V9-05: Laparoscopic varicocelectomy using intraoperative navigation: indocyanine green angiography and indigo carmine lymphatic dye
Varicocelecomy is widely performed to treat of male infertility, scrotal pain, and testicular atrophy. A variety of techniques have been reported. Laparoscopic varicocelectomy is still a commonly used method for varicocele repair. However, the most popular surgery for varicocele uses a microsurgical inguinal or subinguinal approach mainly because of the disadvantages of a retroperitoneal approach including a high incidence of varicocele recurrence and hydrocele formation. Failure is usually caused by preservation of persistent tiny veins and postoperative hydrocele is caused by cutting of lymphatics. On the other hand, a laparoscopic procedure should allow preservation of the testicular artery in a majority of cases and preservation of lymphatics. It is extremely vital to eliminate spermatic venous flow completely to reduce the recurrence rate as much as possible. To facilitate the identification of spermatic vessels and ensure the ligation of veins as well as arterial and lymphatic preservation, we performed laparoendoscopic single-site (LESS) varicocelectomy using intraoperative navigation.
An umbilical incision of 25 mm was made. We placed a GelPOINT? Mini Advanced Access Platform (Applied Medical, Rancho Santo Margarita, CA, USA), which has one 12 mm trocar and two 5 mm trocars. After exposing of the spermatic cord, 2 ml of indigo carmine was injected into the space between the tunica vaginalis and tunica albuginea. Then, 1 ml of indocyanine green (ICG, 2.5 mg/ml) was injected intravenously. Spermatic veins were cauterized by bipolar forceps. The spermatic artery and lymphatics were preserved. ICG was injected again to confirm preservation arterial blood flow and that there were no remaining veins.
A few seconds after injection of indigo carmine, one bundle of lymphatics was stained. About 20 s after injection of ICG, fluorescence of gonadal arterial flow was detected clearly. About 20 s after that, gonadal veins were observed somewhat dully. The artery and lymphatics could be preserved and the veins were cut. Finally, we performed ICG angiography again. Arterial flow was preserved and venous flow was not observed. 3 months later, color Doppler ultrasonography confirmed complete disappearance of the varicocele.
LESS varicocelectomy using ICG angiography and indigo carmine lymphatic dye facilitates visualization and identification of spermatic vessels. Continued investigation should determine whether it could reduce the disadvantages of laparoscopic varicocelectomy.