Intraoperative Use of Fluorescent Imaging with Indocyanine Green Changes Management of Abdominal Wall Flaps During Open Hernia Repair

Jonathan Cho, MS, Audriene Sanchez, MS, Heidi Ryan, MD, Shawn Tsuda, MD, FACS. Department of Surgery, University of Nevada School of Medicine.

BACKGROUND: Wound complications including infection and necrosis remain common during complex open ventral hernia repair. Advancements or enhancements in imaging technology may abate some of these issues but requires more investigation. Laser-assisted fluorescent imaging with indocyanine green (Spy Elite, LifeCell) allows visualization and quantification of perfusion, facilitating management of poorly perfused tissue.

METHODS: Ten patients, who underwent large or massive ventral/incisional hernia repair with biologic graft reinforcement and either perforator-sparing components separation or primary open repair, underwent intraoperative use of laser-assisted fluorescent imaging with indocyanine green from August 2012 to August 2013. The cases were reviewed by an independent data collector with primary outcomes of postoperative skin infection and/or abdominal wall necrosis.

RESULTS: Three (30%) patients had adequate perfusion, while 7 (70%) patients had inadequate skin perfusion and necessitated excision of additional tissue. Of the patients whose ischemic tissue was removed, 4 (57%) patients developed an infection, while no patients developed necrosis. Of the patients who had no removal of additional skin, 1 (33%) and 1 (33%) patients developed an infection and necrosis, respectively.

CONCLUSION: The intraoperative use of laser-assisted fluorescent imaging with indocyanine green may change management of abdominal wall flaps, even in perforator sparing operations. Our study series is small and cannot suggest statistical significance in the potential benefit of intraoperative imaging, but shows that up to 70% of patients may require change in management due to poorly perfused tissue flaps.