This video demonstrates Total Laparoscopic Hysterectomy with infrared fluorescence imaging of Ureter and Uterine artery with ICG at World Laparoscopy Hospital by Dr. R.K. Mishra. Injecting indocyanine green (ICG) enables the operators to identify the ureter and the uterine artery to perform a safe laparoscopic hysterectomy. A cyanine vital dye indocyanine green (ICG) is a safe NIR fluorophore emitting 800~840 nm of light and has been used in numerous surgical procedures. It also allows them to decide on the extent of the dissection and validate the completeness of the dissection. In this video, a laparoscopic near-infrared fluorescent camera was used, showing the fluorescent signal in diverse modes. According to the increasing needs and interest in precision surgery, which is characterized by individual tailored surgical strategies, image-guided surgery is receiving increased attention as the most intuitive and strong methodology to implement precision surgery

Total Laparoscopic Hysterectomy with Bilateral Salpingo-Oophorectomy (TLH + BSO) has become the gold standard for the management of many benign and malignant gynecological conditions. Advancements in imaging technology have further enhanced the safety and precision of this minimally invasive procedure. One such advancement is fluorescence imaging, which allows real-time visualization of critical structures such as the ureter and uterine artery, significantly reducing the risk of iatrogenic injury.

Indications for TLH + BSO

TLH with BSO is commonly indicated in:

Symptomatic uterine fibroids

Endometriosis

Adenomyosis

Ovarian tumors (benign or selected malignant cases)

Prophylactic surgery in high-risk patients (e.g., BRCA mutation carriers)

Chronic pelvic pain unresponsive to conservative treatment

Role of Fluorescence Imaging

Fluorescence imaging involves the intravenous administration of Indocyanine Green (ICG) dye, which emits near-infrared light when illuminated. This technology enables surgeons to visualize vascular and urinary structures clearly during laparoscopy.

Advantages of Fluorescence Imaging:

Real-time identification of ureters

Clear delineation of uterine arteries and their branches

Enhanced depth perception of pelvic anatomy

Reduced risk of ureteric and vascular injury

Improved surgical confidence and operative safety

Preoperative Preparation

Detailed clinical evaluation and imaging (USG/MRI)

Informed consent explaining fluorescence imaging and dye use

Assessment for iodine or ICG allergy

Prophylactic antibiotics and thromboprophylaxis

Placement of urinary catheter

Surgical Technique
1. Patient Positioning and Port Placement

The patient is placed in the lithotomy position with steep Trendelenburg. Standard laparoscopic ports are inserted, including a camera port and working ports under direct visualization.

2. Fluorescence Mapping of Ureters

After intravenous injection of ICG, near-infrared fluorescence mode is activated. The ureters become visible bilaterally, allowing precise identification and safe dissection, especially in cases with distorted pelvic anatomy.

3. Identification of Uterine Artery

Fluorescence imaging highlights the uterine artery at its origin from the internal iliac artery, aiding early and controlled vascular ligation. This step minimizes blood loss and ensures ureteric safety.

4. Total Laparoscopic Hysterectomy

Coagulation and transection of the round ligaments

Opening of the broad ligament

Safe skeletonization and division of uterine vessels under fluorescence guidance

Bladder dissection and colpotomy

Removal of uterus through the vaginal route or morcellation if indicated

5. Bilateral Salpingo-Oophorectomy

The infundibulopelvic ligaments are identified and divided with continuous visualization of the ureter using fluorescence imaging, ensuring safe adnexal removal.

6. Vault Closure

The vaginal vault is sutured laparoscopically with delayed absorbable sutures, ensuring hemostasis.

Postoperative Care

Early ambulation

Pain control with minimal analgesics

Monitoring of urine output

Early oral intake

Discharge usually within 24–48 hours

Outcomes and Benefits

Significantly reduced intraoperative blood loss

Lower incidence of ureteric injury

Shorter operative time in complex cases

Faster recovery and minimal postoperative pain

Improved surgical precision and patient safety

Limitations

Additional cost of fluorescence imaging equipment

Learning curve for optimal interpretation

Rare allergic reaction to ICG

Conclusion

TLH + BSO using fluorescence imaging of the ureter and uterine artery represents a significant advancement in minimally invasive gynecologic surgery. By providing real-time anatomical visualization, this technique enhances surgical safety, reduces complications, and improves patient outcomes. Fluorescence-guided laparoscopy is particularly valuable in complex cases with altered pelvic anatomy and is fast becoming an essential tool in modern gynecological practice.