Intraoperative Indocyaningrün-Fluoreszenzdiagnostik mittels Operationsmikroskop in der plastischen Chirurgie

Zusammenfassung

Das Wissen über die Qualität der Gewebsperfusion kann eine Prognose über den Erfolg einer Lappenplastik liefern und das intraoperative Erkennen von Durchblutungsstörungen bietet die Möglichkeit einer sofortigen chirurgischen Intervention. Die intraoperative Perfusionskontrolle mittels Indocyaningrün (ICG)-Fluoreszenzangiografie ermöglicht eine genaue topografische Analyse der Perfusion und bietet darüber hinaus die Möglichkeit der Untersuchung der Lymphabflusswege zur Sentinel-Markierung und ermöglicht eine Aussage zur Tiefenausdehnung von Verbrennungsverletzungen. Der Integration der Technik in das Operationsmikroskop ermöglicht zusätzlich die Visualisierung des Blutflusses über Mikroanastomosen und die Messung der zeitlichen Latenz zwischen arteriellem Ein- und venösem Ausstrom. Im Beobachtungszeitraum wurden 11 freie Lappenplastiken (3 M. latissimusdors, 3 M. rectus abdominis-, 1M. gracilis, 2 A. radialis-,1 ALT, 1 DIEP-Lappenplastik) untersucht. Die topografischen Analyse erfolgte im Anschluss an die Messung der Mikroanastomosen. Keine der untersuchten Lappenplastiken zeigte im postoperativen Verlauf Zeichen einer Lappennekrose. Die zeitliche Latenz zwischen arteriellem Ein- und venösen Ausstrom betrug im Schnitt 32,8 s. Hierbei zeigten sich deutliche Unterschiede zwischen reinen Muskel-Lappenplastiken (27,7 s), und faszio-kutanen Lappenplastiken (47,5 s). Bei einer der untersuchten Lappenplastiken stellte sich bei klinisch nicht eindeutigem Patency-Test der venösen Anastomose eine ICG-fluoreszenzangiografisch eindeutige Thrombose dar, die umgehend revidiert werden konnte. Die Methode der ICG-Fluoreszenzangiografie stellt insbesondere im intraoperativen Einsatz ein überaus nützliches, leicht zu handhabendes und sicheres Verfahren dar. Durch die Integration in ein Operationsmikroskop entsteht die Möglichkeit eines quantifizierbaren „fluoreszenzangiografischen Patency-Tests“. Die Analyse der Passagezeit ermöglicht eine neue Möglichkeit der Beurteilung der Durchblutungssituation innerhalb der Lappenplastik. Insbesondere bei der Planung von Perforans-Lappenplastiken ermöglicht die Technik durch das schnelle Erkennen von Perfusionsgrenzen eine hervorragende Planungssicherheit.

Abstract

The knowledge of tissue perfusion has not only a prognostic value in microvascular surgery but also the intraoperative detection of malperfusion can lead to a quick surgical intervention. Indocyanine green (ICG) angiography allows a topographic analysis of perfusion and is used to assess lymphatic drainage pathways and to analyse the depth of burn injuries. Integrating the technique into an operating microscope enables visualisation of the flow over microanastomoses and allows the assessment of the transit time of blood flow between arterial and venous anastomosis. Using this method we analysed 11 microsurgical free flaps (3 latissimus dorsi, 3 rectus abdominis, 1 gracilis muscle, 2 radial forearm, 1 ALT, and 1 DIEP flap). The topographic analysis was performed after the assessment of the microanastomoses. We observed no flap loss or partial flap necrosis. The transit time between arterial inflow and venous outflow was 32.8 s on average. Here we observed distinct differences between muscle flaps (27.7 s) on the one hand and fasciocutaneous and perforator flaps (47.5 s) on the other hand. We detected one venous thrombosis by ICG angiography in a case where the clinical patency test was not distinct. Revision was performed immediately. Particularly for intraoperative assessment, ICG angiography is a useful, reliable and safe technique. The integration into the operating microscope allows an “angiographic patency test” and the analysis of the transit time allows the evaluation of blood flow within the flap. Especially when planning perforator flaps the method of ICG angiography provides a new level of safety in flap design by quickly demonstrating the borders of perfusion.

Schlüsselwörter

Mikrozirkulation - Mikrochirurgie - freie Lappenplastiken - Indocyaningrün(ICG)-Angiografie

Key words

microcirculation - microsurgery - free flaps - indicycanine green (ICG) angiography - perfusion

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