Fluorescence-guided nerve-sparing surgery for deep endometriosis using indocyanine green

BACKGROUND: Although the benefit of nerve-sparing surgery for deep endometriosis (DE) with postoperative voiding dysfunction has been demonstrated, it requires a high level of surgical skill to accurately remove endometriosis lesions while preserving autonomic nerves in situations of severe adhesions and fibrosis and has been performed only by expert surgeons. However, endometriosis is a common disease, and methods for intraoperative identification of endometriosis lesions, ureters, vessels, and nerves using near-infrared imaging with indocyanine green (ICG) have been explored to enable more surgeons to safely offer such procedures to their patients. OBJECTIVES: To demonstrate the step-by-step technique of single-port robotic nerve-sparing DE surgery with ICG navigation. PARTICIPANT: The patient was a 48-year-old woman with chronic pelvic pain. Magnetic resonance imaging revealed uterine adenomyosis and a right ovarian endometrioma with DE involving the uterosacral ligament and surface of the rectum. INTERVENTION: An intravenous injection of 0.25 mg/kg body weight of ICG for intraoperative near-infrared fluorescence (NIR) imaging with the da Vinci Single-Port. CONCLUSIONS: The use of ICG with NIR during nerve-sparing DE surgery may improve the surgeon's decision-making process. ICG may be useful in highlighting pelvic autonomic nerves, identifying DE lesions, checking for pelvic organ injury, and assessing tissue perfusion and haemostasis. However, further research is needed to confirm the possible role of ICG in this setting. WHAT IS NEW?: This video illustrates the potential of ICG fluorescence to enhance intraoperative visualisation of autonomic nerves and DE lesions, offering educational insights into safer and more widely accessible advanced surgical techniques.