Fluorescence-enabled assessment of adrenal gland localization and perfusion in posterior retroperitoneoscopic adrenal surgery in a preclinical model



The posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation. The aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and assessment of intraoperative remnant perfusion for adrenal resection in the posterior retroperitoneoscopic approach.


Six pigs underwent simultaneous (n = 5) or sequential (n = 1) bilateral posterior retroperitoneoscopic adrenalectomy (n = 12). Fluorescence imaging was obtained via intravenous administration of 3 mL of Indocyanine Green (ICG) and by switching the camera systems to near-infrared mode (D-LIGHT P, KARL STORZ; Germany). Fluorescence-based visualization of adrenal glands before vascular division (n = 4), after the main vascular pedicle ligation (negative control, n = 1) or after adrenal resection (n = 7), was followed by completion adrenalectomy. The fluorescence signal intensity dynamics were recorded and analyzed using proprietary software. For each pixel, the slope of fluorescence signal intensity evolution over time was translated into a color-coded perfusion cartography, which was superimposed onto real-time images obtained with the corresponding left and right camera systems. Quantitative fluorescence signal analysis in the regions of interest (ROIs) served to assess adrenal remnant perfusion in divided adrenal glands.


In the retroperitoneum, the vascular anatomy was illuminated in fluorescence imaging first. The adrenal glands were promptly highlighted after primary intravenous ICG administration (n = 9) or showed a fluorescence signal intensity increase upon reinjection (n = 3). Quantitative fluorescence analysis showed a statistically significant difference between perfused and ischemic segments in divided glands (p = 0.0156).


Fluorescence imaging provides real-time guidance during minimally invasive adrenal surgery. Prior to dissection, it allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. After adrenal gland division, ICG injection associated with a computer-assisted quantitative analysis helps to distinguish between well-perfused and ischemic segments. Further studies are underway to establish the correlation between remnant perfusion and viability.

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The authors would like to thank Catherine Cers-Meunier for illustrating the anatomical features, and Lionel Grienenberger for the video editing. The authors are also grateful to Camille Goustiaux, Christopher Burel, and Guy Temporal, professionals in medical English proofreading, for their assistance in proofreading the manuscript. The laparoscopic equipment for this study has been kindly supplied by KARL STORZ SE & Co. KG.


This study was funded by a Grant from the ARC Foundation for Cancer Research (9, rue Guy Môquet; 94803 Villejuif Cedex—France,, within the framework of the ELIOS (Endoscopic Luminescent Imaging for precision Oncologic Surgery) project.

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Correspondence to Barbara Seeliger.

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Barbara Seeliger, Martin K. Walz, Pier F. Alesina, Vincent Agnus, Raoul Pop, Manuel Barberio, Alend Saadi, and Marc Worreth have no conflicts of interest or financial ties to disclose. Jacques Marescaux is President of both the IRCAD and IHU Institutes, which are partly funded by KARL STORZ, Medtronic, and Siemens Healthcare. Michele Diana is PI of the ELIOS project, which was funded by a grant from the ARC Foundation for Cancer Research (9, rue Guy Môquet; 94803 Villejuif Cedex—France,

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Supplementary material 1—Technique of adrenal localization and perfusion assessment using fluorescence imaging in the simultaneous bilateral retroperitoneoscopic approach. The left adrenal surgery is shown on the left, and the right intervention on the right side. (MP4 336161 kb)

Supplementary material 1—Technique of adrenal localization and perfusion assessment using fluorescence imaging in the simultaneous bilateral retroperitoneoscopic approach. The left adrenal surgery is shown on the left, and the right intervention on the right side. (MP4 336161 kb)

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Seeliger, B., Walz, M.K., Alesina, P.F. et al. Fluorescence-enabled assessment of adrenal gland localization and perfusion in posterior retroperitoneoscopic adrenal surgery in a preclinical model. Surg Endosc (2019) doi:10.1007/s00464-019-06997-3

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  • Posterior retroperitoneoscopic adrenalectomy
  • Minimally invasive adrenalectomy
  • Training model
  • Fluorescence-guided surgery
  • Fluorescence-based enhanced reality
  • Computer-assisted perfusion assessment