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Fluorescence Guided Surgery

Frequently Asked Questions

In the operating room, precision is everything. With the groundbreaking tool known as Fluorescence Guided Surgery (FGS), surgeons can now illuminate what once remained hidden, gaining a clearer view that leads to smarter decisions, safer procedures, and better results for patients.

Fluorescence Guided Surgery

Frequently Asked Questions

In the operating room, precision is everything. With the groundbreaking tool known as Fluorescence Guided Surgery (FGS), surgeons can now illuminate what once remained hidden, gaining a clearer view that leads to smarter decisions, safer procedures, and better results for patients.

Learn about Fluorescence Guide Surgery works and how it benefits many surgical procedures

Are there any significant risks associated with the dye (indocyanine green [ICG]) used for fluorescence guided surgery?
  • The ICG dye is very safe and the imaging devices used with it do not expose patients to any radiation.
  • The ICG dye was approved by the Food and Drug Administration (FDA) in 1959.
  • The dye has some relative contraindications, which include a history of allergy to iodides.
  • The ICG dye has a very low reported incidence of allergic reactions, generally considered safe, with an estimated rate of 0.05%. Mild reactions like rash or nausea can occur in up to 0.2% of patients, while severe reactions including anaphylaxis are extremely rare, occurring in roughly 0.05% of cases. In the presence of said reactions, medical attention is immediately required.
  • The use of all imaging devices used during the performance of fluorescence guided surgery are only for visual aid, and thus have no life-threatening risks.
Do I need to stop taking certain medications before I undergo fluorescence guided surgery?

No. There are no direct drug interactions that will put you at risk during fluorescence guided surgery.

I am pregnant or thinking about pregnancy, should I undergo fluorescence guided surgery?

The ICG dye has been classified as a category C teratogenic effect drug, and as such, can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. If you are pregnant or thinking about pregnancy, you should communicate this to your surgeon before surgery.

My surgeon thinks fluorescence guided surgery would be beneficial for our child’s upcoming surgery? Is it safe for children?

Yes. The ICG dye is safe in infants, children and adolescence. The same precautions should be considered as those for adults. Your surgeon will make sure to not exceed the max dose listed as no more than 2 mg of ICG per kilogram.

FGS Explained

Choose your surgery

Want to learn more about fluorescence guided surgery?
Locate the PubMed IDs under each surgical specialty to read more about it

Laparoscopic Inguinal Hernia Repair
  • Inguinal hernia repair is a very common surgical procedure performed by general surgeons, with over 800,000 cases annually to prevent complications after clinical symptoms appear.
  • ICG fluorescence imaging, initially used in hepatobiliopancreatic surgery, is a new and promising visual aid in inguinal hernia repairs.
  • Early outcomes of ICG fluorescence imaging in inguinal hernia repair show benefits such as reduced operating times, identification of lymphatic injuries, and real-time identification of key anatomical landmarks.
  • ICG fluorescence imaging is particularly helpful in quickly and accurately locating the "triangle of doom," a critical anatomical landmark with high vascularity prone to surgical complications.
  • Precise identification of the triangle of doom using this technique has the potential to shorten surgery duration, ease the learning process for surgeons, and decrease the risk of postoperative chronic groin pain (inguinodynia).
REFERENCES
PubMed ID: 39293222
PubMed ID: 37058799
PubMed ID: 30734117
Thyroidectomy (Partial/Total)
  • Thyroid surgery carries significant risks of complications like hemorrhage, hypoparathyroidism, and vocal cord palsy.
  • Meticulous surgical technique and a cautious approach are crucial for preventing these operative complications.
  • Fluorescence guided surgery is being used in thyroid surgery to aid in the dissection of the thyroid gland.
  • Fluorescence guided surgery serves as a visual aid tool to specifically lower the risk of accidental parathyroid gland damage and subsequent hypoparathyroidism.
  • Fluorescent angiography of the thyroid gland's blood supply may be an effective method for minimizing major bleeding and maintaining the gland's health.
REFERENCES
PubMed ID: 36427932
PubMed ID: 30710614
PubMed ID: 37659862
Sentinel lymph node identification/resection in endometrial cancer surgery
  • The International Federation of Gynecology and Obstetrics (FIGO) staging guides endometrial cancer treatment and prognosis: Pathological assessment of the primary tumor and lymph nodes, according to the FIGO system, is crucial for selecting adjuvant therapy and predicting patient outcomes.
  • Sentinel lymph node biopsy is preferred over systematic lymphadenectomy: It offers higher accuracy, less damage, and directly indicates tumor spread.
  • Fluorescence guided surgery via ICG is a recommended tracer in gynecological cancers: It demonstrates high sensitivity, specificity, and detection rates, particularly for cervical and vulvar cancers.
  • ICG mapping shows high detection rates across different gynecological cancer types: Detection rates are consistently high for cervical, endometrial, and vulvar cancers, regardless of administration method.
  • ICG mapping offers clinical benefits and is superior to other tracers: It is associated with shorter surgeries, less blood loss, shorter hospital stays, and outperforms other tracers in detection rates.
REFERENCES
PubMed ID: 37881680
PubMed ID: 38401483
PubMed ID: 28566221
Nephrectomy (Partial/Total)
  • Malignancy is the primary driver for nephrectomy (partial or total). Surgical intervention for cancerous growths is the main reason for kidney removal or partial resection.
  • Surgical advancements have broadened the use of partial nephrectomy. Improvements in instruments and imaging now allow partial nephrectomy to be used for a wider range of renal masses, not just small ones.
  • Modern surgical practice prioritizes preserving renal function and integrity. Contemporary approaches aim to save as much kidney tissue as possible.
  • ICG fluorescence guided surgery enhances kidney preservation efforts. This technique is a feasible, safe, and cost-effective tool for assessing renal tissue during surgery.
  • Partial nephrectomies via fluorescence guided surgery show improved outcomes. This approach leads to less blood loss, better preservation of kidney function, and excellent results regarding tumor removal and recurrence.
REFERENCES
PubMed ID: 31286194
PubMed ID: 38067266
PubMed ID: 36450121
Sentinel lymph node identification/resection in melanoma
  • A positive sentinel lymph node (SLN) in melanoma significantly affects treatment strategies.
  • Current standard SLN identification methods (technetium-based lymphoscintigraphy and blue dye mapping) have drawbacks including radiation exposure, high costs, technical demands, and inconsistent results.
  • ICG fluorescence guided surgery is a feasible, safe, reproducible, accurate, and cost-effective alternative for SLN diagnosis.
  • Fluorescence guided surgery demonstrates a high sensitivity rate (95%) for SLN identification, outperforming blue dye (48.7%) and showing comparable sensitivity to radiocolloid (90.6%).
  • Fluorescence guided surgery has statistically significant superior detection rates compared to blue dye and similar localization efficacy to radiocolloid techniques.
REFERENCES
PubMed ID: 39013712
PubMed ID: 39061163
PubMed ID: 39581000
Aneurysm clipping in neurosurgery
  • Fluorescence guided surgery, particularly indocyanine green fluorescence angiography (ICG-A) has become a significant tool in vascular neurosurgery since its introduction in 2003.
  • It aids in the decision-making process for treating cerebral aneurysms, arteriovenous malformations, and bypass surgeries at both microscopic and endoscopic levels.
  • Compared to digital subtraction angiography, ICG-A is easier to use and avoids the need for vascular access/diagnostic catheter placement.
  • In aneurysm repair surgery, ICG-A has been crucial in identifying mis-clipping, leading to clip repositioning in a notable percentage of cases, even after digital subtraction angiography.
  • Recent advancements in fluorescence guided surgery have enabled semi-quantitative blood flow examination, allowing for the identification of regions of interest based on relative maximum fluorescence values, which can enhance the preservation of neural tissue after surgery.
REFERENCES
PubMed ID: 12493110
PubMed ID: 12066932
PubMed ID: 31281818
Mastectomy & immediate breast reconstruction surgery
  • Fluorescence guided surgery, particularly ICG angiography (ICG-A), is a key tool during breast reconstruction for predicting and mitigating the risk of mastectomy flap necrosis.
  • ICG-A provides a real-time assessment of tissue perfusion, aiding in preserving tissue vitality and supporting crucial intraoperative decisions.
  • Preoperative ICG-A of the nipple-areola complex (NAC) significantly improves the accuracy of predicting its vitality compared to clinical assessment alone (by 22-34%).
  • Preliminary ICG-A for flap vitality assessment enables flap design optimization, demonstrably reducing flap loss rates in breast reconstruction procedures.
  • Clinical evidence indicates that the use of fluorescence imaging surgery is associated with a substantial reduction in several postoperative complications, including fat necrosis (40%), wound dehiscence (32%), and seroma formation (29%).
REFERENCES
PubMed ID: 39946672
PubMed ID: 39760587
PubMed ID: 38425697
Esophagectomy
  • Fluorescence imaging surgery, specifically ICG angiography (ICG-A) is a feasible and applicable direct marker for assessing the vitality of the gastric tube reconstructive conduit during esophagectomy.
  • This technique has been shown to reduce the risk of anastomotic leaks (AL) by approximately 48%.
  • Fluorescence imaging surgery improves intraoperative decision-making, leading to changes in surgical conduct in about 10.6% of cases, such as additional resection or relocation of the anastomosis.
  • While ICG-A use significantly impacts surgical decisions in a large majority of cases (80%), it has not demonstrated a significant effect on overall mortality and morbidity rates related to AL compared to historical controls.
  • Overall, the benefits of using ICG-A during esophagectomy outweigh its non-utility.
REFERENCES
PubMed ID: 39289637
PubMed ID: 36327490
PubMed ID: 38466450
Laparoscopic cholecystectomy
  • Fluorescent cholangiography is a leading application of fluorescence guided surgery, setting a standard for modern surgical techniques.
  • During laparoscopic cholecystectomy, it enhances visualization of biliary anatomy, particularly the critical view of safety, aiding in the identification of key structures for this procedure.
  • This technique improves intraoperative efficiency by significantly reducing operating times (15-20%) through faster dissection and decreased surgical uncertainty.
  • Fluorescent cholangiography offers several advantages over fluoroscopic cholangiography, including cost-effectiveness, absence of radiation, and its value as a teaching tool for surgeons.
  • The real-time feedback of anatomical landmarks and bile flow provided by fluorescent cholangiography confirms duct patency and contributes to superior postoperative outcomes.
REFERENCES
PubMed ID: 38337557
PubMed ID: 30614881
PubMed ID: 39860547
Low anterior resection in colorectal surgery
  • Anastomotic leaks (AL) are a major concern following sphincter-sparing surgery for rectal cancer, with colorectal-coloanal anastomoses having a significantly higher AL rate compared to ileocolonic-colonic anastomoses.
  • While conservative treatment for AL exists, surgical intervention is often necessary to avoid worsening complications.
  • Fluorescence guided surgery has demonstrated significant benefits, including lower rates of AL, overall postoperative complications, and reoperations.
  • The use of ICG-fluorescence can lead to improvements in surgical technique, such as adjustments to the initial transection line in a notable percentage of cases.
  • Routine use of ICG-fluorescence has been shown to reduce the overall complication rate in colorectal surgery compared to control groups.
REFERENCES
PubMed ID: 31318495
PubMed ID: 25451666
PubMed ID: 30406482
Kasai portoenterostomy in pediatric surgery
  • The Kasai procedure with hepatoenterostomy is the established first line of treatment for biliary atresia in pediatric surgery.
  • A major challenge in the Kasai procedure is the difficult dissection of the fibrous cone at the porta hepatis.
  • ICG fluorescence guided surgery offers real-time guidance during dissection, potentially lowering complications and aiding surgeons in training.
  • This imaging technique allows for intraoperative confirmation of bile excretion and postoperative confirmation via fluorescent stools.
  • Fluorescence guided surgery significantly improves the rate of resolving postoperative hyperbilirubinemia compared to cases without its use.
REFERENCES
PubMed ID: 36528283
PubMed ID: 38614948
PubMed ID: 31575415
Hirschsprung disease in pediatric surgery
  • Fluorescence guided surgery improves surgical precision in pediatric surgery by providing detailed visualization and reducing complications.
  • Anastomosis following colorectal resection for Hirschsprung disease carries a significant risk (up to 19%) of leakage and stricture.
  • Accurate assessment of bowel blood supply, particularly through the marginal artery, is crucial for minimizing complications during colorectal resection for Hirschsprung disease.
  • ICG fluorescence is a valuable visual aid for assessing tissue perfusion in Hirschsprung disease.
  • Routine use of fluorescence guided surgery can help surgeons determine the optimal resection line and anastomosis of well-perfused bowel segments, potentially preventing re-interventions due to leakage or stricture.
REFERENCES
PubMed ID: 31199700
PubMed ID: 39246990
PubMed ID: 38929244
Ureteral visualization
  • The ureter is a crucial anatomical landmark in gynecological, urological, and colorectal surgeries.
  • Distinguishing the ureter from blood vessels can be difficult due to similar appearance and location near the posterior peritoneum, especially in obese patients or those with prior abdominal surgery.
  • The retroperitoneal approach in a complex anatomical region increases the risk of accidental ureteral injury and subsequent complications.
  • ICG-mediated ureteral identification is a technique that offers improved precision and effectiveness in locating the ureter during surgery, leading to better surgical outcomes.
  • Utilizing ICG for ureteral identification significantly reduces the time needed to find the ureter and the total duration of surgical procedures.
REFERENCES
PubMed ID: 39434762
PubMed ID: 39379730
PubMed ID: 39115040
Coronary arterial bypass grafting (CABG) surgery
  • Intraoperative ICG fluorescent coronary angiography is a safe, feasible, and effective technology for assessing the integrity of coronary arterial anatomy.
  • The promising potential of this technique to improve guided surgery is being explored across various surgical specialties.
  • In heart surgery, fluorescence guided surgery has demonstrated the ability to improve vascular graft outcomes, assess congenital coronary anomalies in real-time, and enhance procedural planning to reduce injury in congenital cardiac surgery.
  • Fluorescence guided surgery is a safe and innocuous navigational tool that complements existing surgical techniques in cardiac surgery.
  • This technology has significant potential for imagery enhancement in cardiac surgery and lacks major contraindications.
REFERENCES
PubMed ID: 34401838
PubMed ID: 36203048
PubMed ID: 34401840
Sentinel lymph node identification/resection in breast cancer surgery
  • Sentinel lymph node biopsy is the standard method for axillary staging in clinically node-negative breast cancer patients based on examination and imaging.
  • Despite advancements in tumor detection, positive microscopic margins after conservative breast surgery remain a significant issue, occurring in 14.9% to 26% of cases.
  • Indocyanine green (ICG) mapping for sentinel lymph nodes has been well-established since its introduction.
  • ICG mapping as a standalone technique demonstrates a higher sentinel lymph node identification rate compared to superparamagnetic iron oxide, radio-isotopes, and blue dye, as well as older methods.
  • ICG mapping offers superior identification rates for metastatic lymph nodes and overall better axillary staging compared to conventional tracers.
REFERENCES
PubMed ID: 33183928
PubMed ID: 37326934
PubMed ID: 27864624

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