Tumor visualization and fluorescence angiography with indocyanine green (ICG) in laparoscopic and robotic hepatobiliary surgery – valuation of early adopters from Germany

Abstract

Objectives Indocyanine green (ICG) is a fluorescent dye which was initially used for liver functional assessment. Moreover, it is of value for intraoperative visualization of liver segments and bile ducts or primary and secondary liver tumors. Especially in minimally invasive liver surgery, this is essential to enhance the precision of anatomical guided surgery and oncological quality. As early adopters of ICG implementation into laparoscopic and robotic-assisted liver surgery in Germany, we summarize the current recommendations and share our experiences. Methods Actual strategies for ICG application in minimally invasive liver surgery were evaluated and summarized during a review of the literature. Experiences in patients who underwent laparoscopic or robotic-assisted liver surgery with intraoperative ICG staining between 2018 and 2020 from the Magdeburg registry for minimally invasive liver surgery (MD-MILS) were evaluated and the data were analyzed retrospectively. Results ICG can be used to identify anatomical liver segments by fluorescence angiography via direct or indirect tissue staining. Fluorescence cholangiography visualizes the intra- and extrahepatic bile ducts. Primary and secondary liver tumors can be identified with a sensitivity of 69–100%. For this 0.5 mg/kg body weight ICG must be applicated intravenously 2–14 days prior to surgery. Within the MD-MILS we identified 18 patients which received ICG for intraoperative tumor staining of hepatocellular carcinoma (HCC), cholangiocarcinoma, peritoneal HCC metastases, adenoma, or colorectal liver metastases. The sensitivity for tumor staining was 100%. In 27.8% additional liver tumors were identified by ICG fluorescence. In 39% a false positive signal could be detected. This occurred mainly in cirrhotic livers. Conclusions ICG staining is a simple and useful tool to assess individual hepatic anatomy or to detect tumors during minimally invasive liver surgery. It may enhance surgical precision and improve oncological quality. False-positive detection rates of liver tumors can be reduced by respecting the tumor entity and liver functional impairments.

Attempt of Real-Time Near-Infrared Fluorescence Imaging Using Indocyanine Green (ICG) in Radical Resection of Gallbladder Cancer: A Case Report

“…Based on our center's experience in the field of fluorescent laparoscopy, the utilization of fluorescent laparoscopy in radical resection of GBC was preliminarily tested in this case. ICG was administered to the patient 1 day before surgery as the previous reports had confirmed a good safety and efficiency of the preoperative protocol with intravenous administration in tumor visualization and intraoperative cholangiography for hepatobiliary surgery (15,16). In our case, both the tumor and extrahepatic biliary tree were successfully and clearly imaged during the operation.…”

Laparoscopic and Robot-Assisted Hepatic Surgery: An Historical Review

“…Indocyanine Green (ICG) is a simple and safe agent which has been used for some time for liver imaging. This agent allows for visualization of tumors, bile ducts, and liver parenchyma, and its use has been extensively reported in Japan and other Asian countries since 2008, but much less commonly in other parts of the world [ 70 ]. ICG can demonstrate anatomical liver segments by fluorescence angiography using direct or indirect tissue staining.…”

“…ICG can demonstrate anatomical liver segments by fluorescence angiography using direct or indirect tissue staining. Fluorescence cholangiography visualizes the intra- and extrahepatic bile ducts [ 70 ]. Specialized imaging techniques have been developed which facilitate intraoperative use of ICG.…”

“…Given this, the use of ICG in minimally invasive hepatic surgery is of great importance. Franz and colleagues reported an initial experience with 18 patients who received ICG for intraoperative imaging of hepatocellular carcinoma, cholangiocarcinoma, peritoneal hepatocellular carcinoma metastases, adenomas, or colorectal liver metastases [ 70 ]. Of these, 7/18 were laparoscopic resections and 11/18 were robot-assisted resections.…”

The Role of ICG in Robot-Assisted Liver Resections

“…In this context, Ishizawa et al discovered persisting ICG staining in patients who had received ICG days before hepatic surgery [ 15 ]. ICG staining, either as an intra-tumoral accumulation in hepatocellular carcinoma (HCC) or a halo-like rim accumulation in colorectal liver metastasis (CRLM), was visualized by near-infrared light at an approximate wavelength of 835 nm, presumably due to impaired biliary excretion mechanisms and congestion in perimetastatic cells [ 11 , 13 , 15 , 16 , 17 ].…”