monthly focus

surgical intervention video

This live educational video broadcasted from IRCAD Taiwan shows the case of a 31-year-old woman admitted to hospital for chronic abdominal pain in the right upper quadrant for one month. Ultrasonography (US) demonstrated gallstones with a moderate thickening of the gallbladder wall. The patient had a BMI of 26 and she had a past surgical history of laparotomy for perforated appendicitis and thyroidectomy for papillary cancer. 

This procedure highlights the benefits of intraoperative guidance with ICG fluorescence. In addition to a conventional preoperative intravenous (IV) injection, ICG fluorescence was used intraoperatively to understand and demonstrate the vascular anatomy of the hepatocystic triangle. During this procedure, technical points are discussed between Dr. M Lin, the operator, and Drs. B Dallemagne, HP Wong, W Huang.

How fluorescence can help to obtain the critical view of safety (CVS) during laparoscopic cholecystectomy: a live educational procedure broadcasted from IRCAD Taiwan

Холецистэктомия с использованием ICG

Comment la fluorescence peut aider à obtenir la vision critique de sécurité (CVS) pendant une cholécystectomie laparoscopique : une intervention en direct diffusée depuis l'IRCAD Taïwan 

This is the case of a 56 year-old male patient with a BMI of 27.5. He presented with a renal cell carcinoma at a clinical stage of T1аN0M0. Its R.E.N.A.L. score was 6a. The tumor was 2.4 x 3.3 x 3.5cm in size, and was localized in the inferior segment of the left kidney. On the CT-scan, the segmental branch of a renal artery was identified. The surgery was performed under general anesthesia. The patient was placed in left kidney position at an angle of 45°. Ports were placed in a standard fashion for laparoscopic kidney surgery. After the dissection of renal vein and arteries in the hilum, the inferior kidney segment containing the tumor was exposed. The inferior segmental arterial branch was identified and clamped with a bulldog clamp. An intravenous injection of 12.5mg indocyanine green (ICG) was performed, so that 2-3 minutes later the ischemic zone with the tumor could be defined. Enucleoresection of the tumor was performed using a standard technique. “Cold” scissors were used to clearly visualize the surgical margins. The first suture line was placed in the tumor crater using a 3-0 polyglycolic acid suture. It was secured with Hem-o-lok® clips at each end for hemostasis, and was combined with a local hemostasis using Absolock clips. The second suture line was placed using a 0 polyglycolic acid suture, and was secured with Hem-o-lock clips to close the parenchymal defect.

The blood flow was controlled in the resection zone by performing a 12.5mg indocyanine green intravenous injection. There was no sign of ischemia. Segmental ischemic time was 9 min 40 sec, and blood loss was 75ml. The postoperative course was uneventful. 

Conclusion: ICG visualization helps to better control both segmental ischemias during partial nephrectomy and blood flow in the parenchyma at the end of the surgery.

Laparoscopic partial nephrectomy with ICG-guided segmental ischemia in a patient with T1aN0M0 kidney cancer

Лапароскопическая частичная нефрэктомия с использованием ICG у пациента с раком почки T1aN0M0

Néphrectomie partielle laparoscopique guidée par vert d'indocyanine avec ischémie segmentaire chez un patient atteint d'un cancer du rein T1aN0M0

This is the case of a 25-year-old male patient presenting with recurrent intractable abdominal pain he has been suffering from for the last 6 months. Three months prior to admission to our clinic, the patient underwent ERCP, endoscopic stenting of the main pancreatic duct due to ductal obstruction and refractory pain. The procedure had no therapeutic effect. CT-scan showed signs of chronic pancreatitis, multiple stones from 3 to 6mm in the pancreatic parenchyma and dilated main pancreatic duct in the head and body of the pancreas up to 10 and 8mm respectively. The patient was referred for a laparoscopic partial removal of the head of the pancreas with longitudinal Roux-en-Y pancreaticojejunostomy – a technique known as Frey procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis. 

An adequate resection of the pancreatic head is a crucial step of this procedure. Insufficient volume of the resected pancreas and residual fibrotic tissues are the most common reasons of procedure failure, leading to pain recurrence. To perform an adequate resection, it is important to stick to the anatomical boundaries, one of which is the intrapancreatic portion of the common bile duct. Consequently, one of the most common complications during the Frey procedure is the distal bile duct injury, which can be easily misidentified within the surrounding fibrotic tissues, developed due to chronic inflammation. A method that helps to prevent this complication is indocyanine green (ICG) fluorescence-guided imaging, which allows to clearly visualize the biliary tract. Two hours prior to surgery, our patient received an intravenous injection of 25mg of indocyanine green. During the resection step, ICG imaging allowed us to reveal the intrapancreatic portion of the common bile duct, thereby significantly facilitating the prevention of its injury and making the resection much safer. 

The purpose of this video is to demonstrate that the laparoscopic Frey procedure is safe and feasible, and provides all the well-known advantages of the minimally invasive approach, particularly lower postoperative pain, earlier functional recovery, and shorter hospital stay. Also, in this particular case, we highlight the important role of ICG fluorescence-guided imaging in the prevention of one of the most serious complications, namely common bile duct injury. 

Laparoscopic Frey procedure with ICG fluorescence-guided biliary tract imaging

Intervention de Frey par approche laparoscopique avec imagerie des voies biliaires guidée par fluorescence au vert d'indocyanine

Gastrectomie robotisée subtotale pour cancer : Localisation de la tumeur avec fluorescence par injection de vert d'indocyanine ICG et cartographie des ganglions lymphatiques

Subtotal or near total gastrectomy for T1b-T2 differentiated cancer of the middle and lower thirds of the stomach is the best therapeutic option with a chance of cure. Eastern experiences have demonstrated the safety of a minimally invasive gastrectomy although this approach remains challenging. The use of the robot has been proven to enhance the precision of each step of this operation. In particular, the possibility of using near-infrared (NIR) vision facilitates the 2 technical key points for a successful resection, i.e. the precise intraoperative determination of tumor distance from the proximal resection margin and the definition of the lymph node basin for an accurate lymphadenectomy. The video outlines relevant surgical steps, i.e. ICG fluorescence-guided tumor identification, definition of surgical margin, and D2 lymph node dissection. Other steps such as subtotal gastrectomy and anastomosis performed as a side-to-side antecolic vertical gastrojejunostomy on the greater gastric curvature according to the Woo Jin Hyung technique are also shown. The peculiarity of our technique lies in ICG fluorescence guidance. In this respect, the robotic NIR vision offers an optimal image modulation necessary to obtain the best image contrast and intraoperative vision. 

Robotic subtotal gastrectomy for cancer: ICG fluorescence-guided tumor location and lymph node mapping

video lecture

Chirurgie colorectale guidée par fluorescence

In this authoritative lecture, Dr. Ronan Cahill, MD, FRCS provides a clear introduction to the use of near-infrared fluorescence imaging in colorectal surgery, highlighting the essentials of this type of imaging and the role of image analysis programs to quantify the fluorescence signals.

Dr. Ronan Cahill, MD, FRCS does not have any conflicts of interest or financial ties to disclose.

Fluorescence-guided colorectal surgery

Segmentectomie anatomique laparoscopique avec coloration de fluorescence par vert d'indocyanine : de S1 à S8

In this key lecture, Dr. Xiaoying Wang focuses on laparoscopic anatomical segmentectomy with ICG fluorescence staining (from S1 to S8).

Laparoscopic anatomical segmentectomy with ICG fluorescence staining: from S1 to S8

Chirurgie gastrique guidée par fluorescence

In this key lecture, Professor Hyung, an expert in gastric surgery who performed over 5,000 gastrectomies, provides a clear introduction to the use of near-infrared fluorescence imaging in gastric surgery, laying emphasis on gastric lymph node dissection (LND) and its impact on oncological outcomes.

Fluorescence-guided gastric surgery

Navigation de précision en chirurgie laparoscopique grâce à l'imagerie par fluorescence

In this interactive state-of-the-art presentation, Dr. Mahdi Al-Taher is providing an outline on the use of near-infrared fluorescence imaging (NIRF) during minimally invasive surgery. In this presentation, the background and basic principles of NIRF imaging are described followed by an introduction to its current advanced practices in ureteral imaging (PART I), urethral imaging (PART II), bile duct and liver imaging (PART III), endometriosis imaging (PART IV), and bowel perfusion assessment (PART V). Finally, the future perspectives on this type of imaging are briefly addressed. 

Educational objectives are the following:

- to provide an introduction to the basic principles of near-infrared fluorescence imaging, 

- to address the current advanced practices of NIRF for various (minimally invasive) surgical indications,

- to provide a brief introduction on the future perspectives of near-infrared fluorescence imaging. 



Precision navigation in laparoscopic surgery using fluorescence imaging

In this key lecture presented during the IRCAD online course on laparoscopic left colectomy, Professor Laurents Stassen is providing an outline on the use of near-infrared fluorescence imaging (NIRF) for intraoperative ureteral identification. Currently available options and promising preclinical NIRF imaging techniques along with future perspectives are outlined. 

Ureteral fluorescence imaging during colorectal surgery: the future (of the ureter) is bright

L'imagerie par fluorescence urétérale lors de la chirurgie colorectale : l'avenir (de l'uretère) est prometteur

In this key lecture, Dr. Michele Diana outlines the physiological principle of fluorescence imaging and the clinical application of indocyanine green (ICG), in hepatobiliary surgery, highlighting major publications. Dr. Diana emphasizes the current limitations and future perspectives of fluorescence image-guided surgery.

Fluorescence imaging in HPB surgery

L'imagerie par fluorescence dans la chirurgie hépatopancréatobiliaire

In this key lecture presented during the IRCAD online course on laparoscopic cholecystectomy, Dr. Michele Diana is providing an outline on the use of near-infrared fluorescence imaging (NIRF) cholangiography during laparoscopic cholecystectomy procedures. Additionally, the role of NIRF cholangiography, multimodal intraoperative imaging, and other imaging technologies are described with an emphasis on the key published studies on these topics. 

Imaging during laparoscopic cholecystectomy

L'imagerie lors d'une cholécystectomie laparoscopique

Colectomie droite : la fluorescence comme guide peropératoire  

In this authoritative lecture presented during the IRCAD online course on laparoscopic right colectomy, Prof. Salvador Morales-Conde is providing an outline on the use of near-infrared fluorescence imaging (NIRF) for intraoperative angiography in the clinical setting and its influence on the intraoperative decision-making and surgical outcomes. In addition, during this presentation, the intraoperative NIRF lymphography with lymph node mapping is described and clinical examples of its use are provided. 



Right colectomy: intraoperative guidance: fluorescence

Résection oncologique du côlon gauche guidée par fluorescence

In this authoritative lecture presented during the IRCAD online course on laparoscopic left colectomy, Professor Ronan Cahill is providing an outline on the use of near-infrared fluorescence imaging (NIRF) for intraoperative angiography with the ultimate purpose of anastomotic leak reduction. During this presentation, the intraoperative decision-making with the beneficial use of technology to quantify the fluorescence intensity is described and clinical examples of its use are provided.  

Focus on intraoperative near-infrared fluorescence (NIRF) imaging