The advancement of fluorescence-guided surgery is adding a new dimension to minimally invasive gynecology. In Total Laparoscopic Hysterectomy (TLH), where critical structures such as the ureters, uterine vessels, bladder, and pelvic sidewall may lie within a narrow operative field, Indocyanine Green (ICG) near-infrared fluorescence imaging can provide additional real-time visual information to support anatomical orientation and surgical precision.

This educational lecture focuses on how ICG can be incorporated into TLH with particular attention to ureteral mapping, vascular identification, tissue perfusion, and safety during pelvic dissection. World Laparoscopy Hospital's published surgical demonstrations describe ICG-guided TLH and bilateral salpingectomy with fluorescence-based ureter identification as an advanced image-guided approach.

The ureter is one of the most important structures to identify during hysterectomy. It travels through the pelvis in close relationship to the uterine vessels and cervix before entering the bladder. Because of this anatomical relationship, procedures involving uterine vessels, cardinal and uterosacral regions, parametrial tissues, or extensive pelvic adhesions require careful attention to the ureteral course.

The challenge becomes greater when normal anatomy is distorted. Deep endometriosis, previous pelvic surgery, severe adhesions, large masses, advanced uterine pathology, and oncological procedures can make conventional identification more difficult. In these situations, fluorescence-guided imaging may provide an additional visual reference that helps the surgeon maintain awareness of the ureter during dissection.

ICG is a fluorescent dye that can be visualized using a near-infrared imaging system. Depending on the clinical application, different administration techniques can be used. When used for direct ureteral mapping, ICG may be introduced into the urinary tract using an appropriate catheter-based technique, allowing the ureters to become visible under fluorescence imaging. Published WLH demonstrations describe intraureteral administration and visualization of the ureter during laparoscopic hysterectomy.

One of the strengths of this technology is that it provides dynamic intraoperative information. Rather than relying exclusively on static anatomical landmarks, the surgeon can switch between conventional white-light visualization and fluorescence imaging to obtain additional information during critical portions of the operation.

The technique can be incorporated into the normal sequence of TLH. After laparoscopic access and pelvic inspection, the surgeon performs systematic dissection while maintaining awareness of the ureter and other critical structures. Fluorescence can then be used at appropriate stages to confirm the ureteral course before proceeding with difficult dissection or energy application.

The concept of a critical view of safety is especially important in minimally invasive hysterectomy. A recent international Delphi consensus identified specific safety checkpoints for parametrial transection, including adequate bladder mobilization, confirmation of important vascular anatomy, and maintaining a safe distance from the ureter when using energy devices.

ICG therefore fits naturally into a broader framework of surgical safety. It does not eliminate the need for dissection or anatomical identification. Instead, it can provide an additional layer of visualization that may be particularly useful when the surgeon encounters difficult or distorted anatomy.

Another area of interest is uterine vascular anatomy. WLH's published TLH videos demonstrate fluorescence imaging of both the ureter and uterine artery. Visualizing these structures can help the surgeon understand the relationship between vascular anatomy and the ureter during the steps involving uterine vessel management.

ICG can also be used to evaluate tissue perfusion. Near-infrared fluorescence can demonstrate patterns of blood flow and perfusion that may not be apparent under standard white-light imaging. In selected procedures, this information may help surgeons assess tissue viability and understand the vascular consequences of dissection.

This becomes particularly relevant during complex hysterectomy, where extensive dissection may alter local blood supply. Research has explored ICG-based assessment of ureteral vascularity during extended hysterectomy, with encouraging findings in one cohort study. However, further research is necessary before the technology can be considered definitive for preventing ureteral complications.

The growing evidence regarding ICG-guided ureteral identification is encouraging but should be interpreted carefully. A systematic review published in 2026 found successful ureter visualization across seven eligible studies involving 299 patients and no reported ICG-related complications or ureteral injuries in those studies. Nevertheless, the authors concluded that the evidence remains limited and called for prospective studies with standardized outcomes.

This distinction is important for surgical education. Fluorescence imaging improves information, but it does not replace surgical skill. Surgeons still need a thorough understanding of pelvic anatomy and must be capable of identifying and protecting the ureter using conventional laparoscopic principles.

The lecture also highlights the importance of energy safety. The presence of a fluorescent ureter does not make the structure immune to injury. Thermal spread from an energy device can extend beyond the visible point of contact, and excessive traction or dissection can also compromise the ureter. Controlled energy application, adequate visualization, appropriate tissue planes, and careful handling remain fundamental.

For patients with complex pelvic anatomy, the integration of ICG with conventional laparoscopy can create a multimodal visualization strategy. White-light imaging provides the overall operative view, while near-infrared fluorescence adds information about selected structures or perfusion. The surgeon can move between these imaging modes according to the operative requirement.

The approach is particularly relevant for advanced gynecologic laparoscopy and precision surgery. As minimally invasive surgery continues to evolve, technologies that provide additional anatomical or functional information are increasingly being incorporated into surgical workflows. ICG represents one example of this transition from purely anatomical visualization toward image-guided surgery.

The educational significance of ICG-guided TLH extends beyond hysterectomy itself. The principles of fluorescence imaging can also be relevant to other gynecological procedures involving ureteral dissection, endometriosis surgery, pelvic sidewall surgery, oncological procedures, and complex reconstructive operations.

For surgeons and trainees, the key lesson is that technology should be integrated into a systematic surgical strategy. Before beginning a difficult dissection, the surgeon should understand the anatomy, anticipate potential hazards, identify critical structures, select appropriate instruments, and establish a safe operative sequence. ICG can then serve as an additional tool within that framework.

The future of image-guided gynecologic surgery may include increasingly sophisticated fluorescence systems, improved imaging resolution, quantitative perfusion assessment, and integration with robotic and digital surgical platforms. These developments may expand the applications of fluorescence imaging, although clinical validation and appropriate training will remain essential.

This lecture on Safety in Total Laparoscopic Hysterectomy with ICG Fluorescence Imaging therefore provides a valuable educational perspective on the intersection of advanced imaging and surgical anatomy. It demonstrates how real-time fluorescence can complement conventional laparoscopy, particularly when ureteral identification, vascular anatomy, or tissue perfusion presents a challenge.

Ultimately, the safest approach is not simply to add more technology, but to use technology intelligently. ICG fluorescence, combined with detailed anatomical knowledge, careful dissection, controlled energy application, and disciplined surgical technique, can become a valuable component of precision-oriented laparoscopic gynecologic surgery.