Fluorescent ureterography with indocyanine green in laparoscopic colorectal surgery

Abstract

Intraoperative injuries to the ureter can occur in complicated colorectal and gynaecologic procedures in minimal access surgery. The majority of these go unrecognised at the time of the operation, which can be disastrous to the patient. The routine use of ureteric stents is controversial, with some studies showing that stents only enable detection of ureteric injury but do not prevent it. Fluorescent image-guided surgery with indocyanine green (ICG) to visualise the ureter is a relatively new technique. We report our method of visualisation of the ureter in two patients undergoing laparoscopic anterior resection and Hartmann procedure, respectively. After induction of anaesthesia, retrograde catheterisation of both ureters was performed by the urologist. 2.5 mg ICG was injected into each catheter at the start of the procedure. Both ureters were visualised very well throughout the procedure with no post-operative complications. This technique using ICG adds visual cues to make up for the loss of tactile feedback, making it a safe strategy to prevent intraoperative ureteric injury.

Utility of indocyanine green fluorescent dye in emergency general surgery: a review of the contemporary literature

“…The left ureter can take more time to visualize, requiring initial medial to lateral dissection before the ureter is seen. Continued identification has been reported to last up to eight hours throughout the reported cases ( 59 , 60 , 67 , 68 , 71 ).…”

“…ICG can be used to visualize the ureters clearly. ICG is useful in cancer surgery and has shown to be beneficial in colon resection for diverticular disease, where inflammation can distort the visualization of the ureters ( 60 – 62 , 66 – 68 ). In elective surgery, ICG has also been used to detect anastomotic leaks using an intraluminal injection of diluted dye.…”

“…This injection of ICG is performed once at the start of the procedure and lasts throughout the resection with adequate visualization of the ureters. A ureteral catheter is usually left in place as well and removed at the end of surgery, with some reports of self-resolving hematuria after surgery ( 68 ). The intra-ureteric (IU) ICG is detected using NIFI ( 61 ).…”

“…Doses vary between 1 and 2 ml of ICG (2.5 mg/ml) diluted in 5 ml of distilled water injected into each ureter. This can also be followed by a 10cc flush of distilled water ( 67 , 68 , 70 ). This is sufficient for ureteric identification throughout the surgery.…”

The role of ureteric indocyanine green fluorescence in colorectal surgery: a retrospective cohort study

“…Its use in colorectal surgery, particularly in bowel perfusion assessment and lymph node mapping, has been widely adopted [ 10 , 11 ]. The use of ICG-FI along with ureteric stents has not been extensively assessed in the published literature, but the current published studies show promise in real-time visualization of the ureter [ 12 – 15 ]. Owing to the paucity of studies on the role of ICG-FI in ureter detection, we conducted this retrospective study with the hypothesis that using real-time ICG-FI as an adjunct to ureteric stenting may serve to facilitate the detection of and/or minimize the incidence of UI.…”