Intraoperative endometrial visualization using intracavitary indocyanine green during laparoscopic myomectomy.

OBJECTIVE: 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. SETTING: A tertiary referral center for gynecologic minimally invasive surgery in Japan. PARTICIPANTS: 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. INTERVENTIONS: 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. CONCLUSION: 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.