Near‐infrared (NIR) fluorescence imaging is gaining clinical acceptance over the last years and has been used for detection of lymph nodes, several tumor types, vital structures and tissue perfusion. This review focuses on NIR fluorescence imaging with indocyanine green and methylene blue for different clinical applications in abdominal surgery with an emphasis on oncology, based on a systematic literature search. Furthermore, practical information on doses, injection times, and intraoperative use are provided.

Background: Fluorescence videography is a promising technique for assessing bowel perfusion. Fluorescence-based enhanced reality (FLER) is a novel concept, in which a dynamic perfusion cartogram, generated by computer analysis, is superimposed on to real-time laparoscopic images. The aim of this experimental study was to assess the accuracy of FLER in detecting differences in perfusion in a small bowel resection-anastomosis model. Methods:A small bowel ischaemic segment was created laparoscopically in 13 pigs. Animals were allocated to having anastomoses performed at either low perfusion (25 per cent; n = 7) or high perfusion (75 per cent; n = 6), as determined by FLER analysis. Capillary lactate levels were measured in blood samples obtained by serosal puncturing in the ischaemic area, resection lines and vascularized areas. Pathological inflammation scoring of the anastomosis was carried out.Results: Lactate levels in the ischaemic area (mean(s.d.) 5⋅6(2⋅8) mmol/l) were higher than those in resection lines at 25 per cent perfusion (3⋅7(1⋅7) mmol/l; P = 0⋅010) and 75 per cent perfusion (2⋅9(1⋅3) mmol/l; P < 0⋅001), and higher than levels in vascular zones (2⋅5(1⋅0) mmol/l; P < 0⋅001). Lactate levels in resection lines with 75 per cent perfusion were lower than those in lines with 25 per cent perfusion (P < 0⋅001), and similar to those in vascular zones (P = 0⋅188). Levels at resection lines with 25 per cent perfusion were higher than those in vascular zones (P = 0⋅001). Mean(s.d.) global inflammation scores were higher in the 25 per cent perfusion group compared with the 75 per cent perfusion group for mucosa/submucosa (2⋅1(0⋅4) versus 1⋅2(0⋅4); P = 0⋅003) and serosa (1⋅8(0⋅4) versus 0⋅8(0⋅8); P = 0⋅014). A ratio of preanastomotic lactate levels in the ischaemic area relative to the resection lines of 2 or less was predictive of a more severe inflammation score. Conclusion:In an experimental model, FLER appeared accurate in discriminating bowel perfusion levels. Surgical relevanceClinical assessment has limited accuracy in evaluating bowel perfusion before anastomosis. Fluorescence videography estimates intestinal perfusion based on the fluorescence intensity of injected fluorophores, which is proportional to bowel vascularization. However, evaluation of fluorescence intensity remains a static and subjective measure.Fluorescence-based enhanced reality (FLER) is a dynamic fluorescence videography technique integrating near-infrared endoscopy and specific software. The software generates a virtual perfusion cartogram based on time to peak fluorescence, which can be superimposed on to real-time laparoscopic images. This experimental study demonstrates the accuracy of FLER in detecting differences in bowel perfusion in a survival model of laparoscopic small bowel resection-anastomosis, based on biochemical and histopathological data.It is concluded that real-time imaging of bowel perfusion is easy to use and accurate, and should be translated into clinical use.

An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy (LC) with the goal of deriving expert recommendations for the reduction of biliary and vascular injury. Nineteen hepato-pancreato-biliary (HPB) surgeons from high-volume surgery centers in six countries comprised the Research Institute Against Cancer of the Digestive System (IRCAD) Recommendations Group. Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC. Consensus was achieved when 80% of respondents ranked an item as 1 or 2 (Likert scale 1-4). Seventy-one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants. The IRCAD recommendations were structured in seven statements. The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety (CVS), systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome-down (fundus-first) cholecystectomy. Highest consensus was achieved on the importance of the CVS as well as dome-down technique and partial cholecystectomy as alternative techniques. The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events.

After a Health Technology Assessment on 3D vision technology completed last year, the aim of one of the consensus meetings 2018 of the EAES was to generate a guideline on the same topic based on best available evidence and expert opinions of EAES Technology Committee members. After a systematic review of the literature by an international group of research fellows, an expert panel with extensive engineering and clinical experience in the use of 3D vision technology discussed statements and recommendations. Twenty-two statements and 2 recommendations were obtained unanimously by the experts and were discussed and voted at the consensus meeting of the EAES in London in May 2018 by the attendees of the meeting. The most important regarding general topics were: a) 3D vision improves outcomes for junior trainees in performing standardized tasks in box trainers, only when 3D systems with HD screen and passive polarized glasses are used and only when properly set up; b) The use of 3D imaging systems improves laparoscopic box trainer task completion time and error rate but this benefit has not been studied in clinical practice. The most important regarding clinical setting were: a) 3D laparoscopy shortens the operating time in all the analysed surgical settings (general surgery, urology and gynaecology); b) The pooling of data from the different settings seems to suggest a lowering in the overall rate of complications after surgical procedures involving suturing in 3D laparoscopy, especially in the gynaecology setting; indeed data are too heterogeneous and weak to sustain any recommendation, other than implications for future research. These produced 2 recommendations: a) 3D laparoscopy might shorten operative times; b) Future research is recommended to demonstrate that 3D vision may lower complications rate in laparoscopy. The majority of the EAES members supported these statements.These consensus proceedings provide additional guidance to surgeons and surgical residents providing help when using 3D vision technology.