Robotic-Assisted Resection of Adenomyoma Using ICG to Define Borders: A Novel Surgical Technique

INTRODUCTION: Adenomyosis is defined as heterotopic growth of endometrial glands and stroma into the myometrium of the uterus. Typical symptoms involve dysmenorrhea, abnormal uterine bleeding, and pelvic pain. Data shows that one-third of patients, however, are asymptomatic. The definitive diagnosis of adenomyosis is made by histologic examination, but adenomyosis can be suspected on transvaginal ultrasound or MRI imaging with a heterogeneous appearing myometrium, myometrial cysts, or a thickened myometrial junctional zone. OBJECTIVE: In this video, we aim to show a novel technique of using ICG dye to identify the endometrial cavity and confirm maximal resection of adenomyoma. To our knowledge, this is the first video describing this specific technique. METHODS: The patient was a 36-year-old G0 patient who was referred to our clinic for dysmenorrhea, abnormal uterine bleeding, and infertility. Patient also had a known adenomyoma that measured 8.5 cm and had been stable. The patient was counseled extensively about her options for treatment and elected for surgery. She was taken to the OR for hysteroscopy, robotic-assisted laparoscopy, adenomyomectomy, and possible excision of endometriosis. Prior to beginning the resection of the adenomyoma, 80 mL of dilute vasopressin was injected into the uterus via spinal needle through the abdominal wall. Adhesions to the rectum were taken down with sharp and blunt dissection. Once the area of the adenomyoma was identified, monopolar scissors were used to make a deep incision through the serosa and into the myometrium and adenomyoma. In order to fully define the borders of the normal endometrium and ensure complete resection of the adenomyoma, ICG was injected through the Jarcho manipulator and the robotic camera was switched to firefly mode. This technique also allowed the surgeon to visualize any entry to the endometrium and identify the area for repair if necessary. RESULTS: The uterus was repaired in multiple layers and seen to be hemostatic at the completion of the procedure. Pathology from the surgery resulted as benign endometrial glands surrounded by endometrial stroma, with leiomyomatous smooth muscle—consistent with adenomyoma. She was started on a GnRH antagonist post-surgery with plans for a repeat saline ultrasound 3 months after the procedure and IVF planning. CONCLUSIONS: In conclusion, ICG injection through the manipulator is a promising tool that can be used to aid in the complete resection of adenomyomas.