Indocyanine green (ICG) imaging: case report of innovative isthmocele diagnosis and repair in a post-ablation patient and literature review

• Published in: Archives of gynecology and obstetrics Vol. 312; no. 3; pp. 997 - 1001
• Main Authors: Tam, Teresa, Mabini, Christopher, Fernandez, Carlos M., Levine, Elliot M.
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01.09.2025; Springer Nature B.V
• Subjects: Ablation; Adult; Bladder; Case reports; Cesarean section; Coloring Agents; Conflicts of interest; Endocrinology; Female; Fertility; Gynecology; Human Genetics; Human subjects; Humans; Hysteroscopy - methods; Indocyanine Green; Infertility; Informed consent; Laparoscopy; Laparoscopy - methods; Medicine; Medicine & Public Health; Nonsteroidal anti-inflammatory drugs; Obstetrics; Obstetrics/Perinatology/Midwifery; Pain; Patients; Pelvic Pain - etiology; Pregnancy complications; Robotic Surgical Procedures; Robotics; Surgery; SWOT analysis; Ultrasonic imaging; Uterine Diseases - diagnostic imaging; Uterine Diseases - surgery; Uterine Hemorrhage - etiology; Uterine Hemorrhage - surgery; Uterus - diagnostic imaging; Uterus - surgery; Visualization; Hysteroscopy; Indocyanine green; Laparoscopy; Isthmocele repair
• ISSN: 1432-0711; 0932-0067; 1432-0711
• DOI: 10.1007/s00404-025-08071-x

Objective To present a case of a 43-year-old woman with a uterine isthmocele causing severe abnormal uterine bleeding (AUB) and chronic pelvic pain and to demonstrate the effectiveness of indocyanine green (ICG) fluorescence in minimally invasive surgical management. Case Presentation A 43-year-old woman, gravida 7, para 2052, was referred for surgical management of a uterine isthmocele after experiencing persistent AUB and chronic pelvic pain despite multiple conservative treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal therapy. The patient expressed a desire to avoid hysterectomy. Methods Preoperative evaluation included a 2-dimensional transvaginal ultrasound (2D-TVUS) with saline infusion sonohysterogram (SIS), which revealed a 10-mm echolucent space at the anterior uterine isthmus, confirming the diagnosis of isthmocele. The patient underwent hysteroscopic and robotic-assisted laparoscopic resection of the isthmocele. ICG fluorescence was utilized to enhance visualization during the procedure. ICG was prepared by mixing a 25 mg vial with 10 cc of sterile water to achieve a 2.5 mg/cc concentration, with 2 cc (5 mg) injected into the uterine cavity via syringe through the inflow port of the uterine manipulator 10 minutes before the surgical incision. Results The surgical procedure was successful, with improved residual myometrial thickness observed in follow-up imaging. The patient reported resolution of AUB and pelvic pain two months post-surgery. Conclusion This case demonstrates that ICG imaging enhances defect localization and surgical precision, reducing operative time and complications. By optimizing the procedure and minimizing intraoperative challenges, ICG represents a significant advancement in isthmocele repair surgery, offering improved outcomes for complex uterine pathologies.