CASE REPORT
Use of Fluorescence Imaging Technology to Identify Peritoneal Endometriosis: A Case Report of New Technology Kenneth A. Levey, MD, MPH
Abstract: Indocyanine green has long been used to determine the vascularity of various anatomic structures. Endometriosis is a disease that features neovascularization as a part of its pathologic process. Presented is a case of detecting endometriosis with indocyanine green using the fluorescence imaging technology built into the daVinci Si surgical platform. Key Words: daVinci, indocyanine green, robotic surgery, endometriosis, new technology
(Surg Laparosc Endosc Percutan Tech 2014;24:e63–e65)
t is well established that endometriosis1 is a disease that is commonly found in women with chronic pelvic pain (CPP). However, questions continue to exist regarding the optimal management of endometriosis when it is found in such patients. Surgery that includes resection of endometriosis can be an effective tool for managing pain symptoms in women with CPP.2,3 One limitation of performing such surgery is the proper identification of all areas of endometriosis. Much of this identification is subject to surgeon experience, surgeon knowledge of the disease, and the characteristics of visible areas of endometriosis.4 In short, identification of endometriosis surgically is largely subjective. This results in difficulty performing research across centers and surgeons as well, leading to inconsistent clinical outcomes. Indocyanine green (ICG) is a fluorescent dye that has wide applications throughout medicine in identifying vascularity of tissues for the purposes of both removing abnormal vasculature and retaining normal healthy vasculature. Endometriosis is a disease in which lesions have a high degree of demonstrated neovascularization. Thus, it is possible that ICG may be useful in identifying endometriotic lesions.
I
dysmenorrhea and deep dyspareunia that replicated baseline symptoms in location. She had no irritative voiding symptoms and no dysuria or dyschezia. She had no generalized muscle or joint pain. She was generally able to function at work and home but the pain had been worsening. She had been unable to use oral contraceptive pill as an adult because of its side effects, and nonsteroidal anti-inflammatory drugs had been minimally effective. The remainder of her history was only significant for a laparoscopic ovarian cystectomy of unknown laterality and a laparoscopic cholecystectomy in 2010. Her family history was negative for known endometriosis. The physical examination was significant for mild tenderness at the right lower quadrant with a negative Carnett test. There were normal vaginal fornices. There was tenderness with leftward, rightward, and anterior deviation of the cervix. The cervix was midline. There was bilateral uterosacral ligament and adnexal tenderness. There were no adnexal masses. The pelvic floor and rectal examinations were normal. Ultrasound at the initial evaluation revealed a left ovary that appeared to be adhered to the uterus. Magnetic resonance imaging revealed a 9.7 4.6 4.8 cm uterus with a 1.6 cm junctional zone. The bilateral ovaries were normal. The patient was counseled that she likely had both adenomyosis and endometriosis and elected for primary surgical evaluation and management. She underwent a fertility sparing radical resection of endometriosis, presacral neurectomy, appendectomy, and cystoscopy. The procedure was performed using the daVinci Si surgical assistant platform (Intuitive Surgical, Sunnyvale, CA) with built in fluorescence detection technology. The general abdominal survey was unremarkable. However there were multiple areas of black implants and white scar over the bilateral uterosacral ligaments and pelvic sidewalls. There were Allen-Masters windows in the peritoneum overlying the right pararectal peritoneum and rectovaginal peritoneal reflection. These areas and lesions were visualized using a plain white light imaging (Fig. 1).
CASE REPORT The patient is a 32-year-old woman (G2P1011) who presented in March 2012 for evaluation and management of CPP. She had a 1-year-long history of daily pain that was localized to the right lower quadrant with radiation to the midline lower back. The pain started suddenly and there was no associated accident injury or psychological trauma. She had a history of teen dysmenorrhea that was managed with oral contraceptive pilland nonsteroidal antiinflammatory drugs. She rated her overall pain 8/10 with Received for publication November 2, 2012; accepted February 1, 2013. From the Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York, NY. K.A.L. receives speaking and proctoring fees from Intuitive Surgical Inc. Reprints: Kenneth A. Levey, MD, MPH, Department of Obstetrics and Gynecology, NYU Langone Medical Center, 90 Maiden Lane Suite 300, New York, NY (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
FIGURE 1. Black outlines demonstrate likely areas of endometriosis seen with 3-dimensional imaging and white light.
Volume 24, Number 2, April 2014
www.surgical-laparoscopy.com |
e63
Levey
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 2, April 2014
FIGURE 2. White outlines demonstrate avascular areas in the center of likely endometriosis lesions consistent with the scar. Indocyanine green (ICG) is not seen in these areas because of lack of vascularity. The pelvic sidewalls anterolateral to the uterosacral ligaments are represented. She was given 5 mg of ICG intravenously. There was no adverse reaction to the ICG. After approximately 60 seconds, the obvious areas of endometriosis appeared green in stark difference to the surrounding areas of normal peritoneum. There was no fluorescence in the center of black lesions consistent with avascular portions of the scar (Fig. 2). Critically, however, there were areas of
peritoneum that appeared normal with white light and demonstrated unexpectedly higher density of fluorescence after ICG had been administered. This area was resected and labeled “ICG positive” (Fig. 3). Histopathology revealed endometriosis (glands and stroma) in the resected areas that appeared abnormal under white light.
FIGURE 3. An area of ICG density of the peritoneum is seen outlined with white. This represents an area that was not clearly visualized with white light but was visualized easily with ICG fluorescence. ICG indicates indocyanine green.
e64 | www.surgical-laparoscopy.com
r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 2, April 2014
Flourescence Imaging and Endometriosis
DISCUSSION
determine the difference between normal and abnormal. Finally, prospective trials will be conducted to evaluate the use of this technology across a broader population of women with endometriosis and evaluate the differences in clinical outcomes.
Endometriosis, even in the hands of experienced surgeons, can be difficult to properly diagnose. Maximal surgical resection relies on correctly identifying the area of peritoneal and retroperitoneal abnormalities. In the past, narrow band imaging has been applied in 2 dimensional laparoscopy for the detection of endometriosis.5,6 However, prospective studies to determine clinical outcomes are lacking. Using the 3-dimensional high-definition technology offered by the daVinci Si platform in combination with ICG and the platform’s fluorescence imaging technology has the potential to offer surgeons a greater ability to detect endometriotic lesions and improve the surgical management of endometriosis. This is the first reported use of the daVinci Si’s fluorescent technology and ICG being used as visual cues to aid in the detection and treatment of endometriosis. In the future, visual cues will not be adequate. Software will be required to standardize the level of fluorescence to
1. Guo SW, Wang Y.. The prevalence of endometriosis in women with chronic pelvic pain. Gynecol Obstet Invest. 2006;62:121–30. 2. Chen CC, Falcone T.. Endoscopic management of endometriosis. Minerva Ginecol. 2006;58:347–360. 3. Jacobson TZ, Duffy JM, Barlow D, et al. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database Syst Rev. 2009;2009, CD001300. 4. Greene R, Stratton P, Cleary SD, et al. Diagnostic experience among 4,334 women reporting surgically diagnosed endometriosis. Fertil Steril. 2009;91:32–39. 5. Demco L. Laparoscopic spectral analysis of endometriosis. J Am Assoc Gynecologic Laparoscopists. 2004;11:219–222. 6. Kuroda K, Kitade M, Kikuchi I, et al. Vascular density of peritoneal endometriosis using narrow-band imaging system and vascular analysis software. J Minim Invasive Gynecol. 2009;16:618–621.
Endometriosis was also revealed in the resected area of peritoneum area that only appeared abnormal after administering ICG and using the daVinci Si’s fluorescence imaging technology.
r
2014 Lippincott Williams & Wilkins
REFERENCES
www.surgical-laparoscopy.com |
e65
Use of Fluorescence Imaging Technology to Identify Peritoneal Endometriosis: A Case Report of New Technology Kenneth A. Levey, MD, MPH
Abstract: Indocyanine green has long been used to determine the vascularity of various anatomic structures. Endometriosis is a disease that features neovascularization as a part of its pathologic process. Presented is a case of detecting endometriosis with indocyanine green using the fluorescence imaging technology built into the daVinci Si surgical platform. Key Words: daVinci, indocyanine green, robotic surgery, endometriosis, new technology
(Surg Laparosc Endosc Percutan Tech 2014;24:e63–e65)
t is well established that endometriosis1 is a disease that is commonly found in women with chronic pelvic pain (CPP). However, questions continue to exist regarding the optimal management of endometriosis when it is found in such patients. Surgery that includes resection of endometriosis can be an effective tool for managing pain symptoms in women with CPP.2,3 One limitation of performing such surgery is the proper identification of all areas of endometriosis. Much of this identification is subject to surgeon experience, surgeon knowledge of the disease, and the characteristics of visible areas of endometriosis.4 In short, identification of endometriosis surgically is largely subjective. This results in difficulty performing research across centers and surgeons as well, leading to inconsistent clinical outcomes. Indocyanine green (ICG) is a fluorescent dye that has wide applications throughout medicine in identifying vascularity of tissues for the purposes of both removing abnormal vasculature and retaining normal healthy vasculature. Endometriosis is a disease in which lesions have a high degree of demonstrated neovascularization. Thus, it is possible that ICG may be useful in identifying endometriotic lesions.
I
dysmenorrhea and deep dyspareunia that replicated baseline symptoms in location. She had no irritative voiding symptoms and no dysuria or dyschezia. She had no generalized muscle or joint pain. She was generally able to function at work and home but the pain had been worsening. She had been unable to use oral contraceptive pill as an adult because of its side effects, and nonsteroidal anti-inflammatory drugs had been minimally effective. The remainder of her history was only significant for a laparoscopic ovarian cystectomy of unknown laterality and a laparoscopic cholecystectomy in 2010. Her family history was negative for known endometriosis. The physical examination was significant for mild tenderness at the right lower quadrant with a negative Carnett test. There were normal vaginal fornices. There was tenderness with leftward, rightward, and anterior deviation of the cervix. The cervix was midline. There was bilateral uterosacral ligament and adnexal tenderness. There were no adnexal masses. The pelvic floor and rectal examinations were normal. Ultrasound at the initial evaluation revealed a left ovary that appeared to be adhered to the uterus. Magnetic resonance imaging revealed a 9.7 4.6 4.8 cm uterus with a 1.6 cm junctional zone. The bilateral ovaries were normal. The patient was counseled that she likely had both adenomyosis and endometriosis and elected for primary surgical evaluation and management. She underwent a fertility sparing radical resection of endometriosis, presacral neurectomy, appendectomy, and cystoscopy. The procedure was performed using the daVinci Si surgical assistant platform (Intuitive Surgical, Sunnyvale, CA) with built in fluorescence detection technology. The general abdominal survey was unremarkable. However there were multiple areas of black implants and white scar over the bilateral uterosacral ligaments and pelvic sidewalls. There were Allen-Masters windows in the peritoneum overlying the right pararectal peritoneum and rectovaginal peritoneal reflection. These areas and lesions were visualized using a plain white light imaging (Fig. 1).
CASE REPORT The patient is a 32-year-old woman (G2P1011) who presented in March 2012 for evaluation and management of CPP. She had a 1-year-long history of daily pain that was localized to the right lower quadrant with radiation to the midline lower back. The pain started suddenly and there was no associated accident injury or psychological trauma. She had a history of teen dysmenorrhea that was managed with oral contraceptive pilland nonsteroidal antiinflammatory drugs. She rated her overall pain 8/10 with Received for publication November 2, 2012; accepted February 1, 2013. From the Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York, NY. K.A.L. receives speaking and proctoring fees from Intuitive Surgical Inc. Reprints: Kenneth A. Levey, MD, MPH, Department of Obstetrics and Gynecology, NYU Langone Medical Center, 90 Maiden Lane Suite 300, New York, NY (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
FIGURE 1. Black outlines demonstrate likely areas of endometriosis seen with 3-dimensional imaging and white light.
Volume 24, Number 2, April 2014
www.surgical-laparoscopy.com |
e63
Levey
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 2, April 2014
FIGURE 2. White outlines demonstrate avascular areas in the center of likely endometriosis lesions consistent with the scar. Indocyanine green (ICG) is not seen in these areas because of lack of vascularity. The pelvic sidewalls anterolateral to the uterosacral ligaments are represented. She was given 5 mg of ICG intravenously. There was no adverse reaction to the ICG. After approximately 60 seconds, the obvious areas of endometriosis appeared green in stark difference to the surrounding areas of normal peritoneum. There was no fluorescence in the center of black lesions consistent with avascular portions of the scar (Fig. 2). Critically, however, there were areas of
peritoneum that appeared normal with white light and demonstrated unexpectedly higher density of fluorescence after ICG had been administered. This area was resected and labeled “ICG positive” (Fig. 3). Histopathology revealed endometriosis (glands and stroma) in the resected areas that appeared abnormal under white light.
FIGURE 3. An area of ICG density of the peritoneum is seen outlined with white. This represents an area that was not clearly visualized with white light but was visualized easily with ICG fluorescence. ICG indicates indocyanine green.
e64 | www.surgical-laparoscopy.com
r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 2, April 2014
Flourescence Imaging and Endometriosis
DISCUSSION
determine the difference between normal and abnormal. Finally, prospective trials will be conducted to evaluate the use of this technology across a broader population of women with endometriosis and evaluate the differences in clinical outcomes.
Endometriosis, even in the hands of experienced surgeons, can be difficult to properly diagnose. Maximal surgical resection relies on correctly identifying the area of peritoneal and retroperitoneal abnormalities. In the past, narrow band imaging has been applied in 2 dimensional laparoscopy for the detection of endometriosis.5,6 However, prospective studies to determine clinical outcomes are lacking. Using the 3-dimensional high-definition technology offered by the daVinci Si platform in combination with ICG and the platform’s fluorescence imaging technology has the potential to offer surgeons a greater ability to detect endometriotic lesions and improve the surgical management of endometriosis. This is the first reported use of the daVinci Si’s fluorescent technology and ICG being used as visual cues to aid in the detection and treatment of endometriosis. In the future, visual cues will not be adequate. Software will be required to standardize the level of fluorescence to
1. Guo SW, Wang Y.. The prevalence of endometriosis in women with chronic pelvic pain. Gynecol Obstet Invest. 2006;62:121–30. 2. Chen CC, Falcone T.. Endoscopic management of endometriosis. Minerva Ginecol. 2006;58:347–360. 3. Jacobson TZ, Duffy JM, Barlow D, et al. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database Syst Rev. 2009;2009, CD001300. 4. Greene R, Stratton P, Cleary SD, et al. Diagnostic experience among 4,334 women reporting surgically diagnosed endometriosis. Fertil Steril. 2009;91:32–39. 5. Demco L. Laparoscopic spectral analysis of endometriosis. J Am Assoc Gynecologic Laparoscopists. 2004;11:219–222. 6. Kuroda K, Kitade M, Kikuchi I, et al. Vascular density of peritoneal endometriosis using narrow-band imaging system and vascular analysis software. J Minim Invasive Gynecol. 2009;16:618–621.
Endometriosis was also revealed in the resected area of peritoneum area that only appeared abnormal after administering ICG and using the daVinci Si’s fluorescence imaging technology.
r
2014 Lippincott Williams & Wilkins
REFERENCES
www.surgical-laparoscopy.com |
e65
