LAUSR

Video Objective To demonstrate a laparoscopic surgical technique to enhance identification of peritoneal endometriosis for effective operative excision. Setting Academic Medical Center. Interventions Introduction of indocyanine green (ICG) contrast with fluorescence imaging for laparoscopic identification of apparent and occult endometriosis. Endometriosis is a common medical condition of reproductive age women impacting up to 90% of women with pelvic pain. Laparoscopic excision is effective in pain reduction and considered the gold standard for histologic diagnosis. Conversely, incomplete resection has been associated with persistent pain and recurrent disease. Endometriosis is implantation of endometrial tissue outside of the uterus and may be challenging to identify laparoscopically secondary to its variable appearance. Lesions of peritoneal endometriosis include red flame like lesions, puckered black or bluish lesions, and subtle white opacified lesions. Evidence supports that angiogenesis is required for development and persistence of endometriosis. Additionally, studies have found no difference in vascular density between the various types of lesions. ICG is a nontoxic, nonionizing contrast agent that binds to blood lipoproteins. It was FDA approved in 1959 as a contrast agent and has been used clinically to measure cardiac output, liver function and study retinal vessels. Fluorescence imaging with ICG has been used in surgical oncology including sentinel lymph node mapping in gynecologic patients with endometrial cancer. More recently, fluorescence imaging with ICG laparoscopically, has been demonstrated to correlate with visible areas of endometriosis as well as identify occult endometriosis in >15% of women with visible endometriosis. More effective identification and excision of endometriosis with ICG enhanced laparoscopy, specifically occult disease, is proposed to significantly decrease postoperative pain and recurrence of endometriosis. Conclusion We demonstrate an effective laparoscopic surgical technique to employ the use of fluorescence imaging with ICG contrast to identify apparent and occult endometriosis to optimize surgical excision.