Human Factors and Quantitative Data: Diverging Perspectives on ICG use in Emergency Bowel Surgery -  A systematic...

Indocyanine Green (ICG) fluorescence imaging is increasingly used in emergency bowel surgery to assess intestinal perfusion. While literature reports high technical efficacy, intraoperative interpretation remains variable. This systematic review explores how cognitive and systemic human factors influence ICG's perceived effectiveness, compared to reported quantitative outcomes. A systematic search of PubMed and Embase identified 31 original studies from 266 screened articles. Qualitative synthesis was guided by ENTREQ principles. Bias identification followed a thematic approach using cognitive bias categories based on established clinical decision-making frameworks. ICG was reported to influence surgical decision-making in 302 of 308 cases. However, discrepancies between fluorescence findings and clinical actions occurred in 38.3% of cases. Common cognitive patterns included confirmation and anchoring bias, overconfidence in fluorescence interpretation, and reliance on ICG to support pre-established surgical decisions. Systemic limitations included lack of interdisciplinary input, case-report bias, and absence of standardized interpretation protocols. These were analyzed across a full article-by-article bias matrix and summarized by domain and sentiment. ICG is not solely a diagnostic tool, but a cognitive interface shaped by time pressure, decision momentum, and human interpretation. Rather than providing objective certainty, ICG often reinforces existing clinical judgments. Addressing bias-awareness and integrating interdisciplinary frameworks may enhance interpretive consistency and improve patient outcomes. These findings call for greater cognitive standardization in the intraoperative use of ICG during emergency surgery.