Robotic single-site endometriosis resection using near-infrared fluorescence imaging with indocyanine green: a prospective case series and review of literature

  • Jayapriya JayakumaranEmail author
  • Zoran Pavlovic
  • Daniele Fuhrich
  • Karen Wiercinski
  • Cynthia Buffington
  • Aileen Caceres
Original Article


We present our preliminary experience comparing robotic near-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) to 2D laparoscopic white light (WL) and 3D robotic WL illumination, in their ability to visually detect endometriosis lesions during a robotic endometriosis resection procedure in a single center. A total of twenty women were screened and seven of them with symptomatic endometriosis were included in this prospective case series. The mean patient age was 33 years with the mean body mass index being 28.6 kg/m2. The NIRF-ICG imaging technique enabled visualization of a statistically significant higher number of lesions compared to that of robotic and laparoscopic WL (13.4 vs 7.4 vs 4.7, p = 0.012). In addition, we explored the extent of quality of life (QoL) measures of these women affected by endometriosis using the validated QoL RAND Short Form Health Survey questionnaire and Numeric Pain Rating Scale. The largest reduction of quality of life was measured for the domains of social functioning (3.28 SD, 95% CI 45.7–61.5, p = 0.0001), physical limitations (3.04 SD, 95% CI 15.1–44.3, p = 0.0002), and physical functioning (3.02 SD, 95% CI 48.7–64.1, p = 0.0002), respectively. There was a significant reduction in the postoperative mean pain score as indicated by the pain rating of 0.57 ± 0.78 (p = 0.0005). We also performed a literature search to review other cases that describe the potential benefits of robotic NIRF-ICG imaging in the visual detection of peritoneal and deep endometriosis. Our study results demonstrate that the ICG fluorescence system may potentially be useful for more complete intraoperative endometriosis lesion detection and excision. Large multicenter trials with larger sample sizes and across surgeons of differing experience levels are needed to investigate the clinical utility, reproducibility and long-term outcomes of the use of this technology for patients with debilitating endometriosis.


Endometriosis Near-infrared fluorescence imaging Indocyanine green dye Firefly® da Vinci® Chronic pelvic pain Quality of life 


Compliance with ethical standards

Conflict of interest

Jayapriya Jayakumaran, Zoran Pavlovic, Daniele Fuhrich, Cynthia Buffington, and Aileen Caceres declare that they have no conflict of interest.


  1. 1.
    Kennedy S, Bergqvist A, Chapron C, D'Hooghe T, Dunselman G, Greb R et al (2005) ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 20:2698–2704CrossRefGoogle Scholar
  2. 2.
    Kvaskoff M, Mu F, Terry KL, Harris HR, Poole EM, Farland L et al (2015) Endometriosis: a high-risk population for major chronic diseases? Hum Reprod Update 21:500–516CrossRefGoogle Scholar
  3. 3.
    Klein S, D'Hooghe T, Meuleman C, Dirksen C, Dunselman G, Simoens S (2014) What is the societal burden of endometriosis-associated symptoms? A prospective Belgian study. Reprod Biomed Online 28:116–124CrossRefGoogle Scholar
  4. 4.
    Abbott JA, Hawe J, Hunter D, Holmes M, Finn P, Garry R (2004) Laparoscopic excision of endometriosis: a randomized, placebo controlled trial. Fertil Steril 82:878–884. CrossRefGoogle Scholar
  5. 5.
    The Practice Committee of the American Society for Reproductive Medicine (2014) Treatment of pelvic pain associated with endometriosis. Fertil Steril 10:927–935. Google Scholar
  6. 6.
    Nisenblat V, Bossuyt PM, Farquhar C, Johnson N, Hull ML (2016) Imaging modalities for the non-invasive diagnosis of endometriosis Cochrane Database Syst Rev 2:CD009591.
  7. 7.
    Jansen RP, Russell P (1986) Nonpigmented endometriosis: clinical, laparoscopic, and pathologic definition. Am J Obstet Gynecol 155:1154–1159CrossRefGoogle Scholar
  8. 8.
    Walter AJ, et al. (2001) Endometriosis: correlation between histologic and visual findings at laparoscopy. Am J Obstet Gynecol 1841407-11 (discussion 1411-3)Google Scholar
  9. 9.
    Marchino GL et al (2005) Diagnosis of pelvic endometriosis with use of macroscopic versus histologic findings. Fertil Steril 84:12–15CrossRefGoogle Scholar
  10. 10.
    Taylor E, Williams C (2010) Surgical treatment of endometriosis: location and patterns of disease at reoperation. Fertil Steril 93:57–61CrossRefGoogle Scholar
  11. 11.
    Cheong Y, Tay P, Luk F, Gan HC, Li TC, Cooke I (2008) Laparoscopic surgery for endometriosis: how often do we need to re-operate? J Obstet Gynaecol 28:82–85CrossRefGoogle Scholar
  12. 12.
    Handgraaf HJ, Verbeek FP, Tummers QR, Boogerd LS, van de Velde CJ, Vahrmeijer AL Gaarenstroom KN (2014) Real-time near-infrared fluorescence guided surgery in gynecologic oncology: a review of the current state of the art. Gynecol Oncol 135(3):606-613. CrossRefGoogle Scholar
  13. 13.
    Dulemba JF, Pelzel C, Hubert HB (2013) Retrospective analysis of robot-assisted versus standard laparoscopy in the treatment of pelvic pain indicative of endometriosis. J Robotic Surg 7:163–169. CrossRefGoogle Scholar
  14. 14.
    Nezhat C, Lewis M, Kotikela S et al (2010) Robotic versus standard laparoscopy for the treatment of endometriosis. Fertil Steril 94(7):2758–2760. CrossRefGoogle Scholar
  15. 15.
    Hays RD, Sherbourne CD, Mazel RM (1993) The RAND 36-Item Health Survey 10. Health Econ 2:217–227CrossRefGoogle Scholar
  16. 16.
    Ware JE, Kosinski M, Keller SD (1994) SF-36 physical and mental health summary scales: a user's manual. The Health Institute, BostonGoogle Scholar
  17. 17.
    Obidoa CA, Reisine SL, Cheniack M (2010) How does the SF-36 perform in healthy populations? A structured review of longitudinal studies. J Soc Behav Health Sci. 4:30–48Google Scholar
  18. 18.
    Rodriguez CS (2001) Pain measurement in the elderly: a review. Pain Manag Nurs 2:38–46CrossRefGoogle Scholar
  19. 19.
    Hawker GA (2011) Measures of adult pain. Arthritis Care Res 63:S240–S252CrossRefGoogle Scholar
  20. 20.
    Cohen J (1998) Statistical power analysis for the behavioral sciences, 2nd edn. Lawrence Erlbaum Associates, New JerseyGoogle Scholar
  21. 21.
    Laschke MW, Menger MD (2018) Basic mechanisms of vascularization in endometriosis and their clinical implications. Hum Reprod Update 24:207–224. CrossRefGoogle Scholar
  22. 22.
    Potente M, Gerhardt H, Carmeliet P (2011) Basic and therapeutic aspects of angiogenesis. Cell 146:873–887CrossRefGoogle Scholar
  23. 23.
    Asahara T, Kawamoto A (2004) Endothelial progenitor cells for postnatal vasculogenesis. Am J Physiol Cell Physiol 287:C572–C579CrossRefGoogle Scholar
  24. 24.
    Lue JR, Pyrzak A, Allen J (2016) Improving accuracy of intraoperative diagnosis of endometriosis: role of firefly in minimal access robotic surgery. J Minim Access Surg 12:186–189. CrossRefGoogle Scholar
  25. 25.
    Tang NZ, Goldman TL, Prabakar C (2015) Robotically-assisted laparoscopic resection of endometriosis using firefly technology. J Minim Invasive Gynecol. Google Scholar
  26. 26.
    Levey KA (2014) Use of fluorescence imaging technology to identify peritoneal endometriosis: a case report of new technology. Surg Laparosc Endosc Percutan Tech 24(2):e63–e65CrossRefGoogle Scholar
  27. 27.
    Guan X, Nguyen MT, Walsh TM, Kelly B (2016) Robotic single-site endometriosis resection using firefly technology. J Minim Invasive Gynecol 23(1):10–11. CrossRefGoogle Scholar
  28. 28.
    Lövkvist L, Bostrom P, Edlund M, Olovsson M (2016) Age related differences in quality of life in Swedish women with endometriosis. J Womens Health 25:646–653CrossRefGoogle Scholar
  29. 29.
    Marki G, Bokor A, Rigo J, Rigo A (2017) Physical pain and emotion regulation as the main predictive factors of health related quality of life in women living with endometriosis. Hum Reprod 32(1432–1438):13Google Scholar
  30. 30.
    Juan J, Estiarte R, Colome E, Artes M, Jimenez FJ, Alonso J (2003) Burden of illness of Crohn’s disease in Spain. Dig Liver Dis 35:853–861CrossRefGoogle Scholar
  31. 31.
    Simoens S, Dunselman G, Dirksen C, Hummelshoj L, Bokor A, Brandes I et al (2012) The burden of Endometriosis: costs and quality of life of women with endometriosis and treated in referral centers. Hum Reprod 27:1292–1299CrossRefGoogle Scholar
  32. 32.
    Al-Taher M, Hsien S, Schols RM, Hanegem NV, Bouvy ND, Dunselman GAJ, Stassen LPS (2018) Intraoperative enhanced imaging for detection of endometriosis: a systematic review of the literature. Eur J Obstet Gynecol Reprod Biol 224:108–116. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Ltd., part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Obstetrics and GynecologyUniversity of Central Florida College of Medicine/Hospital Corporation of America GME Consortium At Osceola Regional Medical CenterKissimmeeUSA
  2. 2.Department of Obstetrics and GynecologyRush University Medical CenterChicagoUSA
  3. 3.Department of Obstetrics and GynecologyUniversity of Central Florida College of MedicineOrlandoUSA
  4. 4.Department of Minimally Invasive and Robotic Surgery, Endometriosis Center for Women and Center for Hereditary Syndromes and GeneticsFlorida Hospital Celebration HealthCelebrationUSA
  5. 5.Bariatric Surgery CenterFlorida Hospital Celebration HealthCelebrationUSA

Personalised recommendations