Application of Intraluminal Indocyanine Green in Advanced Endometriosis Surgery

OBJECTIVE: To demonstrate the step-by-step application of intraluminal indocyanine green (ICG) in endometriosis and adenomyosis surgery, including mucosa-sparing shaving of deep bladder and rectal nodules and excision of superficial tubal endometriosis. DESIGN: Description of surgical technique with narrated video footage. SUBJECTS: First case: A 36-year-old patient with chronic pelvic pain, urinary frequency, and dysuria. Preoperative MRI revealed a bladder endometriosis nodule measuring 1.7 × 1.5 cm. The patient underwent robotic-assisted excision of endometriosis with total hysterectomy. SECOND CASE: A 34-year-old patient with chronic pelvic pain and dyschezia. Preoperative MRI revealed a rectal endometriosis nodule measuring 2.7 × 1.8 cm, located 8 cm from the anal verge. The patient underwent robotic-assisted excision of endometriosis with total hysterectomy. Additional applications of intraluminal ICG highlighted in the video include superficial tubal endometriosis and intrauterine ICG use during adenomyosis excision. EXPOSURE: In the first case, cystoscopy was performed to exclude bladder mucosal involvement. The bladder was backfilled with diluted ICG, and mucosa-sparing shaving of the bladder nodule was performed under fluorescence guidance. In the second case, ICG was administered transrectally, and the rectal nodule was shaved using monopolar energy under fluorescence guidance. In the third case, ICG was used for real-time identification of the tubal lumen during excision of tubal endometriosis. In the fourth case, intrauterine ICG was used to guide the depth of excision during adenomyosis resection. MAIN OUTCOME MEASURES: Demonstration of robotic-assisted excision of endometriosis and adenomyosis using intraluminal ICG guidance. RESULTS: All procedures were completed without intraoperative or postoperative complications, and patients were discharged on the same day of surgery. Bladder mucosal integrity was preserved, allowing avoidance of prolonged catheterization. A voiding trial was successfully completed prior to discharge. At 6-week follow-up, patients reported no complaints. CONCLUSION: Intravenous ICG is well established for assessing bowel perfusion and anastomotic viability [1]. Its use for ureteral perfusion has been described in limited reports, while pelvic nerve visualization has only been reported in isolated case reports [2,3]. Intraluminal injection of ICG into the ureters is commonly used to aid ureteral identification [4]. In this video, we highlight intraluminal ICG as a valuable adjunct in advanced endometriosis and adenomyosis surgery. When combined with the advantages of robotic surgery, it enables precise, mucosa-sparing excision of deep endometriotic lesions and may reduce surgical morbidity.