Applications of indocyanine green-enhanced fluorescence in laparoscopic colorectal resections

Recently, Indocyanine Green (ICG)-enhanced fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical informations. The aim of our study is the application of ICG imaging during laparoscopic colorectal resections: to assess anastomotic perfusion to reduce the risk of anastomotic leak, to facilitate vascular dissection when vascular anatomy of tumor site is unclear, and to identify ureter to prevent iatrogenic injury. After the transection, 5 ml of ICG solution is intravenously injected. A Full HD IMAGE1S camera, switching to NIR mode, in few seconds provides a real-time angiography of colonic perfusion. After anastomosis, another bolus is injected to confirm the anastomotic perfusion. When the tumor is localized in difficult site, the fluorescence provides a real-time angiography of tumor area vascularization to perform the vascular dissection. When the tumor is tightly attached to the ureter, the ICG solution injection through the catheter allows ureter identification. From November 2016, 38 patients were enrolled: ten left colectomies, 22 right colectomies, three transverse resections, and three splenic flexure resections. In five cases, intraoperative angiography led to the identification of vascular anatomy. In one case the surgical strategy was changed. In one procedure, ureter identification allowed to prevent injury. Three postoperative complications that required surgical reoperation occured, of which one anastomotic leak, due to a mechanical problem. ICG-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. It can be employed also in small hospitals without learning curve. It is recommended to obtain additional information on anatomy and perfusion in colorectal surgery.