Skip to main content
Log in

Knowledge, attitudes and practices of using Indocyanine Green (ICG) fluorescence in emergency surgery: an international web-based survey in the ARtificial Intelligence in Emergency and trauma Surgery (ARIES)—WSES project

  • Original Article
  • Published:
Updates in Surgery Aims and scope Submit manuscript

Abstract

Fluorescence imaging is a real-time intraoperative navigation modality to enhance surgical vision and it can guide emergency surgeons while performing difficult, high-risk surgical procedures. The aim of this study is to assess current knowledge, attitudes, and practices of emergency surgeons in the use of indocyanine green (ICG) in emergency settings. Between March 08, 2023 and April 10, 2023, a questionnaire composed of 27 multiple choice and open-ended questions was sent to 200 emergency surgeons who had previously joined the ARtificial Intelligence in Emergency and trauma Surgery (ARIES) project promoted by the WSES. The questionnaire was developed by an emergency surgeon with an interest in advanced technologies and artificial intelligence. The response rate was 96% (192/200). Responders affirmed that ICG fluorescence can support the performance of difficult surgical procedures in the emergency setting, particularly in the presence of severe inflammation and in evaluating bowel viability. Nevertheless, there were concerns regarding accessibility and availability of fluorescence imaging in emergency settings. Eighty-seven out of 192 (45.3%) respondents have a fluorescence imaging system of vision for both elective and emergency surgical procedures; 32.3% of respondents have this system solely for elective procedures; 21.4% of respondents do not have this system, 15% do not have experience with it, and 38% do not use this imaging in emergency surgery. Less than 1% (2/192) affirmed that ICG fluorescence changed always their intraoperative decision-making. Precision surgery effectively tailors surgical interventions to individual patient characteristics using advanced technology, data analysis and artificial intelligence. ICG fluorescence can serve as a valid and safe tool to guide emergency surgery in different scenarios, such as intestinal ischemia and severe acute cholecystitis. Due to the lack of high-level evidence within this field, a consensus of expert emergency surgeons is needed to encourage stakeholders to increase the availability of fluorescence imaging systems and to support emergency surgeons in implementing ICG fluorescence in their daily practice.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Data Availability

The manuscript has no associated data.

References

  1. Hashimoto DA, Rosman G, Rus D, Meireles OR (2018) Artificial intelligence in surgery: promises and perils. Ann Surg 268(1):70–76. https://doi.org/10.1097/SLA.0000000000002693

    Article  PubMed  Google Scholar 

  2. Gumbs AA, Grasso V, Bourdel N, Croner R, Spolverato G, Frigerio I, Illanes A, Abu Hilal M, Park A, Elyan E (2022) The advances in computer vision that are enabling more autonomous actions in surgery: a systematic review of the literature. Sensors (Basel) 22(13):4918. https://doi.org/10.3390/s22134918. (PMID:35808408; PMCID:PMC9269548)

    Article  PubMed  Google Scholar 

  3. Mascagni P, Alapatt D, Sestini L et al (2022) Computer vision in surgery: from potential to clinical value. Npj Digit Med 5:163. https://doi.org/10.1038/s41746-022-00707-5

    Article  PubMed  PubMed Central  Google Scholar 

  4. Diana M (2017) Enabling precision digestive surgery with fluorescence imaging. Transl Gastroenterol Hepatol 2:97. https://doi.org/10.21037/tgh.2017.11.06

    Article  PubMed  PubMed Central  Google Scholar 

  5. Cassinotti E, Boni L, Baldari L (2023) Application of indocyanine green (ICG)-guided surgery in clinical practice: lesson to learn from other organs—an overview on clinical applications and future perspectives. Updates Surg 75(2):357–365. https://doi.org/10.1007/s13304-022-01361-y. (Epub 2022 Oct 6; PMID: 36203048)

    Article  CAS  PubMed  Google Scholar 

  6. Hiwatashi K, Okumura H, Setoyama T, Ando K, Ogura Y, Aridome K, Maenohara S, Natsugoe S (2018) Evaluation of laparoscopic cholecystectomy using indocyanine green cholangiography including cholecystitis: a retrospective study. Medicine (Baltimore) 97(30):e11654. https://doi.org/10.1097/MD.0000000000011654. (PMID:30045318; PMCID:PMC6078678)

    Article  PubMed  Google Scholar 

  7. Stolz MP, Foxhall EN, Gibson BH, Gill S, McNamee MM (2023) Improving the safety of laparoscopic cholecystectomy with indocyanine green dye using critical view of safety plus. Am Surg. https://doi.org/10.1177/00031348231161659. (Epub ahead of print; PMID: 36857190)

    Article  PubMed  Google Scholar 

  8. D’Acapito F, Cucchetti A, Solaini L, Serenari M, Framarini M, Ercolani G (2023) Fluorescence cholangiography using indocyanine green improves the identification of biliary structures during laparoscopic cholecystectomy. World J Surg 47(3):666–673. https://doi.org/10.1007/s00268-022-06854-w. (Epub 2022 Dec 2; PMID: 36459198)

    Article  PubMed  Google Scholar 

  9. van den Bos J, Schols RM, Boni L, Cassinotti E, Carus T, Luyer MD, Vahrmeijer AL, Mieog JSD, Warnaar N, Berrevoet F, van de Graaf F, Lange JF, Van Kuijk SMJ, Bouvy ND, Stassen LPS (2023) Near-infrared fluorescence cholangiography assisted laparoscopic cholecystectomy (FALCON): an international multicentre randomized controlled trial. Surg Endosc. https://doi.org/10.1007/s00464-023-09935-6. (Epub ahead of print; PMID: 36849564)

    Article  PubMed  Google Scholar 

  10. Ris F, Hompes R, Cunningham C, Lindsey I, Guy R, Jones O, George B, Cahill RA, Mortensen NJ (2014) Near-infrared (NIR) perfusion angiography in minimally invasive colorectal surgery. Surg Endosc 28:2221–2226. https://doi.org/10.1007/s00464-014-3432-y

    Article  PubMed  PubMed Central  Google Scholar 

  11. Jafari MD, Wexner SD, Martz JE, McLemore EC, Margolin DA, Sherwinter DA, Lee SW, Senagore AJ, Phelan MJ, Stamos MJ (2015) Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study. J Am Coll Surg 220:82.e81-92.e81. https://doi.org/10.1016/j.jamcollsurg.2014.09.015

    Article  Google Scholar 

  12. Di Maggio F, Hossain N, De Zanna A, Husain D, Bonomo L (2022) Near-infrared fluorescence cholangiography can be a useful adjunct during emergency cholecystectomies. Surg Innov 29(4):526–531. https://doi.org/10.1177/1553350620958562. (Epub 2020 Sep 16; PMID: 32936054)

    Article  PubMed  Google Scholar 

  13. Ryu S, Hara K, Goto K, Okamoto A, Kitagawa T, Marukuchi R, Ito R, Nakabayashi Y (2022) Fluorescence angiography vs direct palpation for bowel viability evaluation with strangulated bowel obstruction. Langenbecks Arch Surg 407(2):797–803. https://doi.org/10.1007/s00423-021-02358-8. (Epub 2021 Oct 19; PMID: 34664121)

    Article  PubMed  Google Scholar 

  14. Guerra F, Coletta D, Greco PA, Eugeni E, Patriti A (2021) The use of indocyanine green fluorescence to define bowel microcirculation during laparoscopic surgery for acute small bowel obstruction. Colorectal Dis 23(8):2189–2194. https://doi.org/10.1111/codi.15680. (Epub 2021 May 5; PMID: 33876537)

    Article  PubMed  Google Scholar 

  15. De Simone B, Abu-Zidan FM, Gumbs AA et al (2022) Knowledge, attitude, and practice of artificial intelligence in emergency and trauma surgery, the ARIES project: an international web-based survey. World J Emerg Surg 17:10. https://doi.org/10.1186/s13017-022-00413-3

    Article  PubMed  PubMed Central  Google Scholar 

  16. Eysenbach G (2004) Improving the quality of web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 6(3):e34. https://doi.org/10.2196/jmir.6.3.e34. (Erratum in: doi:10.2196/jmir.2042; PMID:15471760; PMCID:PMC1550605)

    Article  PubMed  PubMed Central  Google Scholar 

  17. Mascagni P, Longo F, Barberio M et al (2018) New intraoperative imaging technologies: innovating the surgeon’s eye toward surgical precision. J Surg Oncol 118:265–282. https://doi.org/10.1002/jso.25148

    Article  PubMed  Google Scholar 

  18. De Simone B, Chouillard E, Gumbs AA et al (2022) Artificial intelligence in surgery: the emergency surgeon’s perspective (the ARIES project). Discov Health Syst 1:9. https://doi.org/10.1007/s44250-022-00014-6

    Article  PubMed  PubMed Central  Google Scholar 

  19. Belia F, Biondi A, Agnes A, Santocchi P, Laurino A, Lorenzon L, Pezzuto R, Tirelli F, Ferri L, D’Ugo D, Persiani R (2022) The use of indocyanine green (ICG) and near-infrared (NIR) fluorescence-guided imaging in gastric cancer surgery: a narrative review. Front Surg 28(9):880773. https://doi.org/10.3389/fsurg.2022.880773. (PMID:35836598; PMCID:PMC9273882)

    Article  Google Scholar 

  20. Yoneya S, Saito T, Komatsu Y, Koyama I, Takahashi K, Duvoll-Young J (1998) Binding properties of indocyanine green in human blood. Investig Ophthalmol Vis Sci 39(7):1286–1290

    CAS  Google Scholar 

  21. Speich R, Saesseli B, Hoffmann U, Neftel KA, Reichen J (1988) Anaphylactoid reactions after indocyanine-green administration. Ann Intern Med 109(4):345–346. https://doi.org/10.7326/0003-4819-109-4-345_2

    Article  CAS  PubMed  Google Scholar 

  22. Paludis H, Saukane E, Bobrovs E, Pupelis G (2020) Identification of biliovascular anatomy using indocyanine green fluorescent cholangiography in patients with acute cholecystitis. First experience in single institution. HPB (Oxford) 22:S278

    Article  Google Scholar 

  23. Reeves JJ, Broderick RC, Lee AM, Blitzer RR, Waterman RS, Cheverie JN, Jacobsen GR, Sandler BJ, Bouvet M, Doucet J, Murphy JD, Horgan S (2022) The price is right: routine fluorescent cholangiography during laparoscopic cholecystectomy. Surgery 171(5):1168–1176. https://doi.org/10.1016/j.surg.2021.09.027. (Epub 2021 Dec 21; PMID: 34952715)

    Article  PubMed  Google Scholar 

  24. Dip FD, Asbun D, Rosales-Velderrain A, Lo Menzo E, Simpfendorfer CH, Szomstein S, Rosenthal RJ (2014) Cost analysis and effectiveness comparing the routine use of intraoperative fluorescent cholangiography with fluoroscopic cholangiogram in patients undergoing laparoscopic cholecystectomy. Surg Endosc 28(6):1838–1843. https://doi.org/10.1007/s00464-013-3394-5. (Epub 2014 Jan 11; PMID: 24414461)

    Article  PubMed  Google Scholar 

  25. Karampinis I, Keese M, Jakob J, Stasiunaitis V, Gerken A, Attenberger U, Post S, Kienle P, Nowak K (2018) Indocyanine green tissue angiography can reduce extended bowel resections in acute mesenteric ischemia. J Gastrointest Surg 22(12):2117–2124. https://doi.org/10.1007/s11605-018-3855-1

    Article  PubMed  Google Scholar 

  26. Liot E, Assalino M, Buchs NC et al (2018) Does near-infrared (NIR) fluorescence angiography modify operative strategy during emergency procedures? Surg Endosc 32:4351–4356. https://doi.org/10.1007/s00464-018-6226-9

    Article  PubMed  PubMed Central  Google Scholar 

  27. Alekseev M, Rybakov E, Shelygin Y, Chernyshov S, Zarodnyuk I (2020) A study investigating the perfusion of colorectal anastomoses using fluorescence angiography: results of the FLAG randomized trial. Colorectal Dis 22(9):1147–1153. https://doi.org/10.1111/codi.15037. (Epub 2020 Apr 6; PMID: 32189424)

    Article  CAS  PubMed  Google Scholar 

  28. De Nardi P, Elmore U, Maggi G, Maggiore R, Boni L, Cassinotti E, Fumagalli U, Gardani M, De Pascale S, Parise P, Vignali A, Rosati R (2020) Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial. Surg Endosc 34(1):53–60. https://doi.org/10.1007/s00464-019-06730-0. (Epub 2019 Mar 21; PMID: 30903276)

    Article  PubMed  Google Scholar 

  29. Liu D, Liang L, Liu L, Zhu Z (2021) Does intraoperative indocyanine green fluorescence angiography decrease the incidence of anastomotic leakage in colorectal surgery? A systematic review and meta-analysis. Int J Colorectal Dis 36(1):57–66. https://doi.org/10.1007/s00384-020-03741-5

    Article  PubMed  Google Scholar 

  30. Lin J, Zheng B, Lin S, Chen Z, Chen S (2021) The efficacy of intraoperative ICG fluorescence angiography on anastomotic leak after resection for colorectal cancer: a meta-analysis. Int J Colorectal Dis 36(1):27–39. https://doi.org/10.1007/s00384-020-03729-1

    Article  CAS  PubMed  Google Scholar 

  31. Trastulli S, Munzi G, Desiderio J, Cirocchi R, Rossi M, Parisi A (2021) Indocyanine green fluorescence angiography versus standard intraoperative methods for prevention of anastomotic leak in colorectal surgery: meta-analysis. Br J Surg 108(4):359–372. https://doi.org/10.1093/bjs/znaa139

    Article  CAS  PubMed  Google Scholar 

  32. Emile SH, Khan SM, Wexner SD (2022) Impact of change in the surgical plan based on indocyanine green fluorescence angiography on the rates of colorectal anastomotic leak: a systematic review and meta-analysis. Surg Endosc 36(4):2245–2257. https://doi.org/10.1007/s00464-021-08973-2. (Epub 2022 Jan 13; PMID: 35024926)

    Article  PubMed  Google Scholar 

  33. Meyer J, Joshi H, Buchs NC, Ris F, Davies J (2022) Fluorescence angiography likely protects against anastomotic leak in colorectal surgery: a systematic review and meta-analysis of randomised controlled trials. Surg Endosc 36(10):7775–7780. https://doi.org/10.1007/s00464-022-09255-1. (Epub 2022 May 4; PMID: 35508666; PMCID: PMC9485176)

    Article  PubMed  PubMed Central  Google Scholar 

  34. Joosten JJ, Longchamp G, Khan MF, Lameris W, van Berge Henegouwen MI, Bemelman WA, Cahill RA, Hompes R, Ris F (2022) The use of fluorescence angiography to assess bowel viability in the acute setting: an international, multi-centre case series. Surg Endosc 36(10):7369–7375. https://doi.org/10.1007/s00464-022-09136-7. (Epub 2022 Feb 23; PMID: 35199204; PMCID: PMC9485089)

    Article  PubMed  PubMed Central  Google Scholar 

  35. Nakashima K, Ryu S, Okamoto A, Hara K, Ishida K, Ito R, Nakabayashi Y (2022) Usefulness of blood flow evaluation with indocyanine green fluorescence imaging during laparoscopic surgery for strangulated bowel obstruction: a cohort study. Asian J Surg 45(3):867–873. https://doi.org/10.1016/j.asjsur.2021.08.020. (Epub 2021 Sep 10; PMID: 34518078)

    Article  PubMed  Google Scholar 

  36. Madsen MH, Svendsen LB, Achiam MP (2017) Quantification of fluorescence angiography in a porcine model. Langenbeck’s Arch Surg 402:655–662

    Article  Google Scholar 

  37. Diana M, Agnus V, Halvax P, Liu YY, Dallemagne B, Schlagowski AI, Geny B, Diemunsch P, Lindner V, Marescaux J (2015) Intra-operative fluorescence-based enhanced reality laparoscopic real-time imaging to assess bowel perfusion at the anastomotic site in an experimental model. Br J Surg 102:e169–e176

    Article  CAS  PubMed  Google Scholar 

  38. Davis CS, Wilkinson KH, Lin E, Carpenter NJ, Georgeades C, Lomberk G, Urrutia R (2022) Precision medicine in trauma: a transformational frontier in patient care, education, and research. Eur J Trauma Emerg Surg 48(4):2607–2612. https://doi.org/10.1007/s00068-021-01817-7. (Epub 2021 Nov 16; PMID: 34786598; PMCID: PMC8594650)

    Article  PubMed  Google Scholar 

  39. Mukherjee R (2023) An acute need: precision medicine for acute care surgery. BJS Open 7(2):zrad003. https://doi.org/10.1093/bjsopen/zrad003. (PMID: 36893286; PMCID: PMC9997769)

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

ICG fluorescence-guided emergency surgery survey consortium: Luigi Boni, Gian Luca Baiocchi, Elisa Cassinotti, Michele Diana, Ana Maria Gonzalez Castillo, Francesco Di Maggio, Antonio Tarasconi, Hung Truong, Adam Peckham-Cooper, Aishath Azna Ali, Aitor Landaluce-Olavarria, Alan Biloslavo, Alberto Sartori, Aleix Martínez-Pérez, Aleksandar Karamarkovic, Alessandra Marano, Alessandro Bergna, Alessio Giordano,, Alexander Julianov, Alexandros Chamzin, ALEXANDROS CHAMZIN, Alexis Theodorou, Alfie J Kavalakat, Amedeo Antonelli, Amit Gupta, Ana-Maria Musina, Andee Dzulkarnaen Zakaria, Andrea Balla, Andrea Barberis, Andrea Cavallaro, Andrew Gumbs, Andrey Litvin, Antonio Pesce, ARDA ISIK, Aristeidis Papadopoulos, Asyraf Bin Mohd Zuki, Barbara Petronio, Beatrice Torre, Biagio Picardi, Boyko Atanasov, Charalampos Seretis, Chiara Fantozzi, Christos Chouliaras, Christos Doudakmanis, Claudia Zaghi, Damien Massalou, Daniele Delogu, Daniele Morezzi, Danilo Vinci, Daunia Verdi, Davide Luppi, Davide Papis, de'Angelis Nicola, Desire Pantalone, Diego Coletta, Diego Visconti, Diletta Corallino, Dimitrios Oikonomou, DIMITRIOS SCHIZAS, Dionysios Prevezanos, Dmitry Adamovich, Edoardo Baldini, Eftychios Lostoridis, Elena-Adelina Toma, Elisa Reitano, Enrico Pinotti, Ernest E Moore, Evgeni Dimitrov, Fabio Marino, Fabrizio D'Acapito, Fausto Rosa, Felipe Pareja-Ciuro, Filipe Ramalho de Almeida, Firdaus Hayati, Flavio Milana, Francesca Pecchini, Francesco Pata, Francesk Mulita, Gabriela Arroyo Murillo, Gennaro Martines, Gennaro Perrone, Georgios Ioannis Verras, GEORGIOS ZACHARIS, Gianluca Pellino, Gianluca Vanni, Gianmaria Casoni Pattacini, Giorgio Giraudo, Giuseppe Brisinda, Giuseppe Curro, Giuseppe Evola, Giuseppe Palomba, Goran Augustin, Guglielmo Niccolò Piozzi, Gustavo Miguel Machain, Hazim Eltyeb, Heba Taher, Huseyin Kemal Rasa, Ibrahim Umar Garzali, Igor A. Kryvoruchko, Imtiaz Wani, Isidoro DI CARLO, Jacopo Andreuccetti, Jin Jiun Mah, Juan Carlos Salamea, Justin Davies, Kenneth Y. Y. Kok, Konstantinos Perivoliotis, Lali Patsia, Larysa Sydorchuk, Leandro Siragusa, Lorenzo Petagna, Lovenish Bains, Luca Ferrario, Luigi Eduardo Conte, Luis Tallon-Aguilar, Lukas Werner Widmer, Maciej, Mahir Gachabayov, Marco Clementi, Marco Materazzo, Marco Pellicciaro, Maria Papadoliopoulou, Marianna Capuano, Mario Giuffrida, Mario Serradilla-Martín, Massimiliano Veroux, Massimo Chiarugi, Matteo Santoliquido, Mauro Podda, Maximilian Scheiterle, Mercedes Estaire-Gómez, Micaela Piccoli, Michele Ammendola, Mihail Slavchev, Mika Ukkonen, Mirko Barone, Mohamed Arif & Hameed Sulta, Monica Ortenzi, Monika Gureh, Nicola Cillara, Nikolaos Michalopoulos, Nikolaos Pararas, Octavian Enciu, Orestis Ioannidis, Pasquale Cianci, Pierpaolo Sileri, Pierpaolo Sileri, Pietro Fransvea, Piotr Major, Ruslan Sydorchuk, Sara Ingallinella, Selmy S Awad, Semra Demirli Atici, Sentilnathan Subramaniam, Serge Chooklin, Serhat Meric, Sharfuddin Chowdhury, Simone Gargarella, Sofia Xenaki, Stefano Olmi, Stefano Rossi, Theodoros Sidiropoulos, Timothy Craig Hardcastle, Valentin Calu, Vasilescu Alin Mihai, Victor Lopez-Lopez, Vincenza Paola Dinuzzi, Vincenzo Trapani, Vishal Shelat, Zaza Demetrashvili.

Funding

Not applicable.

Author information

Authors and Affiliations

Authors

Consortia

Contributions

BDS conceived, designed the study, wrote the questionnaire, collected and analysed data, revised the literature and wrote the manuscript. FC and FAZ critically revised the draft. BDS revised the manuscript according to comments and suggestions. SS revised last articles published about ICG and emergency surgery. GD revised the English written. All the authors read and approved the manuscript. The ICG consortium answered to the questionnaire.

Corresponding author

Correspondence to Belinda De Simone.

Ethics declarations

Conflict of interest

Belinda De Simone has no conflict of interest to declare. Fikri M Abu Zidan has no conflict of interest to declare. Sara Saeidi has no conflict of interest to declare. Genevieve Deeken has no conflict of interest to declare. Massimo Sartelli has no conflict of interest to declare. Walter Biffl has no conflict of interest to declare. Ernest E Moore has no conflict of interest to declare. Federico Coccolini has no conflict of interest to declare. Salomone Di Saverio has no conflict of interest to declare. Luca Ansaloni has no conflict of interest to declare. Fausto Catena has no conflict of interest to declare.

Ethical Approval

Not applicable for this type of research.

Research Involving Human participants and/or animals

Not applicable.

Informed Consent

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The members of the ICG Fluorescence Guided Emergency Surgery Survey Consortium are listed in Acknowledgements.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 261 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

De Simone, B., Abu-Zidan, F.M., Saeidi, S. et al. Knowledge, attitudes and practices of using Indocyanine Green (ICG) fluorescence in emergency surgery: an international web-based survey in the ARtificial Intelligence in Emergency and trauma Surgery (ARIES)—WSES project. Updates Surg (2024). https://doi.org/10.1007/s13304-024-01853-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s13304-024-01853-z

Keywords

Navigation