When in Doubt, Green It Out: Use of ICG in the Hysteroscopic-Assisted Robotic Excision of an Isthmocele in a Patient With Asherman's Syndrome

Study Objective

To demonstrate the utility of indocyanine green (ICG) as an intraoperative aid in the hysteroscopic-assisted robotic repair of isthmocele in a patient with Asherman's syndrome.

Design

Video case review.

Setting

Procedure was performed by a MIGS fellowship-trained surgeon at a community-based hospital.

Patients or Participants

A 43-year-old G7P5032 referral from OBGYN with history of prior endometrial ablation diagnosed with an isthmocele on TVUS in the setting of cyclic postmenstrual bleeding.

Interventions

Use of ICG during a hysteroscopic-assisted robotic repair of an isthmocele.

Measurements and Main Results

ICG was utilized to enhance visualization of the isthmocele when hysteroscopic transillumination and visual palpatory cues are difficult to appreciate due to abnormal uterine anatomy such as Asherman's Syndrome. Two months follow up saline-infused sonography demonstrated significant improvement in residual myometrial thickness (RMT) and lack of fluid collection at site of previously noted isthmocele defect. Patient's post operative course was uncomplicated with complete resolution of symptoms.

Conclusion

ICG is a valuable tool for identifying an isthmocele defect in complex surgical cases where scarring and adhesions obscure normal uterine anatomy and landmarks. Use of ICG is safe and can improve surgical accuracy and outcomes in the management of an isthmocele, particularly in patients with prior uterine surgeries and altered anatomical structures. This technique warrants further investigation in larger prospective studies to assess its impact in patient outcomes.