Indocyanine green fluorescence-guided TAPP for recurrent inguinal hernia: a technical note with case series

Laparoscopic transabdominal preperitoneal (TAPP) repair for recurrent inguinal hernias carries a nonnegligible risk of injury to the corona mortis, spermatic vessels, and inguinal nerves because of adhesions and distorted anatomy. Indocyanine green (ICG) fluorescence imaging enables real-time visualization of vascular structures, but no standardized application protocol exists for this specific setting. We describe our technique and early experience with ICG guided TAPP in recurrent hernia patients.

We retrospectively analyzed 14 patients with recurrent inguinal hernia who underwent ICG fluorescenceguided TAPP between January 2023 and June 2025. All procedures were performed by a single surgeon using a 4 K fluorescence laparoscopy system. Indocyanine green (2.5 mg per dose) was administered intravenously at key steps-typically after peritoneal opening, during sac mobilization, and before mesh fixation-based on the surgeon's assessment of anatomical clarity. Fluorescence imaging was used to identify the inferior epigastric vessels, corona mortis, spermatic vessels, peri-vas deferens venous plexus, and nerve-adjacent vessels. Mean operative time was 55.9 ± 6.1 min. Mean blood loss was 7.2 ± 2.6 mL. The corona mortis was visualized in 13 of 14 cases (92.9%). No vascular injuries or chronic pain were observed during 6 month follow up. Two minor complications occurred (one seroma, one foreign body sensation).

ICG fluorescence reliably identified key structures in all cases, with consistent visualization occurring 40-60s after injection. The technique was particularly valuable for delineating the corona mortis and the vascular bundles accompanying the iliohypogastric and ilioinguinal nerves, providing real-time visualization of these structures during dissection and mesh fixation. The learning curve for incorporating ICG into the standard TAPP workflow was minimal, and no ICGrelated adverse events occurred.

ICG fluorescence is a safe and feasible adjunct in recurrent inguinal hernia TAPP. It provides real-time anatomical guidance that may assist in identifying these structures during dissection and mesh fixation. We propose a reproducible injection sequence that can be incorporated into the existing TAPP steps as a practical reference. Larger studies with longer follow-up are needed to confirm long-term outcomes.