C. R. Huntington1, B. A. Wormer1, S. W. Ross1, P. D. Colavita1, T. Prasad1, A. E. Lincourt1, I. Belyansky2, S. B. Getz1, B. T. Heniford1, V. A. Augenstein1 1Carolinas Medical Center,Charlotte, NC, USA 2Anne Arundel Medical Center,Annapolis, MD, USA
Introduction: Indocynanine green angiography (ICG-A) has been utilized to measure tissue perfusion during surgical reconstruction procedures and intestinal anastomosis, despite a lack of high quality evidence to support its use. While unsubstantiated, ICG-A has also been proposed to reduce complications in abdominal wall reconstruction (AWR). Two tertiary referral hernia centers conducted a prospective, randomized, controlled, blinded trial to investigate the utility of ICG-A in reducing wound complications in complex AWR.
Methods: After IRB approval, all consented patients underwent ICG-A utilizing the SPY Elite deviceTM prior to flap/skin closure after AWR. In the control group, both the Hernia Surgeon and Plastic Surgeon were blinded to ICG-A images. In the experimental group, the surgery team viewed the images and modified tissue flaps if warranted. ICG-A videos were saved and reviewed by independent, blinded surgeons to ensure correct interpretation. Outcomes included medical, surgical and wound complications and reoperation over 3 months. Groups were compared with Chi square and Wilcoxon rank sum analysis.
Results: Among 95 patients, n=49 control and n=46 experimental, preoperative characteristics were similar: age (58.3vs.56.7years,p=0.4), BMI (34.9vs. 33.6kg/m2,p=0.8), tobacco use (8.2%vs. 8.7%,p=0.9), diabetes (30.6%vs.37.0%,p=0.5), and previous hernia repair (71.4%vs.60.9%,p=0.3). The mean hernia defect was 293cm2 and mesh size 1033cm2. Operative characteristics were also equivalent, including rate of panniculectomy (69.4% vs. 58.7%,p=0.3), component separation (73.5%vs. 69.6%,p=0.6), estimated blood loss (160vs.180mL,p=0.4) and mean operative time (204vs.217minutes,p=0.4). The experimental group was more likely to have skin and subcutaneous flaps modified (37%vs.4.1%,p<0.0001). However, there was no significant difference between control vs. experimental groups in wound infection (10.2%vs.21.7%,p=0.12), skin necrosis (6.1% vs. 2.2%,p=0.3), fat necrosis (10.2% vs. 13.0%,p=0.7), overall wound-related complications (32.7% vs. 37.0%,p=0.7), reoperation rates (14.3%vs. 26.1%,p=0.7), or long-term hernia recurrence (4.1% vs. 2.2%,p=0.6) with mean follow-up of 8.3 months. When limited to significantly at-risk patients (obese, diabetic, concomitant component separation, or panniculectomy), there was no significant difference in wound-related complications between groups. Patients with hypoperfusion on ICG-A (below a threshold of 10 units) had higher rates of wound infection (28%vs.9.4%,p<0.02), however flap modification after viewing images did not improve wound-related complications in these patients (15.6%vs.12.5%,p=0.99).
Conclusion: Though intra-operative ICG-A use during complex AWR may aid in identifying patients at risk of wound infection, it did not decrease wound-related complications or reoperation rates in complex abdominal wall reconstruction. The use of ICG-A in complex AWR is not warrented in ventral hernia repair.