This work was supported by the National Natural Science Foundation of China (grant number 82272105), Guangdong Basic and Applied Basic Research Foundation (grant number 2022A1515011244, 2023A1515011521, 2023A1515010475), Medical Scientific Research Foundation of Guangdong Province of China (A2017421, 2016116212141586).

This research was conducted in compliance with the guidelines of the human research ethics committee of the Fifth Affiliated Hospital of Sun Yat-sen University. Written informed consent was obtained from the patient for participation in this study. The criteria for complex laparoscopic cholecystectomy (LC) included: gallbladder wall edema with thickening &#8805;4 mm; gangrenous cholecystitis with or without perforation; a history of upper abdominal surgery; impacted stones in the gallbladder neck; Mirizzi syndrome or variations in the extrahepatic bile duct; and cases requiring transcystic common bile duct exploration. Details of the reagents and equipment used are provided in the Table of Materials.
1. Fluorescence imaging preparation and patient positioning
<ol>
	<li>Administer 0.25 mg of ICG via a peripheral vein injection 45 min before the surgery. 
	NOTE: Dissolve 1 vial of ICG (25 mg) in 10 mL of normal saline. Inject 1 mL of the solution into 100 mL of normal saline for dilution. Administer 10 mL of the diluted solution via intravenous injection 45 min before the surgery.</li>
	<li>Set up the DPM-I fluorescence system, a dual-channel image-guided device, to operate in white-light (380-665 nm) and near-infrared (810-1200 nm) spectrums.</li>
	<li>Position the patient in a supine position. After inducing general anesthesia (following institutionally approved protocols) and completing all safety procedures (hood, sterile gloves, and sterile scrub), create a sterile field. Perform trocar insertion using a four-port method15.</li>
</ol>
2. Fluorescence-guided visualization and identification of biliary structures
<ol>
	<li>Switch to fluorescence mode to locate the bile ducts. 
	NOTE: In fluorescence mode, the stained bile duct structure may be directly visible or revealed after simple separation of encysted fat tissue (Figure 1A).</li>
	<li>Follow the fluorescence navigation to carefully dissect and isolate the cystic duct (CD) and cystic artery (CA) using a cautery hook to achieve the critical view of safety, also known as Calot&#39;s Triangle. 
	NOTE: In fluorescence mode, the CD exhibits a fluorescent signal, while the CA does not show any fluorescent signal.</li>
	<li>Apply Hem-O-lock clips to both the CD and CA after identifying and distinguishing the bile ducts. Place two clips proximally and one distally on the CD. Place one clip proximally and one clip distally on the CA. 
	NOTE: Identify the CD-common bile duct (CBD) junction carefully to prevent inadvertent injury to the CBD.</li>
</ol>
3. Removal of gallbladder
<ol>
	<li>Dissect the gallbladder from its fossa, divide the cystic duct (CD) and cystic artery (CA) between the clips using scissors, and place the gallbladder in an extraction bag.</li>
	<li>Employ white-light mode to detect any bleeding and switch to fluorescence mode to confirm the absence of bile leakage upon completion of the cholecystectomy.</li>
	<li>Remove the gallbladder from the abdominal cavity, place a drainage tube at the gallbladder fossa, and close the abdomen using 4-0 polyglactin. Suture the skin with a 3-0 non-absorbable suture. 
	NOTE: Cut the CD only after confirming there is a single duct entering the gallbladder, especially in cases of biliary anatomy variations such as a right accessory hepatic duct.</li>
</ol>
4. Postoperative monitoring and management
<ol>
	<li>Review inflammatory markers postoperatively.</li>
	<li>Remove the abdominal drainage tube when the drainage is clear and less than 50 mL per day.</li>
	<li>Administer prophylactic antibiotics as needed based on the patient&#39;s clinical status and surgeon&#39;s recommendation.</li>
	<li>Monitor the patient for signs of infection, including fever, redness, or swelling at the surgical site.</li>
	<li>Schedule a follow-up consultation within 7-10 days to assess recovery.</li>
</ol>

<ol>
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The authors declare that they have no conflicts of interest to disclose.

Laparoscopic cholecystectomy (LC) has long been regarded as the gold standard treatment for cholelithiasis and cholecystitis. However, conventional surgical approaches often pose significant challenges in cases involving acute inflammation, gangrene, perforation, and anatomical variations-collectively referred to as difficult gallbladders16. These challenging conditions significantly increase the risks of bile duct injury (BDI) and cystic artery (CA) injury.
BDI is one of the most severe complications associated with LC, often resulting from the misidentification of the cystic duct (CD) and common bile duct (CBD)17. The key to preventing BDI lies in the precise identification of the CD-CBD junction, making the visualization of biliary tracts essential. Traditional intraoperative visualization techniques (IVT), such as cholangiography, ultrasound, and choledochoscopy, were initially developed for this purpose. However, their adoption was hindered by concerns over radiation exposure, a notable margin of error, and cumbersome procedures5,18.
Near-infrared fluorescence (NIRF) is a newly developed intraoperative visualization technique (IVT) that offers numerous advantages across a broad range of hepatobiliary surgeries. These include detecting lesions in primary liver cancer19, identifying liver metastases20, aiding in liver transplantation procedures21, visualizing biliary tracts22, detecting bile leakage23, and applications in pediatric and robotic surgeries24. Indocyanine green (ICG), excreted through the biliary tract, provides a natural advantage in hepatobiliary surgeries.
During laparoscopic cholecystectomy (LC), NIRF provides clear and real-time visualization of bile ducts, effectively preventing unnecessary injuries to biliary structures. Most importantly, NIRF is easy to implement and operate. NIRF-guided LC is a straightforward enhancement to conventional LC procedures, requiring only the preoperative intravenous administration of ICG as an additional step. This technique does not affect the overall surgical process, causes no additional trauma, and allows seamless switching between white-light and fluorescence modes.
The efficacy of intraoperative fluorescence imaging can be influenced by several factors. First, the administration route of ICG injection plays a crucial role. ICG can be administered through preoperative intravenous injection or intraoperative direct gallbladder injection. While direct gallbladder injection is cumbersome, invasive, and does not provide complete visualization of extrahepatic bile ducts (e.g., the common hepatic duct), preoperative intravenous administration is currently the preferred method25,26. Second, the timing and dosage of ICG injection are critical determinants of fluorescence imaging quality, as they affect the intensity of bile duct visualization and liver background interference12,27. The ideal imaging outcome ensures clear visualization of bile ducts with minimal liver background fluorescence (Figure 1B). Third, conducting fluorescence imaging too late after ICG administration may result in insufficient bile duct fluorescence intensity, hindering the identification of anatomical structures (Figure 1C). Finally, excessively late injection can lead to high liver fluorescence and insufficient bile duct fluorescence, limiting its utility in emergency LC scenarios (Figure 1D).
The optimal timing and dosage of indocyanine green (ICG) injection remain under investigation12,28,29,30,31. After extensive research, the timing of 30-45 min preoperatively and a dosage of 0.25 mg has been identified as optimal for achieving satisfactory fluorescence visualization. It is important to note that these results were obtained using the fluorescence device employed at our center (DPM-I fluorescence system). The optimal timing and dosage of ICG may vary depending on the specific fluorescence system used. This shortened injection time has the potential to enable effective use of ICG in emergency laparoscopic cholecystectomy (LC) procedures. When the thickness of the bile duct wall and the overlying fat layer exceeds 1 cm, the fluorescence signal is significantly weakened or may even disappear. To improve fluorescence imaging, the surface fat tissue can be removed, and the bile duct stretched to thin its wall. The impact of bile duct obstruction on fluorescence imaging varies depending on the location of the obstruction. Obstruction at the hepatic hilum may cause strong fluorescence signals in the liver background but a complete lack of imaging in the extrahepatic bile ducts. Conversely, obstruction of the cystic duct (CD) or common bile duct (CBD) may result in no imaging of the obstructed bile duct segment. This article provides detailed steps for performing fluorescence-guided difficult LC as practiced at our center and summarizes the factors influencing fluorescence imaging. The fluorescence navigation technique has been routinely used at our center, achieving a 91% success rate with satisfying imaging outcomes.
Fluorescence navigation employs ICG as its fluorescent dye. ICG has no toxic side effects or allergic reactions when used at concentrations below 2.0 mg/kg, indicating that the required dosage for intraoperative fluorescence navigation (0.25 mg) is well within the safe range. In conclusion, fluorescence navigation is a safe and effective technique that provides crucial assistance in identifying and distinguishing key structures during surgery. In difficult LC procedures, fluorescence navigation significantly improves precision and reduces the risk of iatrogenic damage. It holds great promise for future clinical applications.

Approximately 20% of adults worldwide are affected by biliary stones, which can lead to acute cholecystitis -- a painful, rapidly progressing, and potentially life-threatening condition1. Timely surgical intervention is imperative for patients with cholecystitis. Laparoscopic cholecystectomy (LC) has become widely accepted as the standard treatment for this condition.
However, conventional surgical approaches may present significant challenges in complex cases. Severe inflammation or adhesions can render biliary tracts indistinct, increasing the risk of inadvertent injury to bile ducts or arteries2. Bile duct injury (BDI) is one of the most severe and common complications in these complex LC procedures. It often results in irreversible, lifelong consequences and, in severe cases, fatal outcomes3. Precise identification of critical biliary structures, such as Calot&#39;s triangle, is essential for facilitating surgical procedures and minimizing potential damage4.
Traditional intraoperative visualization techniques (IVT) integrate cholangiography, ultrasound, and choledochoscopy, enabling real-time monitoring of biliary tracts. However, concerns such as radiation exposure, a notable margin of error5, and cumbersome procedures have hindered the widespread adoption of IVT.
Near-infrared fluorescence (NIRF) is a cutting-edge technique that allows easy switching between fluorescence and white-light modes through a single laparoscope, enabling real-time visualization of biliary tracts during surgery. This technique offers high sensitivity, specificity, and tissue penetration capabilities6. NIRF can effectively prevent bile duct injury (BDI) during laparoscopic cholecystectomy (LC), particularly in complex cases involving severe inflammation or adhesions7.
Compared to traditional IVT, NIRF is easier to implement, provides clearer visualization of biliary tracts, and does not cause additional trauma8,9,10. Its fluorescent dye, indocyanine green (ICG), has been proven safe for human use by the Food and Drug Administration11. ICG is typically injected intravenously before surgery; however, the timing and dosage of ICG injection remain uncertain12,13. These factors are critical determinants of high-quality fluorescence imaging. Optimal ICG performance achieves a strong fluorescence signal in the bile ducts while minimizing background fluorescence from liver tissue14.
Through extensive exploration, we have identified the optimal timing and dosage of ICG injection as 0.25 mg administered 45 min preoperatively. This study aims to demonstrate the imaging effects of this timing and dosage in various complex surgical scenarios.

<table><tbody><tr><td>3-0 MERSILK</td><td>JOHNSON MEDICAL (CHINA) LTD.&amp;nbsp;</td><td>SA84G</td><td>The Suture Material</td></tr><tr><td>4-0 Coated VICRYL</td><td>ETHICON</td><td>VCP310</td><td>The Suture Material</td></tr><tr><td>Endoscopic Fluorescence Imaging System</td><td>ZHUHAI DI PU MEDICAL TECHNOLOGY CO., LTD.&amp;nbsp;</td><td>H380022041YF</td><td>Fluorescence Laparoscope Equipment</td></tr><tr><td>Hem-O-lock Clips</td><td>SINOLINKS MEDICAL INNOVOATION, INC.</td><td>B240714</td><td>Hem-O-lock Clips</td></tr><tr><td>Indocyanine Green for Injection</td><td>DANDONG YICHUANG PHARMACEUTICAL CO., LTD.&amp;nbsp;</td><td>H20055881</td><td>Fluorescence Dye</td></tr></tbody></table>

the role of indocyanine green fluorescence in complex laparoscopic cholecystectomy navigation

Laparoscopic cholecystectomy (LC) is the gold-standard treatment for cholelithiasis and cholecystitis. In difficult cases with severe inflammation and adhesions, the risk of bile duct injury (BDI) is significantly higher. Precise identification of anatomical biliary structures is essential to prevent such injuries. Conventional intraoperative visualization techniques (IVT) have limited clinical application due to their complexity, increased trauma, and high error rates. Near-infrared fluorescence (NIRF) imaging, utilizing indocyanine green (ICG) as a fluorescent dye, has emerged as an innovative IVT technique. It is increasingly recognized as a feasible, safe, and effective approach for LC. However, the efficacy of NIRF in difficult LC procedures remains unclear, and the optimal timing and dosage of ICG administration are yet to be established. This article outlines the main steps for performing fluorescence-guided difficult LC in a patient with acute gangrenous cholecystitis and evaluates the imaging effects of NIRF in various scenarios. The patient was positioned supine, with four trocars placed. Upon switching to fluorescence mode, the fluorescently labeled bile ducts were readily identified. Following fluorescence guidance, Calot's triangle was carefully dissected. The cystic duct (CD) and cystic artery (CA) were individually identified and clipped before the gallbladder was extracted. Finally, the surgical field was inspected in fluorescence mode to detect bile leakage. With satisfactory ICG imaging and a smooth procedure, the patient's postoperative recovery was uneventful. NIRF is a safe and effective technology that shows great promise for future clinical applications.

Following the surgical procedure outlined in the protocol (Figure 2), fluorescence-guided laparoscopic cholecystectomy (LC) was successfully performed in three patients with difficult gallbladders. There were no conversions to open surgery and no occurrences of bile duct injury (BDI) during the procedure. No bile leakage was observed in fluorescence mode, as demonstrated in the accompanying video. The intraoperative and postoperative outcomes are summarized in Table 1.
Between April and August 2024, a total of 70 cases of fluorescence-guided LC were recorded, with demographic data presented in Table 2. Among these, 91% (64/70) exhibited satisfactory fluorescence imaging, with all bile ducts clearly visualized, strong biliary fluorescence signals, and minimal liver background interference. Three cases failed to demonstrate fluorescence imaging of the extrahepatic bile ducts. This was attributed to common hepatic duct obstruction. Additionally, three cases showed suboptimal fluorescence imaging: two were attributed to early injection of indocyanine green (ICG), and one was due to cystic duct (CD) obstruction.
There were no conversions to open surgery, no bile duct injuries during the procedures, and no postoperative bile leakage, as confirmed through drainage observation. Compared to conventional white-light LC, ICG fluorescence imaging offers the following advantages: (1) Real-time navigation of bile ducts, enhancing surgeons&#39; confidence; (2) Early detection of variant bile ducts; (3) Accurate identification of the CD-common bile duct (CBD) junction, reducing the incidence of BDI; (4) Differentiation between the CD and cystic artery (CA), preventing CA injury; (5) Timely identification of bile leakage. In conclusion, ICG fluorescence navigation makes LC faster, safer, and more precise.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/67562/67562fig01.jpg" /> 
Figure 1: Fluorescence imaging. (A) In fluorescence mode, the stained bile duct is directly observed. (B) Appropriate ICG administration: The biliary fluorescence signal is strong, with bright contrast, while background liver fluorescence is weak. (C) Early injection of ICG: The fluorescence intensity of the bile ducts is insufficient to identify anatomical structures. (D) Late injection of ICG: The liver shows high fluorescence, but the bile ducts do not contain sufficient ICG for adequate visibility. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67562/67562fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/67562/67562fig02.jpg" /> 
Figure 2: Surgery procedure. (A) Intravenous injection of ICG prior to surgery. (B) Pulling the gallbladder upwards to expose Calot&#39;s triangle. (C) Switching to fluorescence mode allows visualization of the bile duct. (D) Following fluorescence navigation to dissect Calot&#39;s triangle. (E) Cleaning the fat tissue from Calot&#39;s triangle reveals a clear visualization of the CHD and CBD. The CD and gallbladder are not visualized, suggesting a stone obstruction at the opening of the CD. (F) After pushing the impacted stone toward the gallbladder, the CD becomes visible. (G) Clamping the CD. (H) After removal of the gallbladder, switching to fluorescence mode detects any bile leakage. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67562/67562fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Variable</td>
			<td colspan="3">Outcomes</td>
		</tr>
		<tr>
			<td>Patients</td>
			<td>First</td>
			<td>Second</td>
			<td>Third</td>
		</tr>
		<tr>
			<td>Operative time (min)</td>
			<td>65</td>
			<td>65</td>
			<td>45</td>
		</tr>
		<tr>
			<td>Conversion to open</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>Blood loss (mL)</td>
			<td>20</td>
			<td>20</td>
			<td>10</td>
		</tr>
		<tr>
			<td>BDI</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>CA injury</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay (days)</td>
			<td>4</td>
			<td>4</td>
			<td>3</td>
		</tr>
		<tr>
			<td>Drainage duration (days)</td>
			<td>4</td>
			<td>3</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Complications</td>
			<td colspan="3"></td>
		</tr>
		<tr>
			<td>Bile leakage</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>Abdominal pain</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>Infection</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>Transferred to the ICU</td>
			<td>NO</td>
			<td>NO</td>
			<td>NO</td>
		</tr>
		<tr>
			<td>Pathological diagnosis</td>
			<td>Acute exacerbation of chronic cholecystitis</td>
			<td>Acute gangrenous cholecystitis</td>
			<td>Acute cholecystitis</td>
		</tr>
	</tbody>
</table>
Table 1: Outcomes of the surgery.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td rowspan="2">Demographics</td>
			<td>Patients underwent&#160;</td>
		</tr>
		<tr>
			<td>ICG-guided LC (n = 70)</td>
		</tr>
		<tr>
			<td>Average age (years)</td>
			<td>55.9 &#177; 14.1</td>
		</tr>
		<tr>
			<td>Sex</td>
			<td></td>
		</tr>
		<tr>
			<td>Male</td>
			<td>32</td>
		</tr>
		<tr>
			<td>Female</td>
			<td>38</td>
		</tr>
		<tr>
			<td>Average BMI (kg/m2 )</td>
			<td>25.2 &#177; 4</td>
		</tr>
		<tr>
			<td>History of upper&#160;abdominal surgery</td>
			<td>5</td>
		</tr>
		<tr>
			<td>Comorbidities</td>
			<td>28</td>
		</tr>
		<tr>
			<td>Hypertension</td>
			<td>18</td>
		</tr>
		<tr>
			<td>Diabetes</td>
			<td>13</td>
		</tr>
		<tr>
			<td>Cardiopathy</td>
			<td>13</td>
		</tr>
		<tr>
			<td>Hepatitis</td>
			<td>3</td>
		</tr>
	</tbody>
</table>
Table 2: Demographic data of the patients.

This protocol outlines the steps for fluorescence-guided laparoscopic cholecystectomy and elucidates the role of fluorescence navigation in diverse surgical scenarios.

The Role of Indocyanine Green Fluorescence in Complex Laparoscopic Cholecystectomy Navigation

Laparoscopic cholecystectomy (LC) is the gold-standard treatment for cholelithiasis and cholecystitis. In difficult cases with severe inflammation and ...

the-role-indocyanine-green-fluorescence-complex-laparoscopic

Nanyang Technological University

Research

JoVE Journal

Medicine

330 Views.  The Fifth Affiliated Hospital of Sun Yat-sen University. Dit protocol schetst de stappen voor fluorescentiegeleide laparoscopische cholecystectomie en verduidelijkt de rol van fluorescentienavigatie in diverse chirurgische scenario's.

Video: De rol van indocyanine groene fluorescentie bij complexe laparoscopische cholecystectomie Navigatie

Multispectral Real-time Fluorescence Imaging for Intraoperative Detection of the Sentinel Lymph Node in Gynecologic Oncology

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical excision of the tumor with a full lymphadenectomy in the drainage area of the tumor. However, removal of lymph nodes is associated with increased morbidity due to infection, wound breakdown and lymphedema.4,5 As an alternative, the sentinel lymph node procedure (SLN) was developed several decades ago to detect the first draining lymph node from the tumor.6 In case of lymphogenic dissemination, the SLN is the first lymph node that is affected (Figure 1). Hence, if the SLN does not contain metastases, downstream lymph nodes will also be free from tumor metastases and need not to be removed. The SLN procedure is part of the treatment for many tumor types, like breast cancer and melanoma, but also for cancer of the vulva and cervix.7 The current standard methodology for SLN-detection is by peritumoral injection of radiocolloid one day prior to surgery, and a colored dye intraoperatively. Disadvantages of the procedure in cervical and vulvar cancer are multiple injections in the genital area, leading to increased psychological distress for the patient, and the use of radioactive colloid.
Multispectral fluorescence imaging is an emerging imaging modality that can be applied intraoperatively without the need for injection of radiocolloid. For intraoperative fluorescence imaging, two components are needed: a fluorescent agent and a quantitative optical system for intraoperative imaging. As a fluorophore we have used indocyanine green (ICG). ICG has been used for many decades to assess cardiac function, cerebral perfusion and liver perfusion.8 It is an inert drug with a safe pharmaco-biological profile. When excited at around 750 nm, it emits light in the near-infrared spectrum around 800 nm. A custom-made multispectral fluorescence imaging camera system was used.9.
The aim of this video article is to demonstrate the detection of the SLN using intraoperative fluorescence imaging in patients with cervical and vulvar cancer. Fluorescence imaging is used in conjunction with the standard procedure, consisting of radiocolloid and a blue dye. In the future, intraoperative fluorescence imaging might replace the current method and is also easily transferable to other indications like breast cancer and melanoma.

Fluorescence imaging is a promising innovative modality for image-guided surgery in surgical oncology. In this video we describe the technical procedure for detection of the sentinel lymph node using fluorescence imaging as showcased in gynecologic oncologicy. A multispectral fluorescence camera system, together with the fluorescent agent indocyanine green, is applied.

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical ...

Development of an Audio-based Virtual Gaming Environment to Assist with Navigation Skills in the Blind

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind. Using only audio based cues and set within the context of a video game metaphor, users gather relevant spatial information regarding a building's layout. This allows the user to develop an accurate spatial cognitive map of a large-scale three-dimensional space that can be manipulated for the purposes of a real indoor navigation task. After game play, participants are then assessed on their ability to navigate within the target physical building represented in the game. Preliminary results suggest that early blind users were able to acquire relevant information regarding the spatial layout of a previously unfamiliar building as indexed by their performance on a series of navigation tasks. These tasks included path finding through the virtual and physical building, as well as a series of drop off tasks. We find that the immersive and highly interactive nature of the AbES software appears to greatly engage the blind user to actively explore the virtual environment. Applications of this approach may extend to larger populations of visually impaired individuals.

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind.

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind. Using only audio ...

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing pancreatitis, if it does not resolve or is accompanied with infected necrosis in the retroperitoneum. As there are rarely any visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is accompanied with the risk of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae. In view of the above disadvantages, we apply real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) during VARD, which enables visualization of the well-perfused adjacent normal tissues. This modified technique (ICG-guided VARD) can provide a clear separating surface during debridement and reduce the risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing ...

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. Surgery is the cornerstone treatment for patients with BC. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection. In recent years, minimally invasive liver surgery (MILS) including robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. Robotic major MILS is still considered technically demanding and a detailed description of the technical approach during robotic major MILS has only been limitedly discussed in the literature. The current article describes the main steps for a robotic left hepatectomy in a patient with a large BC Todani Type V. The patient is in French position with 5 trocars placed (4 robotic, 1 laparoscopic assistant). After mobilizing the left hemiliver, the left and right hepatic artery are dissected carefully followed by a cholecystectomy. Intraoperative ultrasound is performed to confirm localization and margins of the BC. The Left hepatic artery and left portal vein are isolated, clipped, and divided. Indocyanine green (ICG) fluorescence imaging is used regularly during the entire procedure to visualize and confirm biliary tract anatomy and the BC. Parenchymal transection is performed with robotic cautery hook for the superficial part and robotic cautery spatula, bipolar cautery, and vessel sealer for the deeper parenchyma. The postoperative course was uncomplicated. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging aids in delineating the BC and bile duct anatomy. Further, comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ultrasound, important vascular structures, and surgeon experience. With the development of anatomical hepatectomy, visual surgery technology has gradually been applied to this type of surgery, particularly indocyanine green (ICG)-guided anatomical hepatectomy. As ICG can be specifically ingested by hepatocytes and used for fluorescence tracing, negative staining techniques have been applied according to different tumor positions. Under ICG fluorescent guidance, the surface boundary and deep resection plane can be more accurately displayed during liver resection. Thus, the tumor-bearing liver segment can be anatomically removed, which helps to avoid damage to important vessels and reduce ischemia or congestion of the remaining liver tissue. Finally, the incidence of postoperative biliary fistula and liver dysfunction is reduced; therefore, a better prognosis is obtained after the resection of liver cancer. Centrally located liver cancer is usually defined as a tumor located at segments 4, 5, or 8 that requires resection of the middle section of the liver. These are among the most difficult hepatectomies to perform because of the large surgical wounds and multiple vessel transections. Based on the specific tumor location, we formulated the required resection ranges by designing personalized fluorescent staining strategies. By completing anatomical resection based on the portal territory, this work aims to achieve the best therapeutic effect.

The present protocol describes fluorescent negative staining in laparoscopic central hepatectomy. This technique can make hepatectomy more accurate and precise.

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ...

Characterizing Different Lesion Types of Laser-Induced CNV in Mouse

Characterization of Vascular Morphology of Neovascular Age-Related Macular Degeneration by Indocyanine Green Angiography

Age-related macular degeneration (AMD) is a leading cause of blindness among older individuals, and its prevalence is rapidly increasing due to the aging population. Choroidal neovascularization (CNV) or wet AMD, which accounts for 10%-20% of all AMD cases, is responsible for an alarming 80%-90% of AMD-related blindness. Current anti-VEGF therapies show suboptimal responses in approximately 50% of patients. Resistance to anti-VEGF treatment in CNV patients is often associated with arteriolar CNV, while responders tend to have capillary CNV. While fluorescein angiography (FA) is commonly used to assess leakage patterns in wet AMD patients and animal models, it does not provide information about CNV vascular morphology (arteriolar CNV vs. capillary CNV). This protocol introduces the use of indocyanine green angiography (ICGA) to characterize lesion types in laser-induced CNV mouse models. This method is crucial for investigating the mechanisms and treatment strategies for anti-VEGF resistance in wet AMD. It is recommended to incorporate ICGA alongside FA for comprehensive assessment of both leakage and vascular features of CNV in mechanistic and therapeutic studies.

Author Spotlight: Overcoming Anti-VEGF Resistance Through Advanced Vascular Morphology Assessment in Choroidal Neovascularization

Currently, fluorescein angiography (FA) is the preferred method for identifying leakage patterns in animal models of choroidal neovascularization (CNV). However, FA does not provide information about vascular morphology. This protocol outlines the use of indocyanine green angiography (ICGA) to characterize different lesion types of laser-induced CNV in mouse models.

Age-related macular degeneration (AMD) is a leading cause of blindness among older individuals, and its prevalence is rapidly increasing due to the aging ...

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic ...

Complete Laparoscopic Radical Resection of Perihilar Cholangiocarcinoma Type IIIb

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With continuous advancements in laparoscopic techniques and instruments, laparoscopic radical surgery for pCCA is now considered technically safe and feasible. However, due to the high complexity of the surgery and the lack of evidence-based clinical support, laparoscopic radical surgery for type IIIb pCCA is performed only in a few large hepatobiliary centers. Current guidelines recommend left hemihepatectomy combined with total caudate lobectomy and standardized lymphadenectomy for resectable type IIIb pCCA. Therefore, in this article, we provide a detailed description of the surgical steps and technical points of complete laparoscopic left hemihepatectomy combined with total caudate lobectomy, regional lymphadenectomy, and right hepatic duct-jejunal Roux-en-Y anastomosis in patients with type IIIb pCCA, using fluorescence navigation technology to enhance surgical precision and safety. By adhering to standardized surgical procedures and precise intraoperative techniques, we offer an effective means to improve patient outcomes.

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With ...

Trans-Arterial Indocyanine Green Staining for Precise Anatomical Hepatectomy of Liver Segments VII and VIII

Anatomical hepatectomy for resectable hepatocellular carcinoma (HCC) is performed with precision using the Glissonean system, ultrasound imaging, and indocyanine green (ICG) fluorescence staining to define liver segments, enhancing surgical radicality and preserving liver volume. However, laparoscopic clamping and ultrasound-guided ICG staining for deep-seated tumors in liver segments VII and VIII pose challenges due to the depth of the Glissonean ducts and other technical limitations. This study aimed to overcome these obstacles by exploring a protocol using trans-arterial ICG staining, a technique specifically tailored for complex anatomical hepatectomy of liver segments VII and VIII. In this method, an interventionalist accessed the right femoral artery and advanced to the celiac trunk for arteriography, followed by strategic placement of a microcatheter into the tumor's blood supply vessel to facilitate surgical resection. During the operation, ICG was injected through the microcatheter to fluorescently label the tumor's liver segment, enabling precise anatomical resection under fluorescence guidance. This trans-arterial ICG staining approach allows for the accurate identification of tumor subsegments, facilitates complete resection, and optimizes liver function preservation, ultimately improving oncological outcomes without increasing surgical complication rates.

Laparoscopic anatomical hepatectomy has gained global recognition in liver surgery. However, delineating tumor boundaries in liver segments VII and VIII presents distinct technical challenges. This protocol utilizes trans-arterial indocyanine green (ICG) staining to accurately identify liver subsegments, facilitating complete tumor resection while preserving functional liver volume.

Anatomical hepatectomy for resectable hepatocellular carcinoma (HCC) is performed with precision using the Glissonean system, ultrasound imaging, and ...

The Role of Indocyanine Green Fluorescence in Complex Laparoscopic Cholecystectomy Navigation

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