Real-Time Visualization of Ureters Using Indocyanine Green During Laparoscopic Surgeries: Can We Make Surgery Safer?

Abstract

Background. Intraoperative ureteral injury is rare, but a grave complication during laparoscopic surgery. Several methods for intraoperative localization of ureters are described with their own pitfalls. Intraoperative localization using near-infrared (NIR) fluorescence with indocyanine green (ICG) is an easier and assured method during laparoscopic pelvic surgeries. Method. From September 2017 to December 2017, patients undergoing laparoscopic pelvic surgeries were administered cystoscopic-guided intraureteral ICG immediately preoperatively with tip of a 6-Fr ureteral catheter. The fluorescence of ureters was visualized in the NIR mode of the camera system, localizing the ureters precisely and in real time. Results. This technique was used to visualize ureters in 30 surgeries. Median age of the patients was 46.7 years with median body mass index of 23.2 kg/m2. Mean duration between administration of dye and insertion of trocar was 10 minutes. Mean duration for insertion of cystoscopically guided intraureteral ICG was 7 minutes. Ureteral fluorescence was visualized in all cases with some variation in intensity of the brightness perceived depending on surrounding fat. Duration of the lengthiest surgery was 240 minutes, and fluorescence was appreciated till the end. There were no intraoperative or postoperative complications attributed to ICG administration. In 10 patients (33%), there was difficulty in identifying the ureters on conventional white light mode, in which ICG localization was extremely helpful. Conclusion. ICG-stained ureteral visualization under NIR light is a safe and feasible method that provides real-time ureteral demarcation. This easily replicable, sensitive, and specific method of ureteral visualization can make complex laparoscopic pelvic surgeries safer.

Indocyanine Green-Enhanced Colorectal Surgery—between Being Superfluous and Being a Game-Changer

“…It binds with circulating albumins and lipoproteins and is excreted into the bile almost unchanged after hepatic extraction. Its half-time in the blood stream is between 3 to 5 min [ 9 ]. Indocyanine green is very sensitive to ultraviolet light, and therefore it is commercialized as a lyophilisate and kept in dark vials and should be used at maximum 6 h after reconstitution with sterile water.…”

Intra-operative identification of ureters using indocyanine green for gynecological oncology procedures

“…The literature reports rates for ureteral injuries for pelvic surgery ranging from 1% to 10%1 2 as the complexity of the procedure increases. Many of these injuries remain unrecognized during the surgery 3…”

“…Patients with prior surgical procedures, endometriosis, inflammatory bowel disease, or gynecological cancers are more likely to present this complication 2 3…”

“…Different identification techniques have been described, such as regular ureteral stent placement, methylene blue injection, or illuminated ureteral catheter positioning. However, all of them are moderately expensive, time consuming, or with a lack of high-quality ureteral visualization 3 4…”

Intra‐operative visualization of the ureter by near‐infrared fluorescence during robotic‐assisted laparoscopic sigmoidectomy for diverticulitis – a video vignette

“…ICG is not excreted renally; therefore, the only means by which it can be used to identify the ureter is by specific placement into the ureter by cystoscopy and retrograde instillation. Building on earlier reports by others , here we detail the specifics of how this is done by means of an example of its use in a patient (body mass index 31 kg/m 2 ) undergoing robotic‐assisted sigmoidectomy (with a Da Vinci XI, Intuitive) for recurrent diverticulitis with persisting sigmoid phlegmon.…”