Lymphatic Sparing Laparoscopic Varicocelectomy in Pediatric Patients Using Indocyanine Green (ICG) And Immunofluorescence Imaging: A Case Series
Amr Elbakry, MD, Katharina Mitchell, MD, Ahmed Abdelhalim, MD, Osama Al-Omar, MD.
Department of Urology, West Virginia University, Morgantown, WV, USA.
BACKGROUND: To demonstrate the use of indocyanine green (ICG) and immunofluorescence imaging for identification of the lymphatic vessels during laparoscopic lymphatic sparing varicocelectomy in pediatric patients.
Methods: Our standard technique includes using three 5mm laparoscopic ports in linear configuration across the abdomen at the level of the umbilicus. We place the patient in Trendelenburg position. After identification of the gonadal vessels, the posterior peritoneum over the vessels is incised until adequate window is created. Next, we inject 2 cc of indocyanine green (ICG) into the parenchyma of the testicle. Next, we switch to the Overlay Imaging Mode that provides a combination of the immunofluorescence imaging that visualize the ICG, with a background of the standard white light view. This imaging mode allows for detection of the ICG in the lymphatic vessels with the background of the normal laparoscopic view of the surrounding anatomy. This provides an excellent real time identification of the lymphatic vessels during dissection. The lymphatic vessels are dissected and isolated from the gonadal vessels. After creating an adequate window, we perform en bloc ligation of the gonadal veins using three metal clips.
Results: We performed this procedure in 5 patients. Age was ranging from 12 to 18 years old. Average operative time was 59 minutes (range: 49 - 68). All cases were done as an outpatient procedure. No complications were reported.
Conclusions: The use of ICG via intraparenchymal injection in the testicle in combination overlay immunofluorescence imaging provides excellent view of the lymphatic vessels in real time which facilitates their identification and sparing during laparoscopic varicocelectomy procedure. In our limited case series, this technique was found to be safe, effective and reproducible.
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