Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery

Abstract

Background: Recently major developments in video imaging have been achieved: among these, the use of high definition and 3D imaging systems, and more recently indocyanine green (ICG) fluorescence imaging are emerging as major contributions to intraoperative decision making during surgical procedures. The aim of this study was to present our experience with different laparoscopic procedures using ICG fluorescence imaging.

Patients and methods: 108 ICG-enhanced fluorescence-guided laparoscopic procedures were performed: 52 laparoscopic cholecystectomies, 38 colorectal resections, 8 living-donor nephrectomies, 1 laparoscopic kidney autotransplantation, 3 inguino-iliac/obturator lymph node dissections for melanoma, and 6 miscellanea procedures. Visualization of structures was provided by a high definition stereoscopic camera connected to a 30° 10 mm scope equipped with a specific lens and light source emitting both visible and near infra-red (NIR) light (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany). After injection of ICG, the system projected high-resolution NIR real-time images of blood flow in vessels and organs as well as highlighted biliary excretion .

Results: No intraoperataive or injection-related adverse effects were reported, and the biliary/vascular anatomy was always clearly identified. The imaging system provided invaluable information to conduct a safe cholecystectomy and ensure adequate vascular supply for colectomy, nephrectomy, or find lymph nodes. There were no bile duct injuries or anastomotic leaks.

Conclusions: In our experience, the ICG fluorescence imaging system seems to be simple, safe, and useful. The technique may well become a standard in the near future in view of its different diagnostic and oncological capabilities. Larger studies and more specific evaluations are needed to confirm its role and to address its disadvantages.

Fig. 1

Identification of the biliary anatomy during laparoscopic cholecystectomy in non-acute setting. Insert in the upper right corner shows the operative view using a standard light

Fig. 2

Use of ICG-enhanced fluorescence during laparoscopic cholecystectomy for acute cholecystitis. Insert in upper right corner shows the operative view using standard light

Fig. 3

Identification of the cystic artery during laparoscopic cholecystectomy for acute cholecystitis. In the upper right corner, the operative view using standard light

Fig. 4

Identification of the ischemic bowel after mesenteric division during laparoscopic anterior resection. On the left side, the external view using standard light (notice no difference in the two segments). On the right side, the view using near infra-red light after injection of 5 ml of ICG

Fig. 5

Fluorescent perfusion control during anterior resection with identification of a distal ischemic part using near infra-red light after injection of 5 ml of ICG (right side)

Fig. 6

Peri-tumoral lymphatic mapping after ICG injection during laparoscopic right colectomy

Fig. 7

ICG-enhanced fluorescent lymphatic mapping during laparoscopic right colectomy. On the left side, the view using standard light. On the right side, identification of lymph node at the origin of the ileo-colic vessels using NIR light

Fig. 8

The use of ICG during inguino-iliac/obturator lymph node dissection. On the left side, the view using standard light on the right the lymph node enhancement with ICG

Fig. 9

Vascular anatomy study using ICG-mediated fluorescence during right laparoscopic living-donor nephrectomy after injection of 5 ml of ICG. In the upper left corner, operative view using standard light

Fig. 10

Vascular anatomy study of the hepatic artery using ICG-mediated fluorescence during laparoscopic liver resection using near infra-red light after injection of 5 milliliters of ICG. In the upper left corner, the view using standard light

Fig. 11

Vascular anatomy study of the spleen using ICG-enhanced fluorescence during laparoscopic splenectomy. On the right side, view using near infra-red light after injection of 5 ml of ICG. On the left side, view using standard light

Fig. 12

Vascular anatomy study of the inferior mesenteric artery using ICG-mediated fluorescence laparoscopic treatment of type II endoleak. On the left side, view using standard light. On the right side, view using near infra-red light after injection of 5 ml of ICG

Fig. 13

Parenchymal perfusion assessment of the kidney after transplantation (injection of 5 ml of ICG). In the upper left corner, the operative view using standard light