The Role of Indocyanine Green With Near-Infrared Imaging for the Intraoperative Detection and Enhancement of Endometriosis Lesions: A Narrative Review

Background: There is a clinical need for improved intraoperative detection of endometriosis, and the use of Indocyanine Green with Near-Infrared Imaging (NIR-ICG) is a novel technique for this purpose. The aim of this review is to determine whether NIR-ICG is an effective tool for endometriosis detection and establish an evidence-based methodology for its use. Methods: This review searches Ovid MEDLINE and Embase through July 2023 and considers primary literature published in English describing the use of NIR-ICG to detect endometriosis intraoperatively. Case studies, video demonstrations and articles describing NIR-ICG used for other surgical roles were not considered. Identified studies were screened independently by two authors, and data was extracted by a single author. Results: NIR-ICG was found to enhance the detection of endometriosis in six out of the nine included studies with additional lesion identification, and to have an unchanged or reduced efficacy compared to current standards in the remaining three. Across all studies there were lesions missed by NIR-ICG which were detected by conventional imaging. A greater duration of time between dye administration and visualisation of lesions was found to be more effective for detection. The ideal ICG protocol proposed from this review is a fixed amount of dye proportional to patient weight prior to surgery (0.25-0.3 mg/kg) followed by a longer waiting time before imaging (10-30 min). Conclusion: NIR-ICG has a possible role to enhance the identification of endometriosis intraoperatively as an adjunct to conventional white light imaging, particularly deeper infiltrating disease. However, substantial further research is required in this field.