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Intra-operative indocyanine green fluorescence imaging in hepatobiliary surgery: a narrative review of the literature as a useful guide for the surgeon

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Abstract

Introduction

In hepatobiliary surgery, intra-operative indocyanine green (ICG) fluorescence imaging use started in the late 2000s with Japanese surgical teams and is now gaining popularity among surgeons all over the world to improve accuracy and safety of surgical procedures. However, even if ICG fluorescence has been shown to be a safe imaging modality, only a few clinical efficacity studies have been performed and no guidance has been established. This narrative review aims at assessing the potential applications of ICG fluorescence imaging in hepatobiliary surgery.

Methods

We screened the available international literature to identify the most used applications of ICG fluorescence imaging in hepatobiliary surgery.

Results

Three main fields were identified: biliary duct visualization, hepatic segments’ delimitation, and liver tumor detection. Comments, application protocols, prospects, and limitations of each technique were described.

Discussion

These results could guide hepatobiliary surgeons in their use of ICG fluorescence imaging; nevertheless, further prospective studies are needed to assess the sensitivity and specificity of this modality.

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Authors and Affiliations

  1. Department of Digestive, Hepatobiliary and Pancreatic Surgery, Cochin Hospital, AP-HP Centre, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France

    Marie Strigalev, Stylianos Tzedakis, Alexandra Nassar, Alix Dhote, Chloe Gavignet, Martin Gaillard, Ugo Marchese & David Fuks

  2. Faculté de Médecine, Université de Paris, 75006, Paris, France

    Marie Strigalev, Stylianos Tzedakis, Alexandra Nassar, Alix Dhote, Chloe Gavignet, Martin Gaillard, Ugo Marchese & David Fuks

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  1. Marie Strigalev
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Contributions

MS: conceptualization, writing—original draft, investigation, data curation, and visualization. ST: conceptualization, methodology, writing—original draft, and writing—review and editing. A.N: writing—review and editing. AD: writing—review and editing. CG: writing—review and editing. MG: conceptualization, writing—review and editing, resources, and visualization. UM: conceptualization, writing—review and editing, resources, and visualization. DF: conceptualization, writing—review and editing, resources, and supervision.

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Correspondence to Marie Strigalev.

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Hereby, I, Dr. Marie STRIGALEV, consciously assure that for the manuscript intra-operative indocyanine green fluorescence imaging in hepatobiliary surgery: a narrative review of the literature as a useful guide for the surgeon the following is fulfilled: (1) This material is the authors' own original work, which has not been previously published elsewhere. (2) The paper is not currently being considered for publication elsewhere. (3) The paper reflects the authors' own research and analysis in a truthful and complete manner. (4) The paper properly credits the meaningful contributions of co-authors and co-researchers. (5) The results are appropriately placed in the context of prior and existing research. (6) All sources used are properly disclosed (correct citation). Literally copying of text must be indicated as such using quotation marks and giving proper reference. (7) All authors have been personally and actively involved in substantial work leading to the paper, and will take public responsibility for its content. The violation of the Ethical Statement rules may result in severe consequences. I agree with the above statements and declare that this submission follows the policies of Solid State Ionics as outlined in the Guide for Authors and in the Ethical Statement.

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Supplementary Video 1. Fluorescence imaging of hepatic segments. A. Identification of the transection line using ICG fluorescence imaging during laparoscopic left hepatectomy for colorectal liver metastases. In this video with show a planned left hepatectomy to perform resection of colorectal liver metastases. After visualization of the liver metastases with an intra-operative ultra-sonographic probe, the left hepatic pedicle is dissected, exposing an acceptable clamping site. Once the pedicle is clamped, ICG is intravenously injected, and NIR light is turned on. The systemic fluorescence starts with coronary arteries, then the diaphragm and finally all the visceral organs. The right liver illumination is clearly visible whereas the left liver is not illuminated. Hepatic transection is performed following the fluorescence boundary. B. Identification of the transection line using ICG fluorescence imaging during laparoscopic left hepatectomy for polycystic liver disease. In polycystic liver disease, anatomical resection can be difficult to perform because of the number of cysts deforming surgical landmarks. The left hepatic pedicle and a left hepatic artery are once more dissected and clamped. After ICG injection, the right liver is clearly illuminated and the left hepatic pedicle and left hepatic artery are divided. The fluorescence boundary allows identification of the parenchymal transection line. C. Identification of an excluded biliary sector using ICG fluorescence imaging during anterior sectionectomy. In this video we show a resection of an excluded right anterior section (segments 5 and 8) following segmentary biliary injury during previous cholecystectomy. ICG is intravenously injected two days before surgery and accumulates in the excluded anterior sector. Hepatic resection is performed following the fluorescence boundaries. In this case, there was no arterial injury associated to the biliary injury. Such vascular injuries are frequently associated and prevent this use of the ICG fluorescence because ICG could not reach the excluded sector. (MP4 312771 KB)

Supplementary Video 2. Tumor detection using ICG fluorescence imaging during laparoscopic left lobectomy for colorectal liver metastases. In this video we show a fluorescence detection of a liver metastasis bordering the transection line. IGC is intravenously injected 2 days preceding surgery and accumulates in hepatocytes bordering the tumor. During laparoscopic procedure, NIR light is turned on and the lesion illuminates on the liver surface. Left lobectomy is performed under NIR light, guiding the surgeon, and allowing safe margins. After resection, examination of the specimen under near infra-red (NIR) light shows the fluorescence accumulated in the non-tumoral liver area around the lesion. (MP4 150003 KB)

Supplementary Video 3. Identification of biliary ducts using ICG fluorescence cholangiography during laparoscopic right hepatectomy. In this video we show biliary duct anatomy identification. ICG is intravenously injected a 2 h before surgery, and NIR light illumination allows the visualization of biliary ducts, without illumination of hepatic parenchyma. The confluence between left and right biliary ducts is identified, allowing safe right biliary duct ligation and section before hepatic transection. (MP4 66294 KB)

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Strigalev, M., Tzedakis, S., Nassar, A. et al. Intra-operative indocyanine green fluorescence imaging in hepatobiliary surgery: a narrative review of the literature as a useful guide for the surgeon. Updates Surg 75, 23–29 (2023). https://doi.org/10.1007/s13304-022-01388-1

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