Early Experience with Intraoperative Leak Test Using a Blend of Methylene Blue and Indocyanine Green During Robotic Gastric Bypass Surgery

  • Monika E. Hagen
  • John Diaper
  • Jonathan Douissard
  • Minoa K. Jung
  • Leo Buehler
  • Florence Aldenkortt
  • Gleicy Keli Barcelos
  • Philippe Morel
Original Contribution



Leak tests using air or methylene blue (MB) for gastrojejunal anastomoses are often performed during gastric bypass surgeries to avoid leaks due to technical errors. Still, early leaks have been reported in the literature. Indocyanine green (ICG) fluorescence with laser excitement makes this dye easily visible even in small amounts, and, thus, may be an excellent agent for leak testing.


During robotic gastric bypass surgery, a leak test of a gastrojejunal anastomosis was performed with air through a nasogastric tube under manual occlusion of the jejunum. Afterward, 50 ml of a mix of 100 ml sterile water, 2 mg of MB, and 5 mg ICG was injected through the same tube. The entire anastomosis was inspected for integrity under both fluorescent and normal light modes.


Leak tests with air and the blend of MB and ICG have been performed in 95 patients from January 2017 to April 2018. No intraoperative leak test-related adverse events occurred. Zero (0%) patients had a positive leak test with air, 0 patients showed MB excretion, and an ICG leak was observed in four (4.2%) patients. No anastomotic complications, including leaks and/or strictures, were found 30 days postoperatively.


Leak tests using a blend of MB and ICG appear to be more sensitive for small defect detection of gastrojejunal anastomoses during robotic gastric bypass surgery. Larger datasets and research that is more stringent are needed to determine the exact clinical value of this new method.


Leak test Gastric bypass Anastomotic test Indocyanine green Methylene blue 


Compliance with Ethical Standards

Ethical Approval

Our local ethics committee approved the review of our gastric bypass surgeries.

Informed Consent

A statement regarding informed consent does not apply.

Conflict of Interest

Dr. Hagen received personal fees and non-financial support by Intuitive Surgical Inc. and Ethicon Endosurgery Inc., outside this project. Dr. Jung received non-financial support by Intuitive Surgical Inc. and Ethicon Endosurgery Inc., outside this project. Prof. Morel received personal fees and by Intuitive Surgical Inc. All other authors have nothing to disclose.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Digestive and Transplant Surgery, Department of SurgeryUniversity Hospital GenevaGenevaSwitzerland
  2. 2.Division of Digestive and Transplant Surgery, Department of SurgeryUniversity Hospital GenevaGenevaSwitzerland
  3. 3.Department of AnesthesiologyUniversity Hospital GenevaGenevaSwitzerland

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