Ostomy Technology: Laser-Assisted Indocyanine Green Angiography (LA-ICGA) Ensuring Intra-Operative Perfusion of the Formed Stoma

Laser Assisted Indocyanine Green Angiography (fluorescence imaging) has been used for cardiac, hepatic, and ophthalmologic procedures since 2005.  We report new applications for this technology in general surgery and wound care.  We have used this device to evaluate intraoperative stomal and anastomotic perfusion prior to abdominal wall closure in order to confirm that long-term tissue viability is present.  This technology uses a non-nephrotoxic fluorescence imaging marker (indocyanine green) injected systemically.  Tissue of interest are then stimulated by an infrared laser and the quality of perfusion is available with a numeric scale within minutes.  Scoring perfusion using the numeric data provided from laser fluorescence allows evaluation of soft tissue perfusion facilitating wound management decisions in the operating room.  Where perfusion is inadequate, healing failure or stomal necrosis is likely to occur.

Three examples:

Case 1: 54-year-old female underwent takedown of an entero-atmospheric fistula with extensive lysis of adhesions.  Returned to the operating room for lysis of adhesions and creation of ileostomy. 

Case 2: 47-year-old female with multiple operations beginning with management of appendiceal phlegmon complicated by multiple enterocutaneous fistulas and returned to operating room for ileostomy creation. 

Case 3: 71 –year-old male with superior mesenteric artery (SMA) occlusion, extended right hemicolectomy, small bowel resection, and after multiple procedures creation of jejunostomy.

Fluorescence imaging was used to confirm stoma viability during staged reconstruction and viability of anastomoses.

Fluorescence imaging shows great potential in evaluation of complex stoma creation, as a means to predict stoma deformity which may require return to the operating room for revision and as a tool to evaluate viability of anastomoses.  Availability of fluorescence data also allows patient reassurance regarding effectiveness of the stoma creation process and enhanced acceptance of the stoma and appliances.