This video demonstrates Total Laparoscopic Hysterectomy and Bilateral Salpingectomy with Ureteric Mapping using ICG. Indocyanine green (ICG) represents a feasible alternative to the more traditional methods of ureteric mapping during Total Laparoscopic Hysterectomy, and interest in this promising tracer is growing. This video outlines our experience with ICG in a minimally invasive laparoscopic approach in women with DUB using the STRYKER ICG near-infrared fluorescence imaging technology. All patients had undergone simple or laparoscopic hysterectomy with ureteric mapping by means of an intraurethral injection of ICG dye with locations of ureter after the induction of general anesthesia. The detection rate of ICG in ureter was 100 %. All procedures were successfully completed without conversion to open laparotomy, and no intraoperative or postoperative complications occurred. In our preliminary experience, ICG showed a high overall detection rate, and bilateral mapping appears to be a feasible alternative to the more traditional methods of ureteric mapping with a positive impact on patient management.

Total Laparoscopic Hysterectomy (TLH) is a minimally invasive surgical procedure for the removal of the uterus. When combined with bilateral salpingectomy, it involves removing both fallopian tubes, which may be indicated for reducing the risk of ovarian cancer or managing gynecological conditions. In complex cases, especially where pelvic anatomy is distorted by disease or prior surgeries, ureteric injury is a significant risk. To enhance safety, Ureteric Mapping using Indocyanine Green (ICG) has emerged as a valuable technique.

Indications

TLH with bilateral salpingectomy is indicated in patients with:

Uterine fibroids causing symptoms such as heavy bleeding or pain

Adenomyosis

Premalignant or early malignant uterine conditions

Risk reduction for ovarian or tubal cancer in high-risk patients

Pelvic inflammatory disease or recurrent infections affecting fallopian tubes

Ureteric mapping with ICG is particularly useful in:

Patients with dense adhesions from previous surgeries

Endometriosis involving the ureters

Large fibroids or distorted pelvic anatomy

Cases where the ureter course is unclear intraoperatively

Preoperative Preparation

Imaging: Pelvic ultrasound or MRI to assess uterine size, adnexal structures, and pelvic adhesions

ICG Preparation: ICG dye is prepared according to the recommended concentration. It is either injected intravenously for systemic mapping or retrograde into ureters using catheters for direct visualization.

Patient Counseling: Risks, benefits, and alternatives of laparoscopic hysterectomy, bilateral salpingectomy, and ICG mapping are explained.

Surgical Technique
1. Patient Positioning and Port Placement

Patient is placed in the lithotomy position with Trendelenburg tilt.

Pneumoperitoneum is established, and 4–5 laparoscopic ports are inserted.

2. Exploration and Adhesiolysis

Abdominal cavity is inspected.

Adhesions are carefully dissected to mobilize the uterus and adnexa.

3. Ureteric Mapping Using ICG

ICG dye is administered.

A near-infrared (NIR) laparoscope is used to visualize the ureters.

The ureters are traced along their course to avoid injury during dissection.

4. Hysterectomy and Salpingectomy

Round ligaments and uterine vessels are identified and coagulated or ligated.

Bilateral salpingectomy is performed by dissecting and removing both fallopian tubes.

The uterus is separated from the cervix and removed vaginally or via morcellation.

5. Hemostasis and Closure

All vascular pedicles are checked for bleeding.

The pelvic cavity is irrigated, and ports are removed.

Skin incisions are closed with sutures or adhesive strips.

Advantages

Minimally invasive: Reduced pain, shorter hospital stay, and faster recovery

Enhanced safety: Ureteric mapping with ICG significantly reduces ureteral injury

Precision: Better visualization of pelvic structures and pathology

Prophylactic benefit: Bilateral salpingectomy reduces ovarian cancer risk

Postoperative Care

Early ambulation is encouraged.

Pain is managed with analgesics.

Patients are monitored for urinary function and potential complications.

Follow-up includes wound check and imaging if necessary.

Conclusion

Total Laparoscopic Hysterectomy with Bilateral Salpingectomy and Ureteric Mapping using ICG represents a modern, safe, and effective approach to managing various gynecological conditions. By combining minimally invasive techniques with advanced ureter visualization, surgeons can reduce complications and ensure better patient outcomes.