Intraoperative endometrial visualization using intracavitary indocyanine green during laparoscopic myomectomy

Endometrial injury during laparoscopic myomectomy adversely affects reproductive outcomes through postoperative intrauterine adhesions and is associated with placenta accreta spectrum disorders[1,2]. However, the real-time intraoperative identification of the endometrial boundary remains technically challenging, particularly for cavity-adjacent fibroids. The aim of this study was to demonstrate a novel fluorescence-guided technique for intraoperative endometrial boundary visualization using intracavitary indocyanine green during laparoscopic myomectomy.

A tertiary referral center for gynecologic minimally invasive surgery in Japan.

Two women (age: 40 and 35 years) with cavity-adjacent fibroids underwent laparoscopic myomectomy using this technique. Preoperative magnetic resonance imaging of both patients revealed FIGO type 3 fibroids (17×18 mm, 16×10 mm) and a FIGO type 2 fibroid (47×47 mm), respectively. Both patients underwent infertility treatment and desired fertility preservation. They had no infertility factors other than uterine fibroids.

After the induction of general anesthesia, an intrauterine catheter was inserted transcervically into the uterine cavity, and 3 mL of diluted indocyanine green solution (0.02 mg/mL) was injected. Laparoscopic myomectomy was performed using a near-infrared fluorescence imaging system. In both cases, the endometrial boundary was clearly visualized using near-infrared fluorescence imaging, facilitating the recognition of the appropriate dissection plane and avoidance of inadvertent endometrial injury. This technique provided intuitive, real-time visual navigation during myometrial dissection adjacent to the uterine cavity. The procedure was successfully completed without endometrial injury, perioperative complications, or indocyanine green-related adverse events. No hemostatic adjuncts were used in either case.

Intracavitary indocyanine green injection may provide a simple and useful navigation technique for endometrial boundary visualization during laparoscopic myomectomy of cavity-adjacent fibroids. To our knowledge, this is the first report describing intraoperative endometrial visualization using intracavitary indocyanine green injection during laparoscopic myomectomy[3-5]. Methylene blue represents an alternative for cavity delineation, although comparative data with intracavitary ICG are lacking.