WOFAPS 2025 8th World Congress of Pediatric Surgery

António Moreira, Ana Magalhães, Rafael Bernardo, Elizabete Vieira

Hospital de Santa Maria, Lisbon

Introduction
Preservation of lymphatic vessels during laparoscopic varicocelectomy reduces the risk of postoperative hydrocele. Esposito et al. first described intra-testicular indocyanine green (ICG) injection to identify lymphatics intraoperatively. This study reports our preliminary experience using ICG to identify lymphatics during pediatric laparoscopic varicocelectomy, performed without near-infrared fluorescence (NIRF) filters.

Methodology
Four patients aged 12, 15 and 16 years (n=2) with grade III varicocele (Dubin and Amelar classification) underwent laparoscopic varicocelectomy with intraoperative injection of 1 ml of ICG directly into the testicle, following trocar placement. Two patients were asymptomatic, while two reported pain. One had testicular asymmetry (~20%). A standard white light laparoscopic camera was used (without NIRF). Three patients underwent artery-sparing varicocelectomy, while one had the classical Palomo technique (artery and vein ligation), according to surgeon preference. Timing of lymphatic visualization, safety, and technical feasibility were assessed.

Results
Lymphatic vessels were easily visualized in all cases within 30–60 seconds after injection, despite the absence of an NIRF filter. No allergic or systemic reactions were observed. Follow-up ranged from 4 to 16 months, with no postoperative complications or hydrocele cases. Ultrasound follow-up revealed no morphologic testicular abnormalities or hypoechoic areas at the injection site. Varicocele resolved in all cases, and testicular asymmetry improved in the patient with pre-existing asymmetry

Conclusion
Intra-testicular injection of 1 ml ICG allows clear lymphatic visualization during laparoscopic varicocelectomy, even without NIRF filter. This technique may enhance lymphatic sparing and reduce postoperative risk of hydrocele. While Esposito et al. reported millimetric hypoechoic, avascular areas at the injection site with 2 ml ICG (possibly due to high intratesticular pressure), no such changes were observed in our small series using 1 ml. Although promising, the safety of intra-testicular ICG requires further validation.