Background: The risk of ureteric injury during minimally invasive surgery is up to 5-10% (1,2). Indigocyanine green (ICG) dye has gained popularity in colorectal, urological and endometriosis surgery over the last 5-10 years for its ability to improve identification of the ureter (using near-infrared technology) during minimally invasive complex surgery without significantly increasing morbidity for the patients. The current evidence suggests that whilst it increases operating time due to the need for insertion of the ureteric catheters (4-20min) it likely reduces overall operating time as it reduces the need for pelvic side wall dissection for identification of ureters during complex surgery (1-6). A number of techniques are described including insertion of 5 or 6Fr ureteric catheters to 20cm and injecting (2.5-25mg ICG/5-10ml saline) the dye through the lumen or simply inserting the tip of catheter into the ureteric orifice and injecting the dye(1,3-5). The ureters are able to be identified for a median of 489min (268-738min) and the degree of intensity is dependent on dose and depth of ureter from surface of side wall (ie. Adiposity) (1,5). The risks are small (and less than with ureteric stents) but include iatrogenic ureteric injury, acute kidney injury, urinary tract infection and transient haematuria (1,2,7). Given ICG and near-infrared technology is already utilised for identification of sentinel lymph nodes in other gynaecological oncology cancers, we have identified an alternative use for it in gynaecological oncology surgery with the aim to reduce operating time and operator cognitive load.
Aim: To demonstrate a number of techniques for injection of ICG dye to make ureteric identification easier and therefore reduce operating time and operator cognitive load during complex minimally invasive gynaecological oncology operations.
Method: ICG dye can be injected through ureteric catheters either inserted into the ureters or into the ureteric orifice (only) under cystoscopic guidance to allow identification during minimally invasive surgery using near-infrared technology. These techniques will be demonstrated in a number of short videos and we will provide commentary on our clinical experiences with these methods.