Indocyanine Green Near-infrared Fluorescence Imaging Research Articles

Comparison of indocyanine green-near-infrared fluorescence guided and traditional mediastinal lymphadenectomy during radical esophagectomy: A randomized controlled trial

BackgroundThe extent of lymph node dissection during radical esophagectomy remains a controversial topic. Thus, this study mainly aimed to explore the location of sentinel lymph nodes in esophageal squamous cell carcinoma and the application value of the indocyanine green–near-infrared fluorescence system in lymphadenectomy. MethodsThis randomized controlled clinical trial (ClinicalTrials.gov, NCT04615806) included 42 participants without neoadjuvant therapy who were lymph node negative based on positron emission tomography/computed tomography findings. Traditional esophagectomy with indocyanine green–near-infrared fluorescence imaging was performed after injecting 0.5 mL indocyanine green (1.25 mg/mL) into the esophageal submucosa in the 4 peritumoral quadrants. The primary endpoint was to determine the location of the sentinel lymph node in esophageal squamous cell carcinoma based on postoperative pathologic reports. ResultsA total of 40 patients, with 20 in each group, were included in the final analysis. In the indocyanine green group, indocyanine green–near-infrared fluorescence imaging was successful in all subjects. Seven cases (cases 2, 3, 9, 11, 17, 18, and 20) in the indocyanine green group exhibited lymph node metastases, all of which were near-infrared positive. The detection rate, positive predictive value, negative predictive value, sensitivity, and specificity were 100% (20 of 20 cases), 8.7% (13/150), 100% (265/265), 100% (13/13), and 65.9% (265/402), respectively. All near-infrared–negative lymph nodes were nonmetastatic lymph nodes. In addition, the number of mediastinal lymph nodes resected in the indocyanine green group was significantly higher than in the non–indocyanine green group. ConclusionIndocyanine green–near-infrared might be an important and promising technique in predicting sentinel lymph nodes of esophageal squamous cell carcinoma and could significantly improve the detection rate of lymph nodes of esophageal squamous cell carcinoma.

Application of Indocyanine Green Fluorescence Imaging in Assisting Biopsy of Musculoskeletal Tumors

(1) Background: Biopsies are the gold standard for the diagnosis of musculoskeletal tumors. In this study, we aimed to explore whether indocyanine green near-infrared fluorescence imaging can assist in the biopsy of bone and soft tissue tumors and improve the success rate of biopsy. (2) Method: We recruited patients with clinically considered bone and soft tissue tumors and planned biopsies. In the test group, indocyanine green (0.3 mg/kg) was injected. After identifying the lesion, a near-infrared fluorescence camera system was used to verify the ex vivo specimens of the biopsy in real time. If the biopsy specimens were not developed, we assumed that we failed to acquire lesions, so the needle track and needle position were adjusted for the supplementary biopsy, and then real-time imaging was performed again. Finally, we conducted a pathological examination. In the control group, normal biopsy was performed. (3) Results: The total diagnosis rate of musculoskeletal tumors in the test group was 94.92% (56/59) and that in the control group was 82.36% (42/51). In the test group, 14 cases were not developed, as seen from real-time fluorescence in the core biopsy, and then underwent the supplementary biopsy after changing the puncture direction and the location of the needle channel immediately, of which 7 cases showed new fluorescence. (4) Conclusions: Using the near-infrared fluorescence real-time development technique to assist the biopsy of musculoskeletal tumors may improve the accuracy of core biopsy and help to avoid missed diagnoses, especially for some selected tumors.

Use of quantitative indocyanine green near-infrared fluorescence imaging in bariatric surgery: early results

Introduction Indocyanine green fluorescence angiography (ICG-FA) is commonly used in general surgery, but its use in bariatric surgery is still marginal. Moreover, post-operative leaks remain a dramatic complication after this surgery and the leak tests available have poor performance preventing them. The aim of the present paper is to assess the use and utility of a new innovative technology based on quantitative measures of fluorescence signal intensity. Material and methods From January 2022 to June 2022, 40 consecutive patients with a median age of 51 years and a preoperative median body mass index of 45.2 kg/m2 underwent bariatric surgery with quantitative ICG fluorescence angiography in our center. Two different types of surgery, based on the multidisciplinary evaluation, were performed: laparoscopic sleeve gastrectomy (LSG) and one anastomosis gastric bypass (OAGB). For ICG visualization, quantitative laparoscopic ICG platform was used to identify the vascular supply. Results Thirteen patients underwent LSG and 27 patients underwent OAGB. ICG was performed in all patients with no adverse events. An adequate and satisfactory blood supply was assessed in each case. No case of post-operative leak was detected. Conclusions The quantitative ICG-FA seems to be a useful and promising tool for the prevention of complications in bariatric surgery but further studies are mandatory.

V05-09 ROBOT-ASSISTED PARTIAL NEPHRECTOMY FOR NEW OR RECURRENT TUMOR IN PATIENT WITH PRIOR PARTIAL NEPHRECTOMY OR TUMOR ABLATION

You have accessJournal of UrologyCME1 Apr 2023V05-09 ROBOT-ASSISTED PARTIAL NEPHRECTOMY FOR NEW OR RECURRENT TUMOR IN PATIENT WITH PRIOR PARTIAL NEPHRECTOMY OR TUMOR ABLATION Sumit Saini, Timothy O'Rourke, Parth Thakker, and Ashok Hemal Sumit SainiSumit Saini More articles by this author , Timothy O'RourkeTimothy O'Rourke More articles by this author , Parth ThakkerParth Thakker More articles by this author , and Ashok HemalAshok Hemal More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003263.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Salvage robot-assisted partial nephrectomy (sRAPN) for new or recurrent renal tumor is a technically challenging procedure secondary to varying degree of peri & paranephric fibrosis and intrarenal changes in parenchymal architecture. Here in, we demonstrate surgical technique in such complex cases. METHODS: Between January 2013 and July 2022, we queried our prospectively maintained institutional database. We identified 20 renal lesions in 18 patients who underwent robot-assisted salvage partial nephrectomy for local recurrences after prior partial nephrectomy or tumor ablation. Meticulous dissection through the adhesions while ensuring a rim of normal renal parenchyma is the key to achieve negative surgical margins in these challenging cases. Intraoperative ultrasound and indocyanine green-near infrared fluorescence imaging (ICG-NIRF) also play an indispensable role in these cases. RESULTS: Majority of our patients either had prior cryoablation or prior partial nephrectomy (Table 1). A second/new renal lesion was noted in 2 patients in the same kidney following initial cryoablation which were also excised simultaneously. Median time to recurrence from primary procedure was 2 years (1-7) and mean age at salvage surgery was 65±10.2 years. Mean operative time was 161.4 minutes (66-348) and mean warm ischemia time was 23.3±4.6 minutes. All the surgical margins were negative and none of the patients developed any major complications post-operatively. At median follow up of 15 months (3-62), all patients are alive and none of the patients developed any recurrence. CONCLUSIONS: sRAPN for new or recurrent renal tumor in patients with prior partial nephrectomy or tumor ablation is technically feasible with excellent peri-operative and oncological outcomes. However, it requires prudent cross-sectional imaging to understand spatial anatomy and technical tools such as intraoperative ultrasound/near infrared fluorescence imaging with ICG. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e426 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sumit Saini More articles by this author Timothy O'Rourke More articles by this author Parth Thakker More articles by this author Ashok Hemal More articles by this author Expand All Advertisement PDF downloadLoading ...

Quantification of near-infrared fluorescence imaging with indocyanine green in free flap breast reconstruction

One of the complications of free flap breast reconstruction is the occurrence of skin and fat necrosis. Intra-operative use of near-infrared (NIR) fluorescence imaging with Indocyanine Green (ICG) has the potential to predict these complications. In this study, the quantification of the fluorescence intensity measured in free flap breast reconstruction was performed to gain insight into the perfusion patterns observed with ICG NIR fluorescence imaging. ICG NIR fluorescence imaging was performed in patients undergoing free flap breast reconstruction following mastectomy. After completion of the arterial and venous anastomosis, 7.5mg ICG was administered intravenously. The fluorescence intensity over time was recorded using the Quest Spectrum Platform®. Four regions of interest (ROI) were selected based on location and interpretation of the NIR fluorescence signal: (1) The perforator, (2) normal perfusion, (3) questionable perfusion, and (4) low perfusion. Time-intensity curves were analyzed, and two parameters were extracted: Tmax and Tmax slopes. Successful ICG NIR fluorescence imaging was performed in 13 patients undergoing 17 free flap procedures. Region selection included 16 perforators, 17 normal perfusions, 8 questionable perfusions, and 5 low perfusion ROIs. Time-intensity curves of the perforator ROIs were comparable to the ROIs of normal perfusion and demonstrated a fast inflow. No outflow was observed for the ROIs with questionable and low perfusion. This study provides insight into the perfusion patterns observed with ICG NIR fluorescence imaging in free flap breast reconstruction. Future studies should correlate quantitative parameters with clinical perfusion assessment and outcome.

A narrative review of indocyanine green near-infrared fluorescence imaging technique: a new application in thoracic surgery

: In clinical work of thoracic surgery, accurate anatomic location of pulmonary nodules, precise demarcation of segmental and sub-segmental plane, tracing of sentinel lymph nodes (SLNs), protection of thoracic nerve, averting of anastomotic fistula etc. always puzzling the surgeons. Indocyanine green (ICG) is a near-infrared fluorescence (NIRF) contrast agent that is the only reagent approved by the Food and Drug Administration (FDA) for use in human subjects due to its low toxicity and high absorbance in the near-infrared spectrum. The application of ICG NIRF imaging technology in surgery is safe and feasible, it can offer real-time fluorescing information and help surgeons make important decisions during surgery. Many studies demonstrated that ICG NIRF can be used to determine tissue perfusion, lymphatic reflux and other fields. In recent years, it has been reported in the field of thoracic surgery and got success. It can provide more information compared to conventional video-assisted thoracoscopic surgery (VATS). In this review, the research results of this technique in animal models and clinical trials in recent years are reviewed the application of ICG NIRF technique in accurate positioning of pulmonary nodules, precise demarcation of segmental and sub-segmental plane, SLNs tracing, thoracic nerve protection, anastomotic leakage and chylothorax prevention.

Optimization and Quantification of Near-Infrared Fluorescence Imaging in Assessing Tissue Perfusion Following Revascularization

Current diagnostic modalities for patients with peripheral artery disease (PAD) mainly focus on the macrovascular level. Quantitative assessment of perfusion on skin level remains unknown. Reliable information on regional perfusion can guide decision-making and possibly predict wound healing. For the quantitative assessment of tissue perfusion, near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) has shown promising results. In this pilot study, ICG NIR fluorescence imaging was performed to quantify changes in foot perfusion following revascularization.

Assessment of Tissue Viability Following Amputation Surgery Using Near-Infrared Fluorescence Imaging With Indocyanine Green

Patients with chronic limb threatening ischemia have a risk of undergoing a major amputation within 1 year of nearly 30% with a substantial risk of re-amputation since wound healing is often impaired. Quantitative assessment of regional tissue viability following amputation surgery can identify patients at risk for impaired wound healing. In quantification of regional tissue perfusion, near-infrared (NIR) fluorescence imaging using Indocyanine Green (ICG) seems promising. This pilot study included adult patients undergoing lower extremity amputation surgery due to peripheral artery disease or diabetes mellitus. ICG NIR fluorescence imaging was performed within 5 days following amputation surgery using the Quest Spectrum PlatformⓇ. Following intravenous administration of ICG, the NIR fluorescence intensity of the amputation wound was recorded for 10 minutes. The NIR fluorescence intensity videos were analyzed and if a fluorescence deficit was observed, this region was marked as "low fluorescence." All other regions were marked as "normal fluorescence." Successful ICG NIR fluorescence imaging was performed in 10 patients undergoing a total of 15 amputations. No "low fluorescence" regions were observed in 11 out of 15 amputation wounds. In 10 out of these 11 amputations, no wound healing problems occurred during follow-up. Regions with "low fluorescence" were observed in 4 amputation wounds. Impaired wound healing corresponding to these regions was observed in all wounds and a re-amputation was necessary in 3 out of 4. When observing time-related parameters, regions with low fluorescence had a significantly longer time to maximum intensity (113 seconds vs. 32 seconds, P=0.003) and a significantly lesser decline in outflow after five minutes (80.3% vs. 57.0%, P=0.003). ICG NIR fluorescence imaging was able to predict postoperative skin necrosis in all four cases. Quantitative assessment of regional perfusion remains challenging due toinfluencing factors on the NIR fluorescence intensity signal, including camera angle, camera distance and ICG dosage. This was also observed in this study, contributing to a large variety in fluorescence intensity parameters among patients. To provide surgeons with reliable NIR fluorescence cut-off values for prediction of wound healing, prospective studies on the intra-operative use of this technique are required. The potential prediction of wound healing using ICG NIR fluorescence imaging will have a huge impact on patient mortality, morbidity as well as the burden of amputation surgery on health care.

Handheld Near-Infrared Fluorescence Imaging Device Using Modified Action Cameras for Peri-Operative Guidance of Microvascular Flap Surgery.

Indocyanine green near-infrared fluorescence (ICG-NIRF) imaging has recently come into use as a novel method in peri-operative microvascular flap assessment. However, a majority of the many commercial devices launched for clinical use lack mobility, portability, and cost-efficiency and are thus unsuitable for intra-oral applications. This study introduces a cost-effective, customized, handheld NIRF device following principles of ICG-NIRF imaging. Moreover, the novel characteristics of our prototype, considered in conjunction with a literature review highlighting the significance of fluorescence devices in microvascular surgery, point to a new generation of devices for use in microvascular flap surgery.

Demarcating the Exact Midplane of the Liver Using Indocyanine Green Near-Infrared Fluorescence Imaging during Laparoscopic Donor Hepatectomy

Introduction: Indocyanine green (ICG) near-infrared fluoroscopy has been widely implemented in laparoscopic donor hepatectomy for precise demarcation of the liver midplane. This study aims to show the effectiveness of ICG fluoroscopy and to determine that a single injection of ICG is adequate for both midplane dissection and bile duct division.

Indocyanine green fluorescence imaging-guided resection of colorectal liver metastasis

Most people with colorectal cancer eventually develop liver metastasis. Small liver metastasis can be hard to identify and sometimes missed during liver resection. We present our experience and suggest intraoperative navigation using indocyanine green near-infrared fluorescence imaging to ensure complete surgical eradication of liver metastases from colorectal cancer.

Clinical utility of transanal indocyanine green near-infrared fluorescence imaging for evaluation of colorectal anastomotic perfusion.

Although indocyanine green (ICG) fluorescence imaging has been reported to be useful for assessing colorectal perfusion, unstable quantification remains an issue. We performed ICG fluorescence observation from the luminal side and examined the usefulness of the transanal approach. A total of 69 patients who underwent left-side colon surgery were enrolled in this cohort study. After the anastomosis had been constructed, ICG 0.2mg/kg was injected intravenously. The anastomotic site was then observed by a scope inserted transanally. The following items were examined in the areas of the anastomotic site with the highest- and lowest-fluorescence intensity: maximum fluorescence (Fmax), time from ICG injection to Fmax (Tmax), time from start of dyeing to Fmax (ΔT), and the contrast pattern of the mucosa. Anastomotic leakage (AL) occurred in nine cases. Tmax and ΔT values of the lowest-fluorescence area in the distal intestine showed significant differences in the cases with AL (P = 0.015 and P = 0.040, respectively). Regarding the contrast pattern of the mucosa of the lowest-fluorescence area in the proximal and distal intestine, the patients in whom the vessels were not depicted in the area had a significantly higher incidence of AL than those in whom vessels were depicted in the area (P = 0.031 and P = 0.030, respectively). Some of the areas in which vessels were not depicted by ICG fluorescence observation from the luminal side corresponded to the points of leakage. There were heterogeneous changes that might not be grasped by observation from the serosal side. Transanal ICG fluorescence imaging can evaluate perfusion over the entire circumference of the anastomosis in detail and aid in assessing the risk of AL. Therefore, the examination of the detailed low-perfusion area enables us to take measures for AL and to search for safer operative managements.

The application of indocyanine green fluorescent navigation in laparotomy of cholecystectomy

Objective: To explore the application of indocyanine green fluorescence navigation in open cholecystectomy. Methods: Forty-eight patients with extrahepatic cholangiography who underwent open cholecystectomy in our hospital from March 2016 to February 2018 were enrolled. They were divided into the control group (24 cases) and the experimental group (24 cases) by using the random number table method. The control group was treated with conventional X-ray cholangiopancreatography, and the experimental group was treated with indocyanine green near-infrared fluorescence imaging for extrahepatic cholangiography. The cholangiography success rate, cholangiography time, cholangiography economic costs, imaging accuracy and security were compared between two groups. The operation time, intraoperative blood loss, blood transfusion amount, length of hospital stays, and hospital expenses were also compared between two groups. Results: The success rate of cholangiography (98.62% vs 97.22%) and the incidence of adverse reactions (25.00 vs 29.17) were not significantly different between the two groups (P>0.05). The cholangiography time (25.69±3.47 min vs 31.42±4.66 min), operation time (90.18±10.27 min vs 81.44±9.35 min), intraoperative blood loss (82.35±8.24 ml vs 78.14±7.82 ml), blood transfusion volume (35.19±4.77 ml vs 29.58±4.03 ml), hospitalization time (7.59±1.52 d vs 6.24±1.25 d), and hospitalization cost (12.7±3.1 thousands vs 10.4±2.5 thousands) of the experimental group were significant lower than those of the control group. The accuracy rate (92.22% vs 87.50%), sensitivity (85.71% vs 50.00%) and specificity (88.24% vs 68.75%) of cholangiography in the experimental group were significantly higher than those in the control group, with statistically significant differences (P<0.05). Conclusion: Indocyanine green fluorescent navigation is more timely and accurate than traditional X-ray cholangiography during temporary angiography in open cholecystectomy, which can effectively shorten the operation time, intraoperative blood loss, blood transfusion, hospitalization time and hospitalization expenses. It does not increase the incidence of adverse reactions, has high safety, and is worthy of clinical promotion.

Intraoperative detection of the remnant cystic duct during robot-assisted surgery using near-infrared fluorescence imaging: a case report

BackgroundPost cholecystectomy syndrome is characterized as recurrence of symptoms as experienced before cholecystectomy. In rare cases, a remnant cystic duct is causing these symptoms and occasionally surgical resection is performed. During surgery, visualization of the biliary ducts could be difficult due to inflammation and dense adhesions.Case presentationIn this article, we presented a 36-year old woman with post-cholecystectomy syndrome in which we evaluated the feasibility of near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) for visualization of the remnant cystic and common bile duct during robot-assisted surgery. Intraoperative visualization of the remnant biliary duct and other important structures was feasible, and resection of the remnant cystic duct was successfully performed under fluorescence guidance, without any complications.ConclusionsNIR fluorescence imaging of the biliary ducts using ICG does not prolong the operating time, and could potentially decrease the operation time in difficult procedures, because of easy and fast detection of the biliary tract. Furthermore, it is a non-hazardous and non-invasive technique, as it does not require use of radiation and cannot cause bile duct injury. This case illustrated that ICG NIR fluorescence imaging during difficult robot-assisted surgical procedures of the bile ducts is effective and therefore highly recommended.

Pure Laparoscopic Living Donor Right Hepatectomy Using Real-Time Indocyanine Green Fluorescence Imaging

IntroductionIn recent decades, the quantitative and technological development of laparoscopic liver resection has resulted in an extension into the transplantation area.1,2 However, laparoscopic living donor hepatectomy is still in its infancy due to technical difficulties and extreme caution regarding donor safety.3 Several experienced major centers have demonstrated the feasibility and safety of laparoscopic living donor hepatectomy, and recent advances in laparoscopic imaging technology support this move.4 In particular, indocyanine green near-infrared fluorescence imaging helps determine the correct liver parenchyma anatomical resection and the exact point of bile duct division.4-6 This video demonstrates the technique of pure laparoscopic living donor right hepatectomy and the usefulness of indocyanine green fluorescence imaging. MethodsThe donor was a 32-year-old gentleman who decided to donate part of his liver to his wife who was suffering from viral liver cirrhosis and hepatocellular carcinoma. His BMI was 20.3 kg/m2 and the preoperatively estimated donor’s right liver volume was 836 ml, representing 63.6% of his entire liver. With the recipient’s weight of 57 kg, the graft-to-recipient weight ratio (GRWR) was 1.6%. The liver had classic hilar anatomy except that the right posterior intrahepatic duct was joined separately to the left main hepatic duct. The patient setting and the placement of the trocars were the same as for our conventional laparoscopic right hepatectomy technique.7 After right hepatic artery and portal vein isolation and clamping, 2.5 mg of indocyanine green was injected intravenously. ResultsTotal operation time was 370 min and estimated blood loss was 150 ml without transfusion. Indocyanine green fluorescence imaging clearly demonstrated the anatomical demarcation between the lobes and visualized the running of the biliary tree. His postoperative course was uneventful, and he was discharged on postoperative day 7. ConclusionReal-time indocyanine green fluorescence imaging may be particularly helpful for delineating the anatomical surgical plane and determining the appropriate division point of the hepatic duct during laparoscopic living donor hepatectomy.

Potential of indocyanine green near-infrared fluorescence imaging in experimental and clinical practice.

Visualization of Indocyanine Green (ICG) near-infrared (NIR) fluorescence is a promising technique for biomedical applications because of its deep tissue penetration, low autofluorescence, weak dependence on ambient light, safety for patients and medical staff. To apply this technique to animal studies and clinical practice, we developed multispectral NIR fluorescence imaging system FLUM-808, which can be used in experimental studies and clinical practice, in open and endoscopic surgery (fluorescence-guided surgery). The object is illuminated either directly or through an illumination channel depending on what optical instrument is used (camera lens, fiber endoscope, rigid endoscope, surgical microscope, etc.). The system is able to simultaneously display NIR images and images captured under white light. This article provides examples of imaging techniques used during open and endoscopic surgery with ICG as an NIR fluorescent dye and photosensitizer, demonstrates applications of the technique for experimental and clinical purposes: for intraoperative imaging of blood and lymphatic vessels; for detection of tumors and sentinel lymph nodes; for assessment of tissue, organ, or anastomotic blood supply. This method significantly helps to accurately assign the areas of increased fluorescence to certain anatomical structures during surgery. NIR fluorescence diagnosis can be used in important experimental studies and in clinical practice. The described results of ICG studies can help in developing new fluorescence-based diagnostic and theranostic approaches employing more effective exogenous fluorophores and photosensitizers.

Real time cholangiography using indocyanine green near-infrared fluorescence imaging in living donor hepatectomy

Real time cholangiography using indocyanine green near-infrared fluorescence imaging in living donor hepatectomy

Near-infrared fluorescence cholangiography with indocyanine green for biliary atresia. Real-time imaging during the Kasai procedure: a pilot study.

Hepatoportoenterostomy (HPE) with the Kasai procedure is the treatment of choice for biliary atresia (BA) as the initial surgery. However, the appropriate level of dissection level of the fibrous cone (FC) of the porta hepatis (PH) is frequently unclear, and the procedure sometimes results in unsuccessful outcomes. Recently, indocyanine green near-infrared fluorescence imaging (ICG-FCG) has been developed as a form of real-time cholangiography. We applied this technique in five patients with BA to visualize the biliary flow at the PH intraoperatively. ICG was injected intravenously the day before surgery as the liver function test, and the liver was observed with a near-infrared camera system during the operation while the patient's feces was also observed. In all patients, the whole liver fluoresced diffusely with ICG-containing stagnant bile, whereas no extrahepatic structures fluoresced. The findings of the ICG fluorescence pattern of the PH after dissection of the FC were classified into three types: spotty fluorescence, one patient; diffuse weak fluorescence, three patients; and diffuse strong fluorescence, one patient. In all five patients, the feces evacuated after HPE showed distinct fluorescent spots, although that obtained before surgery showed no fluorescence. One patient with diffuse strong fluorescence who did not achieve JF underwent living related liver transplantation six months after the initial HPE procedure. Four patients, including three cases involving diffuse weak fluorescence and one case involving spotty fluorescence showed weak fluorescence compared to that of the surrounding liver surface. We were able to detect the presence of bile excretion at the time of HPE intraoperatively and successfully evaluated the extent of bile excretion using this new technique. Furthermore, the ICG-FCG findings may provide information leading to a new classification and potentially function as an indicator predicting the clinical outcomes after HPE.