Indocyanine green in intestinal endometriosis surgery: a multicenter evaluation of anastomotic safety
Renato Barretto1, Marina Martinelli Sonnenfeld2, Rogers Camargo Mariano da Silva2
1Division of Gynecologic Endoscopy and Endometriosis, Department of Gynecology, Centro Universitário Faculdade de Medicina do ABC, Avenida Lauro Gomes, 2000, Santo André, 09060- 870, SP, Brazil. renatobarrettofsilva@gmail.com.
Objective:
To evaluate whether the use of intraoperative indocyanine green (ICG) fluorescence impacts anastomotic safety and surgical outcomes in patients undergoing bowel endometriosis resection.
Methods:
Retrospective, multicenter observational study conducted in tertiary referral hospitals in the state of São Paulo, Brazil. A total of 1,090 patients who underwent surgery for bowel endometriosis between 2021 and 2025 were included, of whom 301 received ICG fluorescence assessment and 789 did not.
Interventions:
Surgical management of bowel endometriosis using shaving, discoid nodulectomy, or segmental resection, performed via laparoscopy or robotic surgery. Intraoperative fluorescence was used as an adjunct for bowel perfusion assessment during surgery.
Results:
Clinical variables, surgical technique, specimen extraction route, complications (classified by Clavien-Dindo), and length of hospital stay were analyzed. Patients in the ICG group underwent more complex procedures, with higher rates of segmental resection (53.2% vs. 17.3%; p < 0.001) and natural orifice specimen extraction (53.4% vs. 36.9%; p = 0.004). Overall postoperative morbidity, including anastomotic fistula (1.0% vs. 0.8%; p = 0.703) and reoperation (2.0% vs. 1.0%; p = 0.201), was similar between groups. After adjustment for surgical technique, ICG use was not independently associated with prolonged hospitalization.
Conclusion:
The application of indocyanine green fluorescence in bowel endometriosis surgery was safe and did not increase postoperative morbidity. Its use was concentrated in technically demanding cases, supporting its role as an adjunct for intraoperative perfusion assessment rather than a determinant of surgical outcomes.
