Indocyanine Green Fluoroscopy Research Articles

Impact of Indocyanine Green Fluoroscopy on Bile Duct Identification during Laparoscopic Cholecystectomy A 40 Patient Observational Analysis

Background: Laparoscopic cholecystectomy (LC) is a prevalent surgical procedure with inherent risks, notably bile duct injuries (BDIs). Objective: This study aims to evaluate the efficacy of Indocyanine Green (ICG) fluoroscopy in enhancing bile duct identification during LC. Methods: A prospective cohort of 40 patients undergoing LC at Central Hospital Ltd, and Labaid Cancer Hospital and Super Speciality Centre, Dhaka, Bangladesh (2022-2023) was analyzed. Patients received an intravenous dose of ICG (0.5 mg/kg) intraoperatively. Near-infrared fluorescence imaging was employed to visualize biliary structures. Identification rates of bile ducts with and without ICG fluoroscopy were compared using statistical analysis (p < 0.05). Results: ICG fluoroscopy significantly improved bile duct identification, achieving a 95% success rate compared to 72% without ICG (p = 0.003). This represents a 31% relative increase in identification accuracy. The mean operative time was reduced by 15 minutes in the ICG group (mean 92 minutes, SD ±10, range 65-125 minutes). Demographically, 60% were male and 40% female, with a mean age of 37.26 years (SD ±8.5). Additionally, the use of ICG fluoroscopy was associated with a 50% reduction in intraoperative complications related to bile duct misidentification. No adverse events attributable to ICG administration were observed, ensuring its safety profile. The enhanced visualization facilitated clearer delineation of the cystic duct and common bile duct, contributing to improved surgical precision and outcomes. Statistical analysis confirmed the significance of these findings, with confidence intervals for identification rates ranging from 20% to 42%. Conclusions: The integration of ICG fluoroscopy in LC markedly enhances bile duct identification, thereby reducing the incidence of BDIs and improving surgical outcomes. These findings support the routine use of ICG fluoroscopy to enhance patient safety during laparoscopic cholecystectomy

Real-time quantification of bowel perfusion using Laparoscopic Laser Speckle Contrast Imaging (LSCI) in a porcine model

Background/purposeReal-time quantification of tissue perfusion can improve intraoperative surgical decision making. Here we demonstrate the utility of Laser Speckle Contrast Imaging as an intra-operative tool that quantifies real-time regional differences in intestinal perfusion and distinguishes ischemic changes resulting from arterial/venous obstruction.MethodsPorcine models (n = 3) consisted of selectively devascularized small bowel loops that were used to measure the perfusion responses under conditions of control/no vascular occlusion, arterial inflow occlusion, and venous outflow occlusion using laser speckle imaging and indocyanine green fluoroscopy. Laser Speckle was also used to assess perfusion differences between small bowel antimesenteric-antimesenteric and mesenteric-mesenteric anastomoses. Perfusion quantification was measured in relative perfusion units calculated from the laser speckle perfusion heatmap.ResultsLaser Speckle distinguished between visually identified perfused, watershed, and ischemic intestinal segments with both color heatmap and quantification (p < .00001). It detected a continuous gradient of relative intestinal perfusion as a function of distance from the stapled ischemic bowel edge. Strong positive linear correlation between relative perfusion units and changes in mean arterial pressure resulting from both arterial (R2 = .96/.79) and venous pressure changes (R2 = .86/.96) was observed. Furthermore, Laser Speckle showed that the antimesenteric anastomosis had a higher perfusion than mesenteric anastomosis (p < 0.01).ConclusionsLaser Speckle Contrast Imaging provides objective, quantifiable tissue perfusion information in both color heatmap and relative numerical units. Laser Speckle can detect spatial/temporal differences in perfusion between antimesenteric and mesenteric borders of a bowel segment and precisely detect perfusion changes induced by progressive arterial/venous occlusions in real-time.

Application of Indocyanine Green Fluorescence Imaging Combined with Laparoscopic Ultrasound in Laparoscopic Microwave Ablation of Liver Cancer.

BACKGROUND The aim of this study was to assess the effect of indocyanine green (ICG) fluorescence imaging combined with laparoscopic ultrasound in laparoscopic microwave ablation of liver cancer. MATERIAL AND METHODS This study retrospectively analyzed 61 patients who underwent laparoscopic microwave ablation of liver cancer, including laparoscopic microwave ablation with and without ICG fluoroscopy. RESULTS The operative times, ablation times, postoperative hospital stay, postoperative complication rate, hospitalization cost, postoperative liver function changes, and postoperative overall survival were similar between the 2 groups, but there was a statistically significant difference in recurrence-free survival (P<0.05). A total of 5 lesions were found in the fluorescence laparoscopy group that were not found by preoperative imaging, while no new lesions were found in the ordinary laparoscopy group. Fluorescence laparoscopy has obvious advantages over ordinary laparoscopy in finding small lesions that were not found before surgery. In terms of complete ablation rate, 3 patients in the ordinary laparoscopy group and 1 patient in the fluorescence laparoscopy group were judged to be incompletely ablated and were ablated again at 1 month after the operation. CONCLUSIONS For small hepatocellular carcinoma with severe liver cirrhosis and located on the liver surface, fluorescence laparoscopy can better reveal the location and boundary of the tumor, and fluorescence laparoscopy can detect tiny lesions that cannot be detected by preoperative imaging. The combination of fluorescence laparoscopy and microwave ablation has a good effect on the treatment of small hepatocellular carcinoma located on the surface of the liver that is difficult to distinguish.

Laparoscopic Gastric Bypass Conversion to SADI-S with Use of Indocyanine Green Fluoroscopy.

Laparoscopic Gastric Bypass Conversion to SADI-S with Use of Indocyanine Green Fluoroscopy.

Evaluation of the role of indocyanine green fluoroscopy for intraoperative bile duct visualization and prevention of CBD injury during laparoscopic cholecystectomy

Evaluation of the role of indocyanine green fluoroscopy for intraoperative bile duct visualization and prevention of CBD injury during laparoscopic cholecystectomy

The efficacy and safety of laparoscopic cholecystectomy using indocyanine green fluoroscopy

Laparoscopic cholecystectomy (LCC) is now accepted as the gold standard for the management of gallbladder diseases. Currently, one of the basic techniques of general surgical residency in Korea is cholecystectomy. However, it is not easy to overcome the learning curve during fellowship period because about 150 cases are required to overcome. Intraoperative imaging using indocyanine green (ICG) might reduce learning curve and the risk of bile duct injury by improving visualization of the biliary tree. We compared the outcomes of LCC in patients with and without ICG. We performed a retrospective review of total 300 conventional LCC cases with and without ICG performed by three surgeons who started the fellowship of hepatobiliary surgery in a single center. The outcomes of LCC with and without ICG were compared using the operation time, the rate of conversion, complications and the length of stay. The median operation time was 43.0 vs. 39.0 min (p = 0.45) in the group with and without ICG, respectively. Without ICG, after the first 50 cases, operation time is gradually diminished and the mean operation time reached a plateau (average = 35 min). In cases of using ICG, after 30 cases experience, we reached plateau. The rate of conversion was 4.6% in the group without ICG, while 2.5% in the group with ICG. Bile duct injury occurred 1% vs. 2.2% in the group with and without ICG, respectively (p < 0.05). LCC with ICG enables a better visualization and identification of biliary tree and should be considered as a means of increasing the safety and reducing learning curve of LCC.

Perfusion Assessment in Left-Sided/Low Anterior Resection (PILLAR III): A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes With PINPOINT Near-Infrared Fluorescence Imaging in Low Anterior Resection.

Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials. We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak after low anterior resection. We performed a 1:1 randomized controlled parallel study. Recruitment of 450 to 1000 patients was planned over 2 years. This was a multicenter trial. Included patients were those undergoing resection defined as anastomosis within 10 cm of the anal verge. Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy. Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention. This study was concluded early because of decreasing accrual rates. A total of 25 centers recruited 347 patients, of whom 178 were randomly assigned to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p > 0.05). Mean level of anastomosis was 5.2 ± 3.1 cm in perfusion compared with 5.2 ± 3.3 cm in standard (p > 0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of perfusion and 4.2% of standard (p = 0.75). Anastomotic leak was reported in 9.0% of perfusion compared with 9.6% of standard (p = 0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR = 0.845 (95% CI, 0.375-1.905); p = 0.34). The predetermined sample size to adequately reduce the risk of type II error was not achieved. Successful visualization of perfusion can be achieved with indocyanine green fluoroscopy. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine indocyanine green fluoroscopy to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560. ANTECEDENTES:Se ha demostrado que la fluoroscopia con verde de indocianina mejora las tasas de fuga anastomótica en ensayos en fases iniciales.OBJETIVO:Nuestra hipótesis es que la utilización de fluoroscopia para asegurar la irrigación anastomótica puede disminuir la fuga anastomótica luego de una resección anterior baja.DISEÑO:Realizamos un estudio paralelo, controlado, aleatorizado 1:1. Se planificó el reclutamiento de 450-1000 pacientes durante 2 años.AMBITO:Multicéntrico.PACIENTES:Pacientes sometidos a resección definida como una anastomosis dentro de los 10cm del margen anal.INTERVENCIÓN:Pacientes que se sometieron a la evaluación estándar de la irrigación tisular contra la estándar en conjunto con la valoración de la irrigación mediante fluoroscopia con verde indocianina.PRINCIPALES VARIABLES EVALUADAS:El principal resultado fue la fuga anastomótica, y los resultados secundarios fueron la evaluación de la perfusión y la tasa de absceso posoperatorio que requirió intervención.RESULTADOS:Este estudio se cerró anticipadamente debido a la disminución de las tasas de acumulación. Un total de 25 centros reclutaron a 347 pacientes, de los cuales 178 fueron, de manera aleatoria, asignados a perfusión y 169 a estándar. Los grupos tenían datos demográficos específicos del tumor y del paciente similares. Recibieron quimio-radioterapia neoadyuvante el 63,5% de la perfusión y el 65,7% del estándar (p> 0,05). La anastomosis estuvo en un nivel promedio de 5,2 + 3,1 cm en perfusión en comparación con 5,2 + 3,3 cm en estándar (p> 0,05). Se reportó una visualización suficiente de la perfusión en el 95,4% de los pacientes del grupo de perfusión. El absceso posoperatorio que requirió tratamiento quirúrgico fue de 5,7% de los perfusion y en el 4,2% del estándar (p = 0,75). Se informó fuga anastomótica en el 9,0% de la perfusión en comparación con el 9,6% del estándar (p = 0,37). En el análisis de regresión multivariante, no hubo diferencias en las tasas de fuga anastomótica entre la perfusión y el estándar (OR 0,845; IC del 95% (0,375; 1,905); p = 0,34).LIMITACIONES:No se logró el tamaño de muestra predeterminado para reducir satisfactoriamente el riesgo de error tipo II.CONCLUSIÓN:Se puede obtener una visualización adecuada de la perfusión con ICG-F. Sin embargo, no se observaron diferencias en las tasas de fuga anastomótica entre los pacientes que se sometieron a evaluación de la perfusión versus la técnica quirúrgica estándar. En manos expertas, agregar ICG-F a la rutina de la práctica estándar no agrega ningún beneficio clínico evidente. Consulte Video Resumen en http://links.lww.com/DCR/B560. (Traducción-Dr Juan Antonio Villanueva-Herrero).

Modified Orbitozygomatic Craniotomy for a Previously Coiled Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

Clip occlusion of previously coiled aneurysms poses unique technical challenges. The coil mass can complicate aneurysm neck access and clip tine approximation. This patient had a previously ruptured anterior communicating artery (ACOM) aneurysm that had been treated with coil embolization. On follow-up evaluation, the patient was found to have a recurrence of the aneurysm, which prompted an orbitozygomatic craniotomy for clip occlusion. The approach provided a favorable view of the aneurysm neck with the coil mass protruding outside the aneurysm dome. Indocyanine green fluoroscopy was used to assist with ideal permanent clip placement along the aneurysm neck. The segment of coils present outside the aneurysm neck was removed to reduce mass effect on the optic chiasm. Postoperative imaging demonstrated aneurysm obliteration. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Lumbar 4-5 Laminoplasty for Ligation of Dural Fistula: 2-Dimensional Operative Video.

The goal of treatment for spinal dural arteriovenous fistulas is disconnection of the fistulous point to eliminate venous congestion-associated hypoperfusion and mass effect. The nidus can be surgically excised or disconnected from the arterial feeder just proximal to the dilated venous plexus. This patient had a filus terminale dural arteriovenous fistula. The patient had multiple findings of myelopathy, which prompted the imaging evaluation that revealed prominent flow voids and significant caudal thoracic spinal cord edema. Preoperative digital subtraction angiography demonstrated a fistulous point at the lumbar 4 level. A lumbar 4 and lumbar 5 laminoplasty was performed for spinal canal access. Following achievement of intradural access, exploration was performed, augmented by indocyanine green fluoroscopy. The filum terminale was then transected, and the fistula was then completely excised to achieve surgical cure. Following the procedure, the patient's myelopathy improved, and she regained ambulatory status. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Posterior C2-6 Laminoplasty for Resection of Arteriovenous Malformation: 2-Dimensional Operative Video.

Large extramedullary-intramedullary arteriovenous malformations (AVMs) within the spinal cord provide a unique management opportunity, compared with the cranial counterpart, in that the surgical morbidity can be minimized and surgical cure can still be achieved by resecting the extramedullary segment and leaving the intramedullary segment without invading the parenchyma. This management strategy minimizes morbidity and provides an excellent chance of surgical cure. This patient had a history of longstanding left hemiparesis since birth that progressed, prompting imaging evaluation that demonstrated a large cervical AVM with bilateral vertebral artery, anterior spinal artery, and left thyrocervical trunk feeding vessels. The AVM had both extramedullary and intramedullary components, making this a challenging lesion for microsurgical obliteration and preservation of neurological function. Preoperative embolization was utilized through the right vertebral artery pedicle. Microdissection was performed to isolate the extramedullary from the intramedullary component. Surgical cure was attempted for this patient by removing the extramedullary component and leaving the intramedullary segment. Indocyanine green fluoroscopy was used to isolate the feeding pedicle and guide surgical resection. Postoperative imaging demonstrated a small residual from the thyrocervical injection, which was obliterated with embolization. The patient improved neurologically within the postoperative period and regained ambulatory status during long-term follow-up. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Orbitozygomatic Craniotomy for Giant Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

Giant intracranial aneurysms pose a significant surgical challenge because of the associated difficulty in achieving adequate visualization of the parent artery and aneurysm neck. This patient had an incidentally identified giant anterior communicating artery aneurysm. An orbitozygomatic craniotomy was performed for aneurysm exposure and aneurysmal neck dissection. Aneurysm dome opening and thrombectomy was performed to debulk the aneurysmal mass, which facilitated subsequent aneurysmal neck visualization. Sequential utilization of temporary clips of the bilateral A1 and bilateral A2 vessels reduced hemorrhage during thrombectomy. Multiple permanent clips were applied along the dissected aneurysm neck to permit occlusion. A small fracture of the aneurysm neck was identified, and cotton was applied with subsequent tamponade utilizing a fenestrated clip to maintain hemostasis. Indocyanine green fluoroscopy was used to verify parent and distant vessel patency. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Thoracic 11-Lumbar 1 Laminoplasty for Resection of Conus Arteriovenous Malformation: 2-Dimensional Operative Video.

Conus medullaris spinal arteriovenous malformations are uniquely classified by the Spetzler classification. They possess a glomus (type II) nidus in either or both the intra- and extramedullary compartments, with multiple feeding arteries and niduses resulting in complex venous drainage patterns. These characteristics make resection of these lesions challenging, and these lesions are associated with a high risk for recurrence. This patient presented with a subarachnoid hemorrhage, and thorough imaging evaluation revealed a conus arteriovenous malformation. The patient underwent thoracic 11 to lumbar 1 laminoplasty for resection of the lesion. The arteriovenous malformation was circumdissected off the conus and lumbosacral nerve roots using sharp dissection and bipolar forceps. It was visualized both before and after resection with indocyanine green fluoroscopy. The patient tolerated the procedure well, and postoperative angiography demonstrated complete resection. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Right Orbitozygomatic Craniotomy for Clip Wrapping of an A2 Fusiform Aneurysm: 2-Dimensional Operative Video.

Distal anterior cerebral artery aneurysms often rupture at a small size and are associated with overall higher operative morbidity relative to other anterior circulation aneurysms. This patient had an incidentally identified anterior cerebral artery proximal A2 segment fusiform aneurysm that did not respond to endovascular treatment and required open surgical management. The fusiform dilation was mobilized and isolated circumferentially within the interhemispheric fissure, and a Gore-Tex clip-wrapping was planned. A permanent clip was applied along the aneurysmal dilation parallel to the vessel directly prior to completing the wrapping to attempt to establish native flow dynamics through the aneurysmal segment. The clip-wrapping was then completed, and intraoperative indocyanine green fluoroscopy demonstrated good distal flow through the aneurysmal segment. The patient gave informed consent for surgery and video recording. The institutional review board approval was deemed unnecessary. Used with permission from the Barrow Neurological Institute, Phoenix, Arizona.

The role of indocyanine green fluoroscopy for intraoperative bile duct visualization during laparoscopic cholecystectomy: an observational cohort study in 70 patients

BackgroundBile duct injury is the most feared complication during laparoscopic cholecystectomy. Real-time intraoperative imaging using indocyanine green (ICG) might reduce the risk of bile duct injury by improving visualization of the biliary tree during laparoscopic cholecystectomy. We compared the outcomes of laparoscopic cholecystectomy in patients with and without real-time ICG.MethodsA retrospective analysis of the data of patients undergoing laparoscopic cholecystectomy with and without ICG in a referral centre for minimally invasive surgery was performed. We hypothesized that laparoscopic cholecystectomy with real-time ICG enables a better identification of the biliary tree and thus increases surgical safety. The outcomes of laparoscopic cholecystectomy with and without ICG were compared using the duration of surgery, the rate of bile duct injury, the rate of conversion, complications and the length of stay.ResultsSeventy patients including 29 with and 41 without ICG underwent laparoscopic cholecystectomy within the period of investigation. The median duration of surgery was 53.0 vs. 54.0 min while the median length of stay was 2.0 d in the group with and without ICG respectively. The rate of conversion was 2.4% in the group without ICG, while no conversion was performed in the group with ICG. NO bile duct injury occurred in both groups. These differences were not statistically significant.ConclusionLaparoscopic cholecystectomy with real-time indocyanine green fluorescence cholangiography enables a better visualization and identification of biliary tree and therefore should be considered as a means of increasing the safety of laparoscopic cholecystectomy.

Searching for the right timing of surgical delay: angiogenesis, vascular endothelial growth factor and perfusion changes in a skin-flap model

The angiogenic potential of vascular endothelial growth factor (VEGF) and its oxygen pressure-dependent regulation suggest a strong connection between this growth factor and the 'delay phenomenon'. In this study we focused on the chronological changes in VEGF concentration and flap perfusion in order to optimise the duration of surgical delay. The VEGF concentration in skin and underlying muscle was measured in oversized, random-pattern flaps on 38 male Sprague-Dawley rats after 3, 5 or 7 days of surgical delay. Additionally, flaps were raised 5 or 7 days past preconditioning. The effect on flap perfusion was measured using indocyanine green fluoroscopy and the size of surviving and necrotic areas of the flaps were analysed. Microvessel density was assessed using a monoclonal CD31 antibody, and vessel diameter and morphometry were appraised by means of corrosion casting. VEGF expression in the distal half of the flaps was significantly increased 3 days after preconditioning and perfusion was significantly enhanced after day 5. An interval of 5 days between preconditioning and flap transposition resulted in a significantly reduced average necrosis rate. Microvessel density was significantly increased and vessel diameters were enlarged (P<0.05). We illustrated the chronology of events from the ischaemic procedure to the rise in VEGF concentration and changes in flap perfusion, and demonstrated vasodilatation and the formation of new vessels. Most significantly, we were able to further specify the optimal length of surgical delay based on alterations on a molecular level as well as changes in vascularisation and perfusion.

Evaluation der Perfusion von Lappenplastiken mittels Laserfluoreszenz von Indocyaningrün

Prediction of necrosis in critically perfused skin flaps is difficult and rarely precise. An early detection of insufficiently perfused skin is highly desirable since it may lead to surgical decisions such as operative flap revision or early resection. The application of laser-induced indocyanine green (ICG) fluoroscopy allows an objective quantification of skin perfusion and a high topographical resolution. Aim of the present study is to determine a threshold value for flap perfusion under well-defined experimental conditions and test the validity of the results in the clinical application. Twenty overdimensioned random pattern flaps with a length to width ratio of 4 : 1 (8 x 2 cm) were dissected at the anterior abdominal wall of 20 male Sprague-Dawley rats weighing 365 g on average. ICG fluorescence was performed at the end of the operation by intravenous injection of 1 g ICG/kg bodyweight into a tail vein and digital recording. On the seventh postoperative day, both the necrotic and surviving areas of the flaps were measured and the ICG-fluorescence was analysed in the areas that had undergone necrosis. 41 flaps with areas of critical perfusion (18 skin flaps, 13 muscle flaps, 8 replantations) were analysed in 39 patients. The surviving part of the flap had a mean perfusion index of 62 % compared to reference skin. The distal parts of the flap that necrotized during the experiment showed an average perfusion index of 19 % postoperatively. Differences were statistically significant (p < 0.001). In clinical application, a number of 13 flaps were found to have a perfusion index less than 25 % in a region of critical perfusion. Eleven of these developed a partial necrosis in that region, one flap underwent total necrosis. Indocyanine green fluoroscopy allows a detailed topographical analysis of flap perfusion and the prediction of necrosis. Experimental findings presented a threshold value for the perfusion index of 25 % which could be confirmed in clinical application.

Prediction of flap necrosis with laser induced indocyanine green fluorescence in a rat model

Prediction of necrosis has a clinical relevance in all fields of plastic surgery. The new application of indocyanine green (ICG) fluoroscopy in plastic surgery allows an objective quantification of skin perfusion and a high topographical resolution. The aim of the present study is to determine threshold values for flap perfusion under well-defined experimental conditions. Twenty random pattern flaps with a length to width ratio of 4:1 (8 x 2 cm(2)) were dissected on the anterior abdominal wall of 20 male Sprague-Dawley rats. ICG fluoroscopy was performed at the end of the operation. The animals were sacrificed at the seventh postoperative day with a reliable necrosis of the distal part of the flaps. Postoperative ICG fluoroscopy then was analysed both in regions that will survive and undergo necrosis. At day 7 a mean area of 5.5 cm(2) (57% of the total flap area) survived and a mean of 3.8 cm(2) (43%) became necrotic. The surviving part of the flap had a mean perfusion index of 62% compared to reference skin. The distal parts of the flap that necrotised showed an average perfusion index of only 19% postoperatively. Differences were statistically highly significant (p<0.001). Indocyanine green fluoroscopy is a useful tool to evaluate perfusion topographically and predict necrosis. From a statistical point of view a perfusion index of less than 25% of the reference skin can be considered as a sign of developing flap necrosis.