dorsal hemivulvectomy with bilateral inguinal lymphadenectomy, complete colpectomy and coverage of tissue defects with fascio-cutaneous flaps. Two weeks later she reported a closed inguinal lymphocele. We attempted a conservative treatment with antibiotics and needle aspirations, nevertheless a multibacterial infection occurred on the right side. <h3>Interventions</h3> By failing conservative measures, surgical correction of assumed lymphatic fistulas was called for in both cases. After debridement of the inguinal wound in local anesthesia, an intracutaneous injection of 2 ml ICG was carried out between the 1st and 2nd ipsilateral toe. <h3>Measurements and Main Results</h3> After 7 minutes a fluorescent effusion from the site of the fistula was identified in real-time NIR imaging, performed with an optic device (VITOM® ICG) installed on the operating table for the extracorporeal detection of the fluorescence produced by ICG. The disrupted lymphatic duct could be ligated. The absence of further fluorescent effusion confirmed the successful repair. The wound was closed and healed well in the follow-up. No recurrence or exacerbation of the lymphedema occurred. <h3>Conclusion</h3> Intraoperative NIR/ICG fluorescence lymphatic imaging with an exoscope enables a highly sensitive detection of lymphatic structures and a tailored curative intervention, with a safe toxicological profile and without radiation exposure.