Real-time near-infrared fluorescence-guided identification of the hypogastric nerve during robot-assisted nerve-sparing surgery for deep endometriosis

Kiyoshi Kanno, Higuchi N, Naofumi Higuchi, T Kashiwabara, Tomoka Kashiwabara, Kashiwabara T, Iwata T, Taisuke Iwata, Akito Endo, Endo A, 雄大 澤井, Sawai Y, Yudai Sawai, Yamada S, Shinji Yamada, Masuda S, Sayaka Masuda, Hiroshi Onji, Onji H, Ochi Y, Yoshifumi Ochi, Kurose Y, Yoshiko Kurose, Mari Sawada, Sawada M, Tsutomu Hoshiba, Hoshiba T, Masaaki Andou, Andou M
Journal of robotic surgery · 2026 · vol. 20(1) · doi:10.1007/s11701-026-03656-3 · PMID:42474902 · W7169758297
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Intraoperative near-infrared indocyanine green fluorescence imaging successfully identified the hypogastric nerve in 92.7% of patients undergoing robot-assisted deep endometriosis surgery, proving a safe and effective adjunctive technique.

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Abstract

Identification and preservation of pelvic autonomic nerves is essential for preventing postoperative functional disorders during surgery for deep endometriosis (DE); however, nerve-sparing surgery in patients with severe fibrosis and cul-de-sac obliteration remains technically demanding. Herein, we describe a surgical technique and perioperative outcomes of fluorescence-guided intraoperative identification of the hypogastric nerve using indocyanine green (ICG) during robot-assisted nerve-sparing hysterectomy (NSH) for DE. This retrospective cohort study included 41 consecutive patients who underwent robot-assisted NSH for DE between November 2020 and December 2025. A low-dose intravenous bolus of ICG (0.25 mg/kg) was administered intraoperatively, and near-infrared fluorescence imaging was used to facilitate intraoperative identification of the hypogastric nerve. Fluorescence onset was retrospectively assessed via surgical video review. The hypogastric nerve was successfully identified in 38 of 41 cases, yielding an overall identification rate of 92.7% (95% CI, 80.6-97.5%). The median time from ICG injection to fluorescence onset was 25 s (range, 12-42 s). No ICG-related adverse events or major perioperative complications occurred. In the three unsuccessful cases, nerve-sparing surgery was completed under conventional white-light visualization without conversion or additional complications. Real-time near-infrared ICG fluorescence imaging is a simple and minimally invasive adjunctive technique that facilitates fluorescence-guided intraoperative identification of the hypogastric nerve during robot-assisted nerve-sparing pelvic surgery. This approach may improve the reproducibility of anatomical nerve-sparing dissection and facilitate safer anatomical navigation during complex pelvic surgery. Larger prospective studies are warranted to validate these preliminary findings.

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MeSH descriptors

Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis

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SciLite annotations

chemicals 1
indocyanine green

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