Real-time Indocyanine Green Fluorescence Research Articles

Real-time indocyanine green fluorescence imaging and navigation for cone unit laparoscopic hepatic resection of intrahepatic duct stone: a case series study

Background Intrahepatic bile duct stones, although common and benign, require varying therapeutic strategies due to their recurrent nature. Inadequate management can escalate to liver cirrhosis or cholangiocarcinoma. A surgical method merging indocyanine green fluorescence imaging (ICG-FI) with liver cone unit resection is optimal, ensuring complete lesion removal and healthy liver tissue conservation. Method A retrospective descriptive study was conducted on 15 patients with intrahepatic bile duct stones who were admitted to Sichuan Provincial People’s Hospital from January 2021 to December 2023. All patients underwent laparoscopic anatomical liver resection guided by ICG-FI. Results Among the 15 patients included in the study, ten were male and five were female, with an average age of 52 years. All patients were free from underlying medical conditions. Intraoperatively, ICG-FI was good, with clear boundaries, and all patients successfully underwent surgery without any conversions to open surgery. The mean operative time was 236 ± 56 min, and the estimated blood loss was 320 ± 75 ml. Patients had a postoperative hospital stay of 5.5 ± 1.5 days. No severe complications occurred. Conclusions Real-time ICG-FI with anatomical liver resection is a safe and effective approach for managing intrahepatic bile duct stones.

Outcomes of Adult Right Graft Living Donor Liver Transplantation Utilizing the Robotic Platform-integrated Real-time Indocyanine Green Fluorescence Cholangiography Compared to the Open Approach.

This study aimed to assess short-term biliary outcomes in adult living donor liver transplants using right grafts, comparing robotic surgery with real-time indocyanine green fluorescence cholangiography for optimal hilar plate transection, against the conventional open approach. Determining the optimal transection plane through the hilar plate is crucial in donor hepatectomies, impacting outcomes significantly. From 2011 to 2023, a total of 839 right graft living donor hepatectomies were performed, with 414 (49%) performed via the open approach and 425 (51%) utilizing the robotic platform. The magnetic resonant cholangiopancreatography predictions correlated moderately with the actual count of graft ducts ( r =0.57, P <0.001). Out of all 839 right donor hepatectomies, 321 (44%) were single duct grafts, of which 193/425 (49%) were retrieved with the robotic while 128/414 (38%) were with the open approach (OR: 1.58, 95% CI: 1.16-2.14), P =0.003). Overall, 50 (6%) of the donors developed a biliary complication during their hospital stay, of whom 38 (9%) were grafts retrieved with the open, while 13 (3%) with the robotic approach (OR: 0.31, 95% CI: 0.15-0.61, P <0.001). Similarly, 63 (15%) of the adult recipients developed a biliary complication of any severity when grafts were retrieved with the open approach compared to 35 (8%) with the robotic approach (OR: 0.50, 95% CI: 0.31-0.79), P =0.002). The robotic platform with integrated real-time indocyanine green fluorescence cholangiography during right donor hepatectomy offers improved safety for the donor by accurately addressing the right hilar corridor, resulting in fewer graft ducts and fewer complications for the donor and recipient when compared to the standard open approach.

The application of real-time indocyanine green fluorescence cholangiography in laparoscopic living donor left lateral sectionectomy.

The judgment of the division point of the bile duct has always been one of the difficulties of laparoscopic left lateral sectionectomy (LLLS). The purpose of this study was to assess the effects of indocyanine green (ICG) fluorescence cholangiography during LLLS on the occurrence of biliary complications in both donors and recipients. The optimal dose and injection time of ICG were also investigated. This is a retrospective cohort study. From October 2016 to December 2022, the clinical data of 103 donors who underwent LLLS and relevant recipients were retrospectively analyzed. According to whether ICG fluorescence cholangiography was used, they were divided into a non-ICG group (n=46) and an ICG group (n=57). Biliary complications were observed and the optimal dose and injection time of ICG were explored. Three donors in the non-ICG group suffered from bile leakage. Four grafts had multiple bile duct openings and biliary complications were observed in the relevant recipients who received these grafts in the non-ICG group. Two recipients had bile leakage, and the other two had biliary stenosis. There was no biliary complications both in donors and recipients in the ICG group. The fluorescence intensity of the liver was 108.1±17.6 at a dose of 0.004 mg/kg 90 minutes after injection, significantly weaker than that at 0.05 mg/kg 30 minutes (200.3±17.6, P=0.001) and 90 minutes after injection (140.2±15.4, P=0.001). The fluorescence intensity contrast value at a dose of 0.004 mg/kg was stronger than that at 0.05 mg/kg, both measured 90 minutes after injection (0.098±0.032 vs. 0.078±0.022, P=0.021). ICG fluorescence cholangiography is safe and feasible in LLLS. It reduces biliary complications in both donors and recipients. The optimal ICG dose was 0.004 mg/kg, and 90 minutes after injection was the best observation time. ICG fluorescence cholangiography is recommended for routine use in LLLS.

Laparoscopic left hepatectomy for a patient with an absence of portal bifurcation using real-time imaging: a case report

BackgroundAbsence of portal bifurcation is an extremely rare anomaly that should be recognized preoperatively, especially prior to a major hepatectomy.Case presentationA 45-year-old woman presented with abdominal pain, and abdominal computed tomography (CT) revealed dilatation of both the common bile duct (CBD) and intrahepatic bile duct (IHBD). Endoscopic retrograde cholangiopancreatography (ERCP) showed CBD and IHBD stones (B2 and B4). The CBD stones were removed, but the IHBD stones could not be, yet there was no evidence of malignancy at the site of IHBD stenosis. Enhanced CT revealed a dilated IHBD, while three-dimensional CT images showed the left portal vein running through the ventral side of the middle hepatic vein, which was diagnosed as the absence of portal vein bifurcation (APB). Laparoscopic left hepatectomy was successfully performed using real-time indocyanine green (ICG) fluorescence imaging.ConclusionSurgeons should be aware of the possibility of APB, a rare portal vein anomaly, before performing major hepatectomy. Real-time ICG fluorescence imaging may be helpful to ensure the precise anatomy of the liver during laparoscopic surgery.

3D laparoscopic anatomical hepatectomy guided by 2D real-time indocyanine green fluorescence imaging for hepatocellular carcinoma.

Laparoscopic anatomical hepatectomy (LAH) for patients with hepatocellular carcinoma (HCC) has been advocated by many surgeons in the hope of producing better oncological outcomes. Two recent techniques, 3D laparoscopic system and 2D real-time indocyanine green fluorescence imaging (r-ICG) guidance, are benefit for improving the operative precision of LAH in different aspects. However, these two techniques cannot be applied concomitantly because of the technical limitation. Although a new modern laparoscopic system with both 3D and indocyanine green (ICG) imaging mode has been designed, it has not been listed in many countries including China. Thus, we design a new procedure to perform the 3D LAH with 2D r-ICG guidance for HCCs with conventional laparoscopic systems. In this procedure, both 3D and 2D laparoscopic systems were used. A total of 11 patients with HCC received 3D laparoscopic right posterior sectionectomy (LRPS) with 2D r-ICG guidance. The right posterior Glissonian pedicle was clamped under the 3D vision. Then ICG solution was then intravenously administrated. The liver parenchyma was transected under the 3D vision and guided by 2D ICG vision simultaneously. There was no severe complications (Clavien-Dindo ≥III) and operation related death. The 90-day mortality was also nil. By using this procedure, the advantages of two techniques, 3D laparoscopic system and 2D r-ICG guidance, were combined so that LAH could be performed with more precision. However, it should be validated in more studies.

Abstract PO3-23-01: Triple-tracer Technique for Sentinel Lymph Node Biopsy of Breast Cancer after neoadjuvant Chemotherapy using Blue-dye, Radioisotope combined with Real-time Indocyanine green(ICG) Fluorescence Imaging Procrdures

Abstract Background: For post-neoadjuvant chemotherapy (NAC) patients (pts) with BC, sentinel lymph node biopsy (SNB) was recommended using the dual-tracer mapping technique (radioisotope plus blue dye) or placing a biopsy clip into the positive node at diagnosis and identifying it at the time of surgery due to SN identification rates (IR) were lower and false negative rates (FNR) were greater for pts with local advanced breast cancer (BC) than those of pts with early stage BC in the absence of NAC. Our previous clinical trial has indicated that the real-time ICG fluorescence (RT-ICG) imaging technique could improve the diagnostic sensitivity and detection accuracy for SNB. Methods: Between April 2019 and May 2022, post-NAC SNB were successfully identified in 45 of 52 patients with stage ⅡA to ⅢB (T1-T3, N0-2, M0) who had histologically confirmed breast cancer selected to receive NAC and the standard surgeries were performed after finishing NAC. The SNs was detected by conventional procedures of blue-dye (Indigo carmine) plus 99mTc radioisotope (dual-tracer) and combined with concurrent RT-ICG technique. Clinical node positive (cN+) was diagnosed by the radiologists using axillary ultrasound, MRI and/or CT scan or assessed by fine needle aspiration cytology (FNAC). The positivity of each single SN by each single tracer (blue dye, ICG, or isotope alone) was counted and identified, respectively. All patients are required to undergo SNB followed by completion axillary lymph node dissection (CND). Then the IR and FNR of each single tracer and their summation (triple tracer) were calculated by comparing the results of the SNB and the histopathology of the resection specimens of CND. Results: Among 45 post-NAC pts, the IR and FNR of each single procedure for SNB was 45.7% and 55.6% when used Indigo Carmine blue, 70.3% and 11.1% when used RI, 82.6% and 0 when used ICG fluorescence, respectively. In contrast, the total calculation of triple tracer showed that IR reached to 100% and FNR was 0, respectively. The IR of triple tracer were 83.9% and 100% for ypN0 and ypN(+) pts after NAC, both FNR were 0%. Conclusion: Our results suggested that the triple tracer technique combining blue dye, ICG, and isotope is effective method for detection of SNs in post-neoadjuvant cN+ BC pts. The IR and FNR of SNB might be improved by this multiple tracer mapping technique, particularly for pts with ypN(+) after NAC. It is considered that the multi-tracer can complement each other for what was not able to be traced and detected by the single tracer with one mapping material, and that result in totally the improvement of identification rate of SNB. Citation Format: Hidetaka Watanabe, Yuko Takao, Yuriko Katagiri, Rie Sugihara, Uhi Toh. Triple-tracer Technique for Sentinel Lymph Node Biopsy of Breast Cancer after neoadjuvant Chemotherapy using Blue-dye, Radioisotope combined with Real-time Indocyanine green(ICG) Fluorescence Imaging Procrdures [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-23-01.

INDURG TRIAL Protocol: A Randomized Controlled Trial Using Indocyanine Green during Cholecystectomy in Acute Cholecystitis

Introduction: Laparoscopic cholecystectomy is one of the most common gastrointestinal surgeries, and bile duct injury is one of its main complications. The use of real-time indocyanine green fluorescence cholangiography allows the identification of extrahepatic biliary structures, facilitating the procedure and reducing the risk of bile duct lesions. A better visualization of the bile duct may help to reduce the need for conversion to open surgery, and may also shorten operating time. The main objective of this study was to determine whether the use of indocyanine green is associated with a reduction in operating time in emergency cholecystectomies. Secondary outcomes are the postoperative hospital stay, the correct intraoperative visualization of the Calot’s Triangle structures with the administration of indocyanine green, and the intraoperative complications, postoperative complications and morbidity according to the Clavien-Dindo classification. Methods: This is a randomized, prospective, controlled, multicenter trial with patients diagnosed with acute cholecystitis requiring emergency cholecystectomy. The control group will comprise 220 patients undergoing emergency laparoscopic cholecystectomy applying the standard technique. The intervention group will comprise 220 patients also undergoing emergency laparoscopic cholecystectomy for acute cholecystitis with prior administration of indocyanine green. Conclusion: Due to the lack of published studies on ICG in emergency laparoscopic cholecystectomy, this study may help to establish procedures for its use in the emergency setting.

Applications of Near-Infrared Fluorescence Imaging and Angiography of Inferior Vesical Artery in Laparoscopic Lateral Lymph Node Dissection: A Prospective Nonrandomized Controlled Study

BACKGROUND: Near-infrared imaging with indocyanine green has been used to guide lateral lymph node dissection, yet its efficacy and benefits need further investigation. OBJECTIVE: To investigate the efficacy and feasibility of near-infrared fluorescence imaging and angiography of the inferior vesical artery in laparoscopic lateral lymph node dissection. DESIGN: A prospective nonrandomized controlled study. SETTINGS: Single-center study. PATIENTS: Patients with lower rectal cancer who underwent total mesorectal excision plus lateral lymph node dissection. MAIN OUTCOME MEASURES: A cohort of 108 patients was enrolled. After propensity score matching, 29 patients in the near-infrared group and 50 patients in the non–near-infrared group were matched. The total number of harvested lateral lymph nodes, positive lateral lymph nodes, inferior vesical artery preservation, and postoperative urinary function were compared. RESULTS: After propensity score matching, both groups had similar baseline characteristics. The total number of harvested lateral lymph nodes in the near-infrared group was significantly higher (12 vs 9, p = 0.013), but positive lateral lymph nodes were similar between the 2 groups (1 vs 1, p = 0.439). The inferior vesical artery preservation ratio was significantly increased with the aid of indocyanine green angiography (93.1% vs 56.0%, p &lt; 0.001). The non–near-infrared group required more days for urinary catheter removal than the near-infrared group (5 vs 4, p = 0.046). Urinary recatheterization tended to occur more frequently in the non–near-infrared group, with a marginally significant trend (16% vs 0%, p = 0.059). The non–near-infrared group tended to have more cases with residual urine volume ≥50 mL than the near-infrared group (20.0% vs 3.4%, p = 0.087), especially in the bilateral dissection subgroup (41.2% vs 0%, p = 0.041). LIMITATIONS: Small sample size. CONCLUSIONS: Near-infrared imaging increased the number of harvested lateral lymph nodes, whereas real-time indocyanine green fluorescence angiography ensured the preservation of the inferior vesical artery and tended to improve postoperative urinary function.

Preliminary results of laparoscopic cholecystectomy using real-time indocyanine green fluorescence: a cross-sectional study.

This is a cross-sectional study of patients with LC using real-time fluorescent ICG to treat gallbladder disease from May 2021 to May 2022 in the 108 Military Central Hospital. There were 68 patients who underwent LC using intraoperative ICG fluorescence for bile duct visualization. The mean age of the patients was 55.4±16.2, and the male/female ratio was 1.52. Chronic cholecystitis caused by stones accounted for the majority (51.47%). The authors detected 7.35% of cases with anatomical changes of the extrahepatic biliary tract using ICG fluorescence and clearly identified the anatomy of the common bile duct and the cystic duct at 100 and 92.65%, respectively. The average surgical time was 42.8±14.6min. There were no postoperative complications or side effects from ICG; the average hospital stay was 2.8±1.5 days. ICG fluorescence cholangiography allows surgeons to easily identify critical anatomical landmarks in the LC. Thereby helping the surgery to be performed safely, avoiding severe complications due to damage to the biliary tract.

Laparoscopic Anatomic Segment III Procurement in Pediatric Living Donor Liver Transplantation Using Real-Time ICG Fluorescence In Situ Reduction by the Glissonean Approach

Nowadays, anatomic hepatectomy has been widely accepted and acknowledged as a feasible practice during laparoscopic procedure. We herein report the first case of laparoscopic anatomic segment III (S3) procurement in pediatric living donor liver transplantation using real-time indocyanine green (ICG) fluorescence in situ reduction by Glissonean approach. A 36-year-old father volunteered for living donation to his daughter who was diagnosed with liver cirrhosis and portal hypertension due to biliary atresia. Preoperative liver function was normal with mild fatty liver. Liver dynamic computed tomography showed a left lateral graft volume of 379.43 cm3 with a graft to recipient weight ratio (GRWR) of 4.77%. The ratio of the maximum thickness of the left lateral segment to the anteroposterior diameter of the recipient's abdominal cavity was 1.20. Hepatic veins of segment II (S2) and S3 separately flowed into the middle hepatic vein. The estimated S3 volume was 173.16 cm3 and GRWR was 2.18%. The estimated S2 volume was 118.54 cm3 and GRWR was 1.49%. Laparoscopic anatomic S3 procurement was scheduled. Liver parenchyma transection was divided into 2 steps. Step I: Anatomic in situ reduction of S2 by using real-time ICG fluorescence. Step II: Separating the S3 along the right side of sickle ligament. The left bile duct was identified and divided by ICG fluorescence cholangiography. The total operation time was 318 minutes without transfusion. The final graft weight was 208 g with GRWR of 2.62%. The donor was discharged uneventfully on postoperative day 4, and the graft function recovered to normal in the recipient without any graft related complication. Laparoscopic anatomic S3 procurement with in situ reduction is a feasible and safe procedure in selected donors in pediatric living donor liver transplantation.

Timing of real-time indocyanine green fluorescence visualization for lymph node dissection during laparoscopic colon cancer surgery.

Although numerous studies have highlighted the potential value of indocyanine green (ICG) imaging in lymph node dissection of cancer surgery, its efficacy and optimal method remain to be clarified. This study aimed to investigate how lymphatic flow observation via ICG fluorescence could contribute to colon cancer surgery. From October 2018 to March 2021, a total of 56 patients with colon cancer who underwent laparoscopic complete mesocolic excision with intraoperative ICG imaging were analyzed. Lymphatic flow was examined at the following time points following ICG injection: within 5 min, 30-60 min, and over 60 min. We also evaluated the distribution of ICG fluorescence per each vascular pedicle. Lymphatic flow was observed within 5 min following ICG injection in 6 cases (10.7%), and at 30-60 min following ICG injection in 43 cases (76.8%). ICG-stained vascular pedicles were variable especially in hepatic flexural, transverse, and splenic flexural colon cancer. Lymph node metastases were observed in 14 cases. Although metastatic lymph nodes were present only in the area along the ICG-stained vascular pedicles in 12 of the 14 cases, two patients exhibited lymph node metastasis in areas along the ICG-unstained vascular pedicles. ICG fluorescence was observed outside the standard range of lymph node dissection in 9 cases (20.9%: 9/43). Although addition of the proposed resection areas was made in 8 of these 9 cases, there was no pathologically positive lymph node. Real-time ICG fluorescence imaging of lymph nodes may improve the performance of laparoscopic colon cancer surgery, although its oncological benefit is not yet clear.

Evaluation of Lymphadenectomy Range Using Preoperative 3D-CT Angiography and Real-time Indocyanine Green Fluorescence Imaging for Lymphatic Flow in Laparoscopic Left Transverse Colon Cancer Surgery

目的：左側横行結腸癌に対する腹腔鏡下手術における術前3D-CT angiography（CTA）と術中ICG蛍光法によるリンパ流評価を駆使したリンパ節郭清範囲について検討する．

High Ligation of the Inferior Mesenteric Artery Induces Hypoperfusion of the Sigmoid Colon Stump During Anterior Resection.

Background: Anastomotic leakage (AL) after colorectal surgery is associated with insufficient vascular perfusion of the anastomotic ends. This study aimed to evaluate the effect of high vs. low ligation of the ileocolic artery and inferior mesenteric artery, respectively, on the vascular perfusion of the bowel stumps during ileocecal resection (ICR) and anterior rectal resection (AR).Methods: We retrospectively evaluated patients who underwent ICR or AR between 2016 and 2020. Real-time indocyanine green fluorescence angiography was performed to measure the fluorescence time (FT) as a marker of the blood flow in the proximal and distal stumps before anastomosis.Results: Thirty-four patients with lower right-sided colon cancer underwent laparoscopic ICR. Forty-one patients with rectosigmoid colon or rectal cancer underwent robotic high AR (HAR) (n = 8), robotic low AR (LAR) (n = 6), laparoscopic HAR (n = 8), or laparoscopic LAR (n = 19). The FT was similar in the ileal and ascending colon stumps (p = 1.000) and did not differ significantly between high vs. low ligation of the ileocolic artery (p = 0.934). The FT was similar in the sigmoid colon and rectal stumps (p = 0.642), but high inferior mesenteric artery ligation significantly prolonged FT in the sigmoid colon during AR compared with low ligation (p = 0.004), indicating that the high ligation approach caused significant hypoperfusion compared with low ligation. The AL rate was similar after low vs. high ligation.Conclusions: Low vascular perfusion of the bowel stumps may not be an absolute risk factor for AL. High inferior mesenteric artery ligation could induce sigmoid colon stump hypoperfusion during anterior rectal resection.

Laparoscopic ultrasound-guided superselective portal vein injection combined with real-time indocyanine green fluorescence imaging and navigation for accurate resection of localized intrahepatic bile duct dilatation: a case report

BackgroundPrimary intrahepatic bile duct dilatation can be very harmful to patients although it belongs to benign biliary disease. It can occur in any part of the liver, intraoperative laparoscopic ultrasound (LUS) guidance combine with real-time indocyanine green (ICG) fluorescence navigation are the means of choice for accurate surgical resection.Case presentationHerein we reported a 43-year-old female patient presented with repeated right upper abdominal pain and distension for 3 years and aggravated for half a year, without fever and jaundice. A diagnosis of localized bile duct dilatation with lithiasis in segment 4 (S4) was made on the basis of preoperative imaging. Correspondingly, we selected to perform a laparoscopic surgery with LUS guided real time ICG fluorescence imaging (ICG-FI) and navigation to make the operation more simply and accurately, as well as to retain normal tissues in a certain extent. Laparoscopic resection of S4b and partial S4a was successfully performed, without any complications.ConclusionLaparoscopic anatomical surgery for intrahepatic bile duct dilatation is a technically challenging operation. The combined use of preoperative three-dimensional computerized tomography (CT) planning, intraoperative LUS guided super-selection, ICG hepatic segment staining and real-time fluorescence navigation could help surgeons accurately complete the segmentectomy or subsegmentectomy with minimized trauma and maximized liver tissue preservation.

Compromised Flap Salvage With Closed Incision Negative Pressure Therapy Under Real-Time Indocyanine Green Fluorescence Assessment.

Skin flap transfer is a commonly used technique by surgeons; however, compromised blood flow may result in flap ischemia and necrosis. We describe the use of closed incision negative pressure therapy (ciNPT) to help manage skin flap reconstructions with indocyanine green fluorescence angiography (ICG-FA) to assess perfusion of the flaps before and after ciNPT. Three female and 5 male patients underwent various skin flap reconstructions, including local flaps, pedicled flaps, and propeller flaps, for wound defects related to trauma, infection, or cancer. After flap setting and suturing, ciNPT (-125 mm Hg) was applied to the closed incision for 7 days. Perfusion was assessed using ICG-FA before applying ciNPT and again at 24 hours later. The Shapiro-Wilk test and Wilcoxon signed rank test were used in statistical analysis. Initial postoperative survival was observed for all skin flaps; however, 1 flap failed after 2 weeks due to uncontrolled infection. The remaining 7 flaps healed well without any surgical revision. All patients were initially determined to have impaired flap perfusion; however, skin flap perfusion was significantly higher after ciNPT than before ciNPT in each case (P = 0.012). This study showed good healing outcomes for skin flap reconstructions without complications, despite the fact that each flap had compromised flap perfusion to some extent during the surgery. This case series is novel in that it used laser-assisted ICG-FA to provide a real-time assessment of skin flap perfusion before and after ciNPT.

Laparoscopic anatomical liver resection guided by real-time indocyanine green fluorescence imaging: experience and lessons learned from the initial series in a single center.

Anatomical liver resection is an established procedure for primary hepatic tumors. Laparoscopic anatomical hepatectomy has been proven to be technically achievable from S1 to S8 in experienced hands. The indocyanine green (ICG) fluorescence imaging technique offers a novel tool of intraoperative visualization in hepatobiliary surgery. This study aims to investigate the feasibility of laparoscopic anatomical liver resection based on segmental staining using real-time ICG fluorescence. From December 2015 to October 2017, 36 patients in our institute underwent lap-ALR using real-time ICG fluorescence mapping of the tumor-bearing portal territory. The procedural and perioperative data were collected and analyzed. In our case series, we successfully performed the fashion of positive staining mostly in segmentectomy or sub-segmentectomy by individually injecting 5-10ml of ICG (0.025mg/ml) into its feeding portal branch guided by intraoperative ultrasound, and the negative staining mainly for sectionectomy, hemihepatectomy and multi-segmentectomy by interrupting the Glissonean pedicle serving the tumor-bearing segments and systemically injecting 1ml of ICG (2.5mg/ml). Our total successful rate of staining is 53%. No conversion to laparotomy, Clavien III-IV complication or 90-day mortality occurred. Valuable technical feedback, experience and lessons are learned from this initial practice. Real-time ICG fluorescence imaging adds much precision to laparoscopic anatomical hepatectomy. The success of segmental staining requires a high proficiency of IOUS and skillful interpretation of preoperative 3D simulation. Decision-making on the fashions of positive and negative staining have been initially recommended. Multi-centered practice and technical modification are necessary to standardize its application.

Laparoscopic duodenum-preserving total pancreatic head resection using real-time indocyanine green fluorescence imaging.

It is technical challenging to perform laparoscopic duodenum-preserving pancreatic head resection (LDPPHR). Only a few case reports and case series of LDPPHR are available in the literature. From February 2019 to November 2019, 24 cases of LDPPHR were carried out in the Department of Pancreas Surgery, West China Hospital, Sichuan University. Data were prospectively collected in terms of demographic characteristics (age, gender, BMI, and pathological diagnosis), intraoperative variables (operative time, estimated blood loss, transfusion, pancreatic texture, and diameter of main pancreatic duct), and post-operative variables (time for oral intake, post-operative hospital stay, and complications). Nine male patients and fifteen female patients were included in this study. The median age of these patients was 43years. All patients underwent duodenum-preserving total pancreatic head resection laparoscopically. The median operative time was 255min. The median estimated blood loss was 200ml. One patient required blood transfusion. The median post-operative hospital stay was 10days. Three patients suffered from biliary fistula. Eleven patients (45.8%) suffered from pancreatic fistula; however, only one patient (4.2%) suffered from grade B pancreatic fistula. No patient suffered from grade C pancreatic fistula. One patient with chronic pancreatitis required re-operation for jejunal anastomotic bleeding on the first post-operative day. No patient suffered from gastroparesis, duodenal necrosis, or abdominal bleeding. The 30-day mortality was 0. LDPPHR is safe and feasible. Real-time indocyanine green fluorescence imaging may help prevent bile duct injury and bile leakage.

A Case of Necrotic Ischemic Colitis in which the Range of Intestinal Resection was Determined by Real-time Indocyanine Green Fluorescence Imaging

A Case of Necrotic Ischemic Colitis in which the Range of Intestinal Resection was Determined by Real-time Indocyanine Green Fluorescence Imaging

New Technique for Management of Separate Right Posterior and Anterior Portal Veins in Pure 3D Laparoscopic Living Donor Right Hepatectomy

BackgroundPure laparoscopic donor hepatectomy, including right hepatectomy, is being increasingly performed at experienced centers (Kim et al. Transplantation 101:1106–1110, 2017; Han et al. Medicine (Baltimore) 96:e8076, 2017; Suh et al. Am J Transplant 18:434–443, 2018; Hong et al. Br J Surg 105:751–759, 2018; Lee et al. Transplantation 102:1878–1884, 2018). However, anatomical variations in the portal vein remain major challenges and are regarded as contraindications by some centers. Using a stapler or clip in donors with these anatomical variations may result in kinking of the remnant portal vein due to the thick linear bite, as well as a reduction in the length of the graft portal vein. This report describes a liver donor with separate right posterior and anterior portal veins who underwent pure 3D laparoscopic donor right hepatectomy, focusing on a new technique of managing separate two portal veins. MethodsA 45-year-old man offered to donate part of his liver to his father, who required a liver transplant for alcoholic liver cirrhosis. The father’s Child-Pugh score was 7 and his Model for End-Stage Liver Disease score was 10.7. Donor height was 175.4 cm, body weight was 79.9 kg, and body mass index was 26.0 kg/m2. Preoperative computed tomography and magnetic resonance cholangiopancreatography showed that the donor had separate right posterior and anterior portal veins. Estimated graft-to-recipient weight ratio was 1.4% and remnant liver volume was 35.7%. The entire procedure was performed under 3D laparoscopic view using a flexible scope and real-time indocyanine green fluorescence cholangiography. The right posterior and anterior portal veins were divided using Hem-O-Lok clips. After retrieving the liver, the stumps of the portal veins were replaced with polypropylene sutures, followed by removal of the Hem-O-Lok clips (SNUH technique). ResultsThe total operation time was 365 min, with no transfusion and no intraoperative complications. The portal veins were divided safely without any torsion or stricture. The stumps of the portal veins were sutured after retrieval of the liver graft, with suturing requiring about 12 min. The donor was discharged on postoperative day 7 with no complications. ConclusionThe SNUH technique, consisting of temporary clipping, intracorporeal suturing, and clip removal is safe and useful for pure laparoscopic right hepatectomy in donors with anatomic variations in the portal vein.

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.