Clinical Use of Indocyanine Green in Bowel Endometriosis Surgery

Abstract

To show feasibility of using indocyanine green (ICG) in endometriosis surgery, especially bowel endometriosis shaving, and to discuss its potential benefits. Design: Stepwise demonstration of this technique with narrated video footage. Setting: Endometriosis is a common benign chronic disorder, characterized by the presence of endometrial tissue outside the uterus. Deep infiltrating endometriosis (DIE) represents the most aggressive presentation. Robot-assisted laparoscopy represents an important innovation and has opened new perspectives for the treatment of endometriosis, offering numerous advantages especially in the most complex procedures, particularly when extragenital endometriosis diffusely involves pelvic structures including the bowel and the urinary tract [1]. Endometriosis affects the bowel in 30% of DIE cases, and it is usually associated with ovarian and ureteral involvement; therefore, a multidisciplinary team with both general and gynecologic surgeons is required. The goal of endometriosis surgery in these cases is to obtain long-term outcomes without compromising intestinal function. One possible treatment is laparoscopic shave excision, which consists of dissection, keeping it as superficial as possible to avoid compromising bowel integrity [2]. Recent studies have shown that ICG can be useful to evaluate the size and depth of penetration of lesions during endometriosis surgery to understand shaving excision and to prevent a major iatrogenic intestinal complication [3−7]. Interventions: Total robot-assisted laparoscopic approach to a DIE case with adnexal, uterine, and intestinal endometriosis, with the presence of a nodular rectal lesion. The excision consisted of several key strategies to minimize iatrogenic rectal injury: Adhesiolysis with adnexal and uterus liberation and pelvic visualization; Endometriosis mapping with an evaluation of adnexal masses, uterus, vesical-uterine septum, pouch of Douglas, sigmoid-rectal wall, and ureters; Endovenous injection of ICG (25 mg of ICG diluted in 10 mL of soluble water and a bolus of 0.25 mg/kg), with visualization of rectal wall vascularization and evaluation of the degree of bowel involvement by endometriosis; Lesion shaving, as superficial as possible, with subsequent reinforcement suture of the rectal serosa. Conclusion: The approach to DIE, particularly rectal endometriotic lesions, could be more accurate with ICG evaluation of vascular pertinence, in attempt to evaluate shaving feasibility of lesions in endometriosis laparoscopic robotic surgery.

New technologies in the surgical management of endometriosis

“…In case of bowel involvement, ICG could be used to evaluate shaving feasibility and to better define the limits between nodule and healthy tissue (Fig. 3) (42).…”

Research progress of indocyanine green fluorescence technology in gynecological applications

“…At the same time, NIR-ICG helps patients who could not avoid intestinal resection observe whether the blood supply of intestinal suture and anastomose was sufficient. 38,40,41 A prospective study on 30 rectosigmoid endometriosis patients used ICG for the intraoperative vascular evaluation. 39 In this study, 40% of women presented a hypervascular pattern, while 60% presented a hypovascular pattern, and the latter seemed to be associated with a larger lesion nodule size and lower vascular density.…”

“…Evaluating vascular correlation via ICG helps to demarcate lesions and normal tissues, which can increase the safety of the lesion removal. At the same time, NIR‐ICG helps patients who could not avoid intestinal resection observe whether the blood supply of intestinal suture and anastomose was sufficient 38,40,41 . A prospective study on 30 rectosigmoid endometriosis patients used ICG for the intraoperative vascular evaluation 39 .…”

Robot-Assisted Surgery in Gynecology

“…Endometrial tissue outside the uterus is a frequent benign chronic condition referred to as endometriosis. The most severe manifestation of endometriosis is DIE presentation [ 18 ]. A major development that has opened up new possibilities for treating endometriosis, particularly DIE, is the development of robot-assisted laparoscopy (RAL).…”