Value of Indocyanine Green Angiography to Guide Wound Management and Prevent Necrosis in a Robotic Surgical Procedure

Background: Inguinal lymph node dissection is performed in penile cancers and has a high complication rate with mostly wound-related complications. This case study demonstrates the use of robotic technique, tissue perfusion assessment, and negative pressure wound dressing to minimize wound-related complications. Case Presentation: A 67-year-old Maltese man was diagnosed with squamous cell carcinoma (SCC) in situ on biopsy of a self-detected penile lump. The patient underwent a partial penectomy and histopathology report confirmed moderately differentiated SCC with clear surgical margins. A positron emission tomography/CT scan was performed preoperatively, which showed several nodes in the right inguinal region with increased metabolic activity and nonspecific findings in the left inguinal region. The patient had a robotic right inguinal node dissection the following month. Assessment of the skin flap was performed using indocyanine green (ICG) angiography with the SPY system and there was excellent vascularity. Further treatment was performed 3 months later with a robotic left inguinal node dissection. Again, assessment of the skin flap was performed using the SPY system but showed an area of poor perfusion in the left femoral triangle, which suggested a high risk of inadequate wound healing and tissue necrosis. The clinical decision to use the negative pressure PICO dressing was made intraoperatively to enhance perfusion of the skin. When the PICO dressing was removed it revealed excellent tissue viability and vascularity of the skin flap. Histopathology analysis showed no evidence of malignancy in the nodes removed and patient was discharged to the outpatient care of their urologist. Conclusion: This case study demonstrates that the use of a tissue perfusion assessment tool avoided a potentially poor clinical outcome for the patient. Robotic inguinal lymph node dissection was performed in coordination with ICG angiography to guide the use of negative pressure wound therapy and facilitate good wound healing.