Giuseppe Spinoglio, MD, Fabio Priora, PhD, Alessandra Marano, MD, Giampaolo Formisano, MD, Andrea Pappalardo, MD, Francesca Pagliardi, MD. Department of General and Oncologic Surgery, SS Antonio e Biagio Hospital, Alessandria, Italy.
Indocyanine green (ICG) is a vital dye with the distinctive feature of being fluorescent if properly excited and it is therefore currently used in near-infrared (NIR) fluorescence image-guided oncologic surgery. Recently, with the advent of the robotic surgery, a new camera has been introduced and it allows real-time switching between a standard three-dimensional vision to a near infrared view. Thanks to this new system, the technique of fluorescence imaging can be applied in several fields of robotic general surgery, some still experimental and continuously evolving.
Methods and procedures
Since the introduction of the NIR camera integrated into the robotic system at our Center in 2011, we performed a total of 227 procedures with the application of the ICG fluorescence technique to visualize vascular and biliary anatomy, assess bowel anastomotic perfusion, tattoo gastrointestinal lesions and perform lymph node (LN) road mapping and sentinel LN biopsy during robotic surgery.
ICG fluorescent cholangiography allowed safe viewing as well as immediate and real-time identification of the biliary tract anatomy preventing bile duct injuries in all 97 cases of Single Site® robotic cholecystectomies.
Moreover, the intravenous injection of ICG aided the surgeon in visualizing the correct perfusion of the colonic stump in order to perform a safer bowel anastomosis during 92 colorectal resections, mainly for cancer.
For the lymphatic road mapping and sentinel LN biopsy, NIR with ICG allowed a rapid and complete lymphatic drainage visualization in the majority of cases.
Our strengthened experience with the application of fluorescence in robotic general surgery shows promising outcomes in all the possible fields of application of this novel technology. However, several technical details still need to be optimized, including the dose of the dye, the timing, the method of injection and especially its role.