Fluorescence-Guided Surgery (FGS) during a Laparoscopic Redo Nissen Fundoplication: The First Case in Children

Abstract

We present the first case of fluorescence-guided surgery (FGS) using indocyanine green (ICG) in a pediatric redo-Nissen fundoplication. The patient is a 17-year-old male with recurrent gastroesophageal symptoms who underwent primary antireflux surgery at 10 months of age. During the redo fundoplication, ICG was intravenously administered to help the visualization during the adhesiolysis between liver, stomach and right crus of the diaphragm and to spare small oesophageal vessels and the left gastric artery. In this case, FGS made the surgery easier than usual and likely reduced the risk of intra-operative complications. Therefore, we believe that this new technology should be regularly used in these types of complex intra-abdominal redo operations.

Evaluating the Development Status of Fluorescence-Guided Surgery (FGS) in Pediatric Surgery Using the Idea, Development, Exploration, Assessment, and Long-Term Study (IDEAL) Framework

“…ICG fluorescence imaging was used to identify and manage insufficient graft perfusion in a boy who underwent liver transplantation [ 19 ]. In one case, fluorescence helped to detect the blood supply during a re-do Nissen [ 20 ] and, in another case, it was useful to validate blood perfusion of the esophageal wall and anastomotic site during esophageal atresia repair [ 21 ].…”

“…A total of 0.125 mg/kg of ICG was infused to achieve visualization of the operative field in the case of re-do Nissen [ 20 ]. The dye was intravenously administered during surgery.…”

“…The dye was intravenously administered during surgery. Paraboschi et al [ 20 ] suggested that the use of FGS significantly impacted intraoperative decision making as ICG helped identify and spare left gastric artery and intrabdominal esophagus blood supply and establish an adequate length of intra-abdominal esophagus. No postoperative complications occurred.…”

The Role of Indocyanine Green in Pediatric Gastrointestinal Surgery: Systematic Review

“…Although the clearance rate decreases subsequently, it is cleared quickly enough to allow multiple injections in most procedures. Despite a paucity of clinical studies evaluating its role in esophagogastric pediatric surgery, FGS has shown promising results in helping guide TEF (13) or thoracic duct identification (15) and improving the accuracy of anatomical delineation in EA repair procedure (11) and redo funduplication surgery (16). The administration of ICG sprayed through the trachea into the fistulae, which had not been previously described, allowed the identification of recurrent TEFs eliminating the need for guide wire placement, which can save anesthesia time and reduce tissue damage (13).…”

“…Regarding fundoplication surgery, Paraboschi et al described that the use of intraoperative ICG helped to identify the esophagogastric junction's main landmarks, which are usually altered in patients with a previous surgery. 16 They reported a 17-year-old male with recurrent gastroesophageal symptoms who underwent primary antireflux surgery at 10 months of age. Intravenous single dose of ICG (0.125 mg/kg) was injected 1 minute before imaging to achieve optimal dye performance.…”