Indocyanine Green Fluorescent Lymphography for Preservation of Spermatic Cord Lymphatic Vessels during Robotic Inguinal Hernia Repair with No Postoperative Symptomatic Seroma: A Case Report.

INTRODUCTION: Postoperative seroma is a relatively common complication of laparoscopic inguinal hernia repair, particularly in patients with large inguinoscrotal hernias. Recently, indocyanine green (ICG) fluorescent lymphography has enabled the visualization of lymphatic vessels within the spermatic cord, and intraoperative lymphatic injury has been suggested as a cause of postoperative clinically significant or symptomatic seroma. However, few studies have demonstrated the clinical significance of lymphatic preservation. CASE PRESENTATION: A 52-year-old man presented with right inguinal swelling. CT revealed a right indirect inguinal hernia with the small bowel extending into the scrotum. A robotic transabdominal preperitoneal repair was performed. After induction of general anesthesia, 1 mL of ICG (0.25 mg/mL) was injected into the right testicle, and lymphatic vessels were visualized using the Firefly mode of the da Vinci surgical system. Two lymphatic vessels were clearly identified and carefully preserved during precise dissection. The postoperative course was uneventful, and the patient remained asymptomatic. CT on POD 10 revealed a small amount of serous fluid accumulation. On POD 24, ultrasonography showed that this serous fluid collection had resolved. CONCLUSIONS: ICG fluorescent lymphography enabled intraoperative visualization and preservation of spermatic cord lymphatic vessels during RTAPP. Although a small asymptomatic fluid collection was observed, no clinically significant seroma developed. Further studies are required to determine whether lymphatic preservation reduces postoperative symptomatic seroma.