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TRT & GreenEgg™

Procedures

Procedures
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GYNECOLOGY

In gynecologic surgeries, EndoGlow products aid the surgeon by transilluminating the rectum and vagina.  This can be beneficial with the identification of subsurface pathology, assisting in the visual identification of scar tissue and evaluating relative tissue depth during robotic assisted or laparoscopic surgery.  This enhanced tissue visualization is not possible using fluorescent dye injections.

Procedure

Issue

Solution

Impact

Endometriosis

Resection

  • Not visualizing sub-surface endometriosis.

Enhanced visualization of subsurface endometriosis by transilluminating the tissue.

  • Superior identification and removal of endometriosis without the use of a proctoscope. 

  • Decreased operative time  and sterilization costs.

Resection of recurrent gynecologic cancers

  • Resection of recurrent gynecologic malignancies is done visually. 

  • Seeding may be optically obscured resulting in incomplete resection and poorer patient outcomes.

Placing the manipulator in the rectum or the vagina will back light the tissue and amplify areas of recurrence or seeding.

  • More complete resection of recurrent cancer will result in improved prognosis.

  • Can be used in conjunction with ICG identifying sentinel lymph nodes.

Post-radiation oncologic resections

  • Radiation results in scaring, poor tissue quality and an increase in intraoperative complications.

By using the manipulator in the rectum or vagina,  anatomic borders are  delineated and  surgical planes are enhanced leading to a decrease in perforation of the bladder, rectum or vagina.

  • By decreasing intraoperative complications, patient outcomes are improved, and surgical time is minimized

Sacrocolpopexy

  • Post-hysterectomy dissection of a scarred bladder off the vagina can result in incidental cystotomies, vaginotomies and prolonged operative time.

By placing the manipulator in the vagina and back lighting the tissue, the surgical planes are enhanced and mesh placement is facilitated. Incidental entry into the bladder or vagina is illuminated.

  • Surgical time is minimized with improved visualization.
    Decreased mesh related complications by avoiding and recognizing incidental cystotomies or vaginal/rectal perforations.

Gynecology
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colorectal

Rectal cancer can distort anatomy.  By utilizing the GreenEgg™ rectal manipulator to  trans-illuminate tissue, surgeons can view the natural borders of the rectum, identify subsurface pathology and illuminate gaps in an anastomosis.

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UROLOGY

In urological surgeries such as radical prostatectomies or cystectomies, back lighting the vagina or rectum enhances anatomic borders.   The fluorescence promotes the sensation of relative tissue depth during minimally invasive surgeries. 

Procedure

Issue

Solution

Impact

Laparoscopic radical prostatectomy

  • Rectal injury

(incidence 1.8-2.2%) 4

Heightened posterior prostate plane visualization and dissection.

  • Reduced rectal injuries.

  • Opportunity for 100% intraoperative recognition of rectal injuries.

Heightened posterior prostate plane visualization and dissection.

  • Reduced rectal injuries. 
    Opportunity for 100% intraoperative recognition of rectal injuries.

  • Rectal injury

(incidence .08%-1.2%) 10, 13

Robotic assisted radical prostatectomy

Female Cystectomy

  • Incidental vaginotomy

  • Shortening of vaginal length

By trans-illuminating the vaginal tissue, anatomic borders are enhanced facilitating the dissection of the bladder off of the vaginal tissue.

  • Preserve post-operative vaginal length and sexual function.

  • Expedite dissections and visualize subsurface pathology.

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Urology
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COLORECTAL

Rectal cancer can distort anatomy.  By utilizing the GreenEgg™ rectal manipulator to  trans-illuminate tissue, surgeons can view the natural borders of the rectum, identify subsurface pathology and illuminate gaps in an anastomosis.

Evaluating lower anastomosis sites

Rectal anastomosis sites need to be evaluated for complete circumferential closure.

Fluorescent probe highlights areas of incomplete anastomosis closure, while ICG can evaluate for perfusion.

Incomplete rectal anastomosis can result in sepsis or fistula formation. Better patient outcomes are expected with primary closure and decreased cost with from fewer re-hospitalizations.

Resection of infiltrating endometriosis

Deep infiltrating rectal endometriosis  can be missed without the use of a proctoscope.

​Transilluminating tissue  allows for the visualization of sub-surface pathology.

Superior identification and removal of endometriosis without the use of a proctoscope. Decreased operative time  and sterilization costs.

Salvage pelvic surgery after radiation and/or chemo-therapy

Radiation results in scaring, poor tissue quality and an increase in intraoperative complications.

Using the manipulator in the rectum or vagina, the anatomy is defined for better visualization of surgical planes and a decrease in perforation of the bladder, rectum or vagina.

By decreasing intraoperative complications, patient outcomes are improved, and surgical time is minimized.

Rectal cancer resection

Seeding may be optically obscured resulting in incomplete resection and poorer patient outcomes.

Placing the manipulator in the rectum or the vagina will transilluminate the tissue and amplify areas of heterogenicity.

Additional visual information in the NIR mode can provide a more complete surgical picture.

Rectopexy

Visualization of the most distal portion of the rectum can be challenging.

Placing the manipulator in the rectum back lights the area and outlines crucial anatomy decreasing unintentionally rectal injury.

A more distal dissection will result in superior surgical outcomes and decreased rectal injuries.

Procedure

Issue

Solution

Impact

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surgical teaching

EndoGlow products enhance anatomic borders, illuminate surgical planes and allow the surgical learner to see relative tissue depth.  These benefits can enhance surgical confidence in and of the surgical trainee, potentially shortening the learning curve for minimally invasive surgeries. 

Radical prostatectomies

  • Lack of haptics during robotic cases

  • Inability to feel tissue quality or tissue depth

  • Input for real time surgical decision making is visual

  • Absence of sub-surface pathology palpation
     

Bladder dissections 

Rextopexies

EndoGlow products back light tissues to outline anatomic borders, reveal subsurface pathology and enhance surgical planes.   The fluorescence promotes the sensation of relative tissue depth during robotic minimally invasive surgeries.  Both aspects have been beneficial when educating surgical learners to operative techniques. 

  • Decreased learning curve for minimally invasive surgical learners

  • Reduce visceral injuries

  • Opportunity for 100% intraoperative recognition of luminal (rectal, bladder, vaginal) injuries.

  • Enhanced visualization of surgical landmarks for better communication between all members of the surgical team.

Reconstructive pelvic surgery

NIR Laparoscope and Robotic Surgical System Usage

  • NIR features on Laparoscopes and Robotic Surgical Systems may not be used as students are not familiar with the features.

  • Hospital investments in these systems are not optimized 

Utilizing EndoGlow products during surgical teaching introduces the NIR features of various surgical platforms.

  • Students learn more about innovations in imaging, surgical technologies and techniques

  • Hospital investments in technology are optimized.

Procedure

Issue

Solution

Impact

Surgical Teaching

References:

1.    Abboudi, H., et al. (2013). "Ureteric injury: a challenging condition to diagnose and manage." Nat Rev Urol 10(2): 108-115.
2.    Cho, J. E. and F. R. Nezhat (2009). "Robotics and gynecologic oncology: review of the literature." J Minim Invasive Gynecol 16(6):  669-681.
3.    Gomez-Rosado, J. C., et al. (2018). "Economic Cost Analysis Related to Complications in General and Digestive Surgery." Cir Esp 96(5): 292-299.
4.    Katz, R., et al. (2003). "Operative management of rectal injuries during laparoscopic radical prostatectomy." Urology 62(2): 310-313.
5.    Lagana, A. S., et al. (2016). "Full-Thickness Excision versus Shaving by Laparoscopy for Intestinal Deep Infiltrating Endometriosis: Rationale and                          Potential Treatment Options." Biomed Res Int 2016: 3617179.
6.     Mustain, W. C. (2017). "Functional Disorders: Rectocele." Clin Colon Rectal Surg 30(1): 63-75.
7.    Nieboer, T. E., et al. (2009). "Surgical approach to hysterectomy for benign gynecological disease." Cochrane Database Syst Rev(3): Cd003677.
8.    Roy, S., et al. (2013). "Economic considerations for mid-urethral sling procedures among patients with stress urinary incontinence." J Long Term Eff                  Med Implants 23(1): 1-8.
9.    Sheikh, L., et al. (2019). "Counting the costs of complications in colorectal surgery." N Z Med J 132(1497): 32-36.
10.    Sotelo, R. J., et al. (2016). "Safer Surgery by Learning from Complications: A Focus on Robotic Prostate Surgery." Eur Urol 69(2): 334-344.
11.    Vonlanthen, R., et al. (2011). "The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients." Ann Surg 254(6):                907-913.
12.    Wang, C. Cost Analysis of Vaginal Mid Urethral Sling Suburethral Removal, Urology Practice, Volume 5, Issue 5,2018,Pages 342-348.
13.    Wedmid, A., et al. (2011). "Rectal injury during robot-assisted radical prostatectomy: incidence and management." J Urol 186(5): 1928-1933.
14.    Yee, D. S. and D. K. Ornstein (2008). "Repair of rectal injury during robotic-assisted laparoscopic prostatectomy." Urology 72(2): 428-431.
15.    https://www.mdsave.com/procedures/sigmoidoscopy-proctosigmoidoscopy/d783f9c4; accessed 6/24/2019.

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