The Applications of 3D Imaging and Indocyanine Green Dye Fluorescence in Laparoscopic Liver Surgery

Laparoscopic liver resections have gained widespread popularity among hepatobiliary surgeons and is nowadays performed for both standard and more complex hepatectomies. Given the increased technical challenges, preoperative planning and intraoperative guidance is pivotal in laparoscopic surgery to safely carry out complex and oncologically safe hepatectomies. Modern tools can help both preoperatively and intraoperatively and allow surgeons to perform more precise hepatectomies. Preoperative 3D reconstructions and printing as well as augmented reality can increase the knowledge of the specific anatomy of the case and therefore plan the surgery accordingly and tailor the procedure on the patient. Furthermore, the indocyanine green retention dye is an increasingly used tool that can nowadays improve the precision during laparoscopic hepatectomies, especially when considering anatomical resection. The use of preoperative modern imaging and intraoperative indocyanine green dye are key to successfully perform complex hepatectomies such as laparoscopic parenchymal sparing liver resections. In this narrative review, we discuss the aspects of preoperative and intraoperative tools that are nowadays increasingly used in experienced hepatobiliary centers.

Assessment of bowel vascularity using indocyanine green fluorescence in incarcerated hernia

Intra-operative assessment of bowel vascularity is often needed during emergent surgery. An objective test to determine the viability could reduce postoperative ischemic complications. Indocyanine green dye has been used for assessing bowel vascularity in colorectal surgery. The following study involving two patients demonstrates its use for assessing the viability of bowel in obstructed hernias after intraoperative intravenous injection. Stryker 1588 AIM laparoscopic setup was used for intraoperative fluorescence. In both cases, dusky areas were noted over the obstructed bowel segment on visual inspection. However, satisfactory fluorescence was seen after dye injection, and hence mesh repair was done without resecting the bowel. All the patients had a good post-operative recovery. Indocyanine green fluorescence may be a good modality to intraoperatively assess bowel vascularity.

Possibilities of the indocyanine green dye application for evaluation of peculiarities of lymph outflow and metastasizing of colorectal cancer

Objective. Studying of velocity of prevalence of luminescent dye indocyanine green along lymphatic vessels in the large bowel surgery. Materials and methods. Estimation of procedure for coloring of tumoral substrate and lymphatic vessels while performance of oncological operations was conducted. We performed laparoscopic resection of sigmoid colon in 7 patients, suffering tumors, and anterior rectal resection in 5 patients, having tumors of upper ampullary part of rectum, using indocyanine green dye. Results. In Group I, consisting of 7 patients, surgical technique of no touch manipulations on the tumor before transection of feeding vessels (NTIT–operations) was applied, and in Group II, consisting of 5 patients, the tumor mobilization was done primarily. Application of indocyanine green dye helped a lot to establish localization and prevalence of the process in rectum. Conclusion. Application of fluorescent dye indocyanine green on tumoral substrate before doing ligation of feeding vessels raises possibility of the complication occurrence, consisting of the cancer cells dissemination in abdominal cavity. While performing laparoscopic procedures in resection of the large bowel tumors it is expedient to ligate the feeding vessels primarily, with secondary manipulation– to dissect and mobilize the tumoral substrate.

Systemic Sentinel Lymph Node Detection Using Fluorescence Imaging After Indocyanine Green Intravenous Injection in Colorectal Cancer: Protocol for a Feasibility Study

Background Nodal staging is a major concern in colorectal cancer as it is an important prognostic factor. Several techniques that could potentially improve patient treatment and prognosis have been developed to increase the accuracy of nodal staging. Sentinel lymph node detection has been shown to accurately reflect nodal status in various tumors and has become the standard procedure in nodal staging of breast cancer and melanoma. However, in colorectal cancer, sentinel lymph node detection techniques are still controversial as the sensitivity reported in the literature varies from one study to another. Recently, indocyanine green fluorescence–guided surgery has been reported to be a useful technique for detection of macroscopic and microscopic metastatic deposits in lymph nodes after intravenous administration of indocyanine green dye. However, no studies have focused on the potential role of sentinel lymph node detection after systemic administration of indocyanine green dye, so-called systemic sentinel lymph nodes, or on the correspondence between the identification of the sentinel lymph node by standard local injection techniques and the detection of fluorescent lymph nodes with this new approach. Objective The aim of this protocol is to validate the concept of sentinel lymph nodes identified by fluorescence imaging after intravenous injection of indocyanine green dye and to compare the sentinel lymph nodes identified by fluorescence imaging with sentinel lymph nodes detected by the standard blue dye technique. Methods This study (SeLyNoFI; Sentinel Lymph Nodes Fluorescence Imaging) is a diagnostic, single-arm, open-label feasibility study, including patients with colorectal adenocarcinoma with or without metastatic disease who are admitted for elective colorectal resection of the primary tumor. This study evaluates the feasibility of a new approach for improving the accuracy of nodal staging using fluorescence imaging after intravenous administration of indocyanine green dye. Sensitivity, positive predictive value, and accuracy of the classical blue dye technique and of the investigatory fluorescence imaging technique will be calculated. Translational research will be proposed, if applicable. Results As of June 2020, this study has been registered. Submission for ethical review is planned for September 2020. Conclusions The potential correlation between the two different approaches to detect sentinel lymph nodes offers new strategies for improving the accuracy of nodal staging in colorectal cancer. This new concept of the systemic sentinel lymph node and a greater understanding of the interactions between systemic sentinel lymph nodes and standard sentinel lymph nodes may provide important information regarding the underlying mechanism of primary tumor lymphatic drainage. The enhanced permeability and retention effect can also play a role in the fluorescence of systemic sentinel lymph nodes, especially if these lymph nodes are inflamed. In this case, we can even imagine that this new technique will highlight more instances of lymph node–positive colorectal cancer. International Registered Report Identifier (IRRID) PRR1-10.2196/17976

Ureteric mapping with Indocyanine green: A new tool to prevent ureteral injury in complex gynecological surgery

Introduction: The aim of this video is to show that ureteric injection of Indocyanine green dye in difficult gynecological operations is a useful tool to identify and safeguard ureters. Case description: A 56-year-old lady with a large 10.5 × 14.5 × 13 cm3 multiloculated endometriotic cyst in the right adnexa was scheduled for robotic-assisted hysterectomy with bilateral salphingooophorectomy. She had undergone a laparotomy and three laparoscopic surgeries for endometriosis and fibroid uterus. Before starting surgery, cystoscopy was performed and with 6 Fr ureteral catheter inserted into ureteral orifice, 5 mL of 0.5% Indocyanine green dye (Aurolab, Madurai, India) was injected into both ureters. Intraoperatively bilateral adnexal cysts were seen densely adherent to omentum, sigmoid colon, sigmoid mesocolon, bladder, and lateral pelvic wall. Bladder and rectosigmoid were pulled up both anteriorly and posteriorly, respectively, and densely adherent to uterus and to adnexal cysts. During surgery, the course of ureter was identified by the green fluorescence emitted by the Indocyanine green dye under near-infrared light on da Vinci Xi camera. During this difficult surgery, the real-time visualization of ureteric course helped to identify and safeguard ureter during adhesiolysis and surgery could be completed without any injury to ureter. Patient did not experience any side effects due to the ureteric Indocyanine green injection. Conclusion: Endometriosis can distort the pelvic anatomy making surgery very challenging. Identifying the course of ureter during surgery can help in avoiding injuries and reduce surgical morbidity.