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

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.