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Review
. 2025 Mar 3;17(5):872.
doi: 10.3390/cancers17050872.

Real-Time Navigation in Liver Surgery Through Indocyanine Green Fluorescence: An Updated Analysis of Worldwide Protocols and Applications

Pasquale Avella  1   2   3 , Salvatore Spiezia  3 , Marco Rotondo  3 , Micaela Cappuccio  1 , Andrea Scacchi  4 , Giustiniano Inglese  3 , Germano Guerra  3 , Maria Chiara Brunese  3 , Paolo Bianco  2 , Giuseppe Amedeo Tedesco  3 , Graziano Ceccarelli  5   6 , Aldo Rocca  2   3
Affiliations
Review

Real-Time Navigation in Liver Surgery Through Indocyanine Green Fluorescence: An Updated Analysis of Worldwide Protocols and Applications

Pasquale Avella et al. Cancers (Basel). .

Abstract

Background: Indocyanine green (ICG) fluorescence has seen extensive application across medical and surgical fields, praised for its real-time navigation capabilities and low toxicity. Initially employed to assess liver function, ICG fluorescence is now integral to liver surgery, aiding in tumor detection, liver segmentation, and the visualization of bile leaks. This study reviews current protocols and ICG fluorescence applications in liver surgery, with a focus on optimizing timing and dosage based on clinical indications.

Methods: Following PRISMA guidelines, we systematically reviewed the literature up to 27 January 2024, using PubMed and Medline to identify studies on ICG fluorescence used in liver surgery. A systematic review was performed to evaluate dosage and timing protocols for ICG administration.

Results: Of 1093 initial articles, 140 studies, covering a total of 3739 patients, were included. The studies primarily addressed tumor detection (40%), liver segmentation (34.6%), and both (21.4%). The most common ICG fluorescence dose for tumor detection was 0.5 mg/kg, with administration occurring from days to weeks pre-surgery. Various near-infrared (NIR) camera systems were utilized, with the PINPOINT system most frequently cited. Tumor detection rates averaged 87.4%, with a 10.5% false-positive rate. Additional applications include the detection of bile leaks, lymph nodes, and vascular and biliary structures.

Conclusions: ICG fluorescence imaging has emerged as a valuable tool in liver surgery, enhancing real-time navigation and improving clinical outcomes. Standardizing protocols could further enhance ICG fluorescence efficacy and reliability, benefitting patient care in hepatic surgeries.

Keywords: fluorescence-guided surgery; indocyanine green (ICG) fluorescence; liver surgery; segmentation; tumor detection.

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Conflict of interest statement

All authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
PRISMA Flowchart of our systematic analysis.
Figure 2
Figure 2
(A) Percentage of open, laparoscopic, and robotic surgery involved in our review. In 1 report, the type of surgery was not specified; (B) Percentage of clinical applications detected.
Figure 3
Figure 3
Indocyanine green fluorescence imaging in HCC, CRLM, and CCA during liver surgery. Abbreviations: HCC, Hepatocellular Carcinoma; CRLM, Colorectal Liver Metastases; CCA, Cholangiocellular Carcinoma.
Figure 4
Figure 4
The flowchart of ICG doses and timing according to our systematic review. The syringe indicates intravenous administration, while the biliary tree implies trans-biliary duct administration. No protocols were reported for cholangiocarcinoma detection due to limited data availability. Abbreviations: HCC, Hepatocellular Carcinoma; CRLM, Colorectal Liver Metastases; BD, Bile Duct.
See this image and copyright information in PMC

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