Superselective intra-arterial hepatic injection of indocyanine green (ICG) for fluorescence image-guided segmental positive staining: experimental proof of the concept
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Intraoperative liver segmentation can be obtained by means of percutaneous intra-portal injection of a fluorophore and illumination with a near-infrared light source. However, the percutaneous approach is challenging in the minimally invasive setting. We aimed to evaluate the feasibility of fluorescence liver segmentation by superselective intra-hepatic arterial injection of indocyanine green (ICG).
Materials and methods
Eight pigs (mean weight: 26.01 ± 5.21 kg) were involved. Procedures were performed in a hybrid experimental operative suite equipped with the Artis Zeego®, multiaxis robotic angiography system. A pneumoperitoneum was established and four laparoscopic ports were introduced. The celiac trunk was catheterized, and a microcatheter was advanced into different segmental hepatic artery branches. A near-infrared laparoscope (D-Light P, Karl Storz) was used to detect the fluorescent signal. To assess the correspondence between arterial-based fluorescence demarcation and liver volume, metallic markers were placed along the fluorescent border, followed by a 3D CT-scanning, after injecting intra-arterial radiological contrast (n = 3). To assess the correspondence between arterial and portal supplies, percutaneous intra-portal angiography and intra-arterial angiography were performed simultaneously (n = 1).
Bright fluorescence signal enhancing the demarcation of target segments was obtained from 0.1 mg/mL, in matter of seconds. Correspondence between the volume of hepatic segments and arterial territories was confirmed by CT angiography. Higher background fluorescence noise was found after positive staining by intra-portal ICG injection, due to parenchymal accumulation and porto-systemic shunting.
Intra-hepatic arterial ICG injection, rapidly highlights hepatic target segment borders, with a better signal-to-background ratio as compared to portal vein injection, in the experimental setting.
KeywordsIndocyanine green (ICG) Intra-arterial ICG injection Fluorescence-guided surgery Hepatic segmentation Laparoscopic liver surgery Image-guided surgery Positive staining
Authors are grateful to Guy Temporal and Christopher Burel, professionals in Medical English proofreading, for their assistance in revising the manuscript. Additionally, authors would like to thank Mourad Bouhadjar and Gaël Fouré, radiology technicians, for their valuable help during the experimental sessions.
Compliance with ethical standards
Jacques Marescaux is the President of both IRCAD and IHU Institutes, which are partly funded by Karl Storz, Medtronic, and Siemens Healthcare. Michele Diana, Yu-Yin Liu, Raoul Pop, Seong-Ho Kong, Andras Legnèr, Remy Beaujeux, Patrick Pessaux, Luc Soler, Didier Mutter and Bernard Dallemagne have no conflicts of interest or financial ties to disclose.
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