Real-time assessment of intestinal viability using indocyanine green fluorescent imaging (with video)

Abstract

Indocyanineuorescent imaging;Intestinal viability;Intraoperativeischemia assessmentOne of the major concerns in colorectal surgery is to assess the viability of a colorectalanastomosis in situ, because poor vascularization is considered to be a risk factor foranastomotic leakage. For some groups, any intraoperative doubts about intestinal viabilitymust be followed by a ‘‘second look’’ at 24 or 48hours because there are no consensualmethod (i.e., clinical, biological, or morphological) to assess the vascular supply of thedigestive tube. Imaging detection based on the uorescence properties of indocyaninegreen has been recently developed in liver surgery for the identication of the bile ductsand livercancersduringsurgery[1].Thistechniquealsoallowsvisualizingvesselswithintheintestine and the surrounding tissues [2]. It has been recently validated in animal modelsof intestinal ischemia [3]. Here, in this video vignette, we detail the use of indocyaninegreen (ICG) uorescent imaging to intraoperatively evaluate the intestinal perfusion andviability during bowel surgery.A 66-year-old woman, without any past medical history, was admitted to our hos-pital with episodes of abdominal pain. The physical examination revealed severe anddiffuse abdominal tenderness and muscle guarding. Computed tomography showed mod-erate ascites and several dilated intestinal loops. The diagnosis of small bowel ischemiawas considered, and an immediate laparotomy was performed. The laparotomy ndingsshowed a massive small intestinal necrosis.Intraoperatively, 12.5mg (5mL) of ICG (Infracyanine, Laboratoire Serb, Paris, France)was injected into a peripheral vein. The device (Photo Dynamic Eye PDE: HamamatsuPhotonics Co) was used for intraoperative uorescent images of small bowel. Beforesmall bowel resection, the uorescent imaging clearly delineated the necrotic regionsof the small bowel. After resection, the serosal surface color of distal part of the resid-ual ileum showed a slightly darker hue than the proximal part of the residual jejunum.