Preliminary Experience with a 3D Digital Fluorescence Microscope and Indocyanine Green Angiography in Subinguinal Varicocelectomy

Summary

This study explores the application of a three-dimensional (3D) digital microscopy platform combined with indocyanine green (ICG) angiography in subinguinal varicocelectomy, highlighting improvements in surgical precision, arterial preservation, and patient outcomes.

Abstract

This study reports the application and preliminary experience of a three-dimensional (3D) fluorescent digital external-viewing microscope platform using indocyanine green (ICG) fluorescence angiography in subinguinal varicocelectomy and explores its impact on surgical outcomes and postoperative recovery. Twenty-six microscope-assisted subinguinal varicocelectomy procedures were performed on 23 patients between September 1, 2024, and October 25, 2024, using this technology.

During each surgery, 3 mL of ICG dye was administered via peripheral intravenous injection for angiography. Under fluorescence mode, the arterial and venous structures were visualized; the arteries were marked and preserved, and the veins were ligated. All operations were completed successfully, with an average operative time of 52.65 ± 8.48 min per procedure. The mean time from ICG injection to arterial fluorescence was 45.88 ± 2.10 s, and the mean time to venous fluorescence was 81.61 ± 3.61 s. On average, 2.1 ± 0.84 arteries (range 1-4) were preserved per patient, and several capillary reticular arteries were observed in most patients' spermatic vessels.

The 3D fluorescent digital external microscope platform using ICG angiography demonstrates promising potential in subinguinal varicocelectomy. It may become a reliable adjunctive technique in microscope-assisted varicocelectomy, aiding surgeons in accurately identifying and locating arterial branches at all levels, thereby preventing arterial injury during surgery.

Introduction

Varicocele refers to the abnormal dilation, elongation, and tortuosity of the pampiniform venous plexus within the spermatic cord, which can cause discomfort and swelling in the ipsilateral scrotum and/or decreased semen quality. It is a common male reproductive system disorder with an incidence rate of 10%-15% and as high as 25.4% among men with abnormal semen quality^1,2. Varicocelectomy is an effective treatment for varicocele, and it mainly includes open surgery, laparoscopic surgery, and microsurgical procedures. The ideal surgical approach is to completely ligate the veins of the spermatic cord while effe....

Protocol

This study involves human subjects and has been approved by the Ethics Committee of the First Affiliated Hospital of Zhejiang Chinese Medical University (Approval Number: 2024-X-163). Written informed consent was obtained from all patients. Authorization was granted to use patients' surgical videos and data for presentation. This study strictly adheres to the Declaration of Helsinki and relevant ethical guidelines. All consumables and equipment used in the study are detailed in the Table of Materials.

1. Preparation for surgery

1. Patient screening
   1. Determine patient eligibility base....

Results

The patients' average age was 28.92 ± 9.24 years (range: 12-59 years), with 20 patients presenting with left-sided varicocele and 3 patients with bilateral varicocele. The mean spermatic vein diameter, measured via ultrasound, was 3.13 ± 0.80 mm. All surgeries were successfully completed, with the average surgical time being 52.65 ± 8.48 minutes (range: 40-67 min). After peripheral intravenous injection of ICG, the time from injection to arterial fluorescence visualization was 45.88 ± 2.10 s (range: 42-51 s), while the t.......

Discussion

Although ICG is generally safe, rare allergic reactions and limitations in patients with renal impairment must be considered. All patients in this study were tested for iodine allergy prior to administration, and no adverse reactions were observed. After intravenous injection of ICG, most arteries and veins can be observed using a fluorescence surgical microscope. The different times of arterial and venous fluorescence allow for effective differentiation between arteries and veins, improving vascular visualization. When .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Digital Surgical Microscope	Aesculap Aeos	PV010-CN	The digital surgical microscope consists of a camera, robotic arm, trolley, and control screen, 3D monitor stand, 26’ full HD 3D monitor, keyboard, mirror head cover, options
Indocyanine Green for Injection	DANDONG YICHUANG PHARMACEUTICAL CO.,ITD	H20055881	Used for choroidal angiography to determine the location of choroidal disorders.
SPSS version 23.0			Data analysis