Usability of Indocyanine Green in Robot-Assisted Hepatic Surgery

Abstract

Recent developments in robotic surgery have led to an increasing number of robot-assisted hepatobiliary procedures. However, a limitation of robotic surgery is the missing haptic feedback. The fluorescent dye indocyanine green (ICG) may help in this context, which accumulates in hepatocellular cancers and around hepatic metastasis. ICG accumulation may be visualized by a near-infrared camera integrated into some robotic systems, helping to perform surgery more accurately. We aimed to test the feasibility of preoperative ICG application and its intraoperative use in patients suffering from hepatocellular carcinoma and metastasis of colorectal cancer, but also of other origins. In a single-arm, single-center feasibility study, we tested preoperative ICG application and its intraoperative use in patients undergoing robot-assisted hepatic resections. Twenty patients were included in the final analysis. ICG staining helped in most cases by detecting a clear lesion or additional metastases or when performing an R0 resection. However, it has limitations if applied too late before surgery and in patients suffering from severe liver cirrhosis. ICG staining may serve as a beneficial intraoperative aid in patients undergoing robot-assisted hepatic surgery. Dose and time of application and standardized fluorescence intensity need to be further determined.

Laparoscopic Liver Resection Enhanced by an Intervention-Guided Fluorescence Imaging Technique Using Sodium Fluorescein

“…During the last few decades, several studies have investigated the process used to locate tumors during hepatectomy. Currently NIR fluorescence imaging is an innovative way to localize the tumor or anatomical segment to be resected [10,[12][13][14][18][19][20]. However, there have been some limitations for this method to be applied in LLR procedures.…”

“…Although a Glissonean pedicle approach or the tattooing method historically has been carried out to confirm the hepatic resection area in LLR, a Glissonean approach for subdivided branches can be limited by the complicated anatomy of the liver, and laparoscopic indigo carmine tattooing is a technically demanding procedure [10,11]. Recently, several researchers have introduced a near infra-red (NIR) fluorescence imaging technique to create a distinction between liver tumors and their boundaries using indocyanine green (ICG) as a fluorescent tracer during LLR [10,12]. Anatomical resection of the hepatic segment is also achieved with the use of a "negative staining technique," in which portal branches are closed after the targeted segment is determined [13,14].…”

Augmented Reality and Image-Guided Robotic Liver Surgery

“…Furthermore, an IOUS exclusive evaluation could be insufficient because it is a user-dependent procedure and presents a heterogeneous detection rate according to tumor size and location and parenchymal stiffness [ 62 , 63 , 64 ]. In this context, fluorescence is a precious tool in robotic surgery, with some authors reporting an enlargement of the resection area after ICG application, both in benign ad malignant lesions, in order to achieve a R0 resection [ 57 , 65 , 66 , 67 ], and a significantly higher rate of margin-free specimens when comparing robotic hepatectomies with and without ICG [ 67 ]. As in open surgery, even in robotic surgery, some series described the detection of newer superficial lesions that the dye injection missed before [ 57 ].…”

How molecular imaging will enable robotic precision surgery

“…In the clinic, fluorescence detection of the visible dye fluorescein and near-infrared (NIR) dye indocyanine green (ICG) is currently a routinely applied tool for angiographic purposes. An increasing number of trials are being conducted in the area of lymphatic mapping (e.g., [134]), perfusion-based tumor resection (e.g., [135]), and receptor-targeted imaging (e.g., [136]). The main advantage of fluorescence is that it provides realtime visual feedback concerning the tracer uptake during surgery, especially useful to confirm successful lesion localization during excision.…”