Image-Guided Pediatric Surgery Using Indocyanine Green (ICG) Fluorescence in Laparoscopic and Robotic Surgery

Abstract

Background: Indocyanine green (ICG)-guided near-infrared fluorescence (NIRF) has been recently adopted in pediatric minimally invasive surgery (MIS). This study aimed to report our experience with ICG-guided NIRF in pediatric laparoscopy and robotics and evaluate its usefulness and technique of application in different pediatric pathologies.Methods: ICG technology was adopted in 76 laparoscopic and/or robotic procedures accomplished in a single division of pediatric surgery over a 24-month period (January 2018-2020): 40 (37 laparoscopic, three robotic) left varicocelectomies with intra-operative lymphography; 13 (10 laparoscopic, three robotic) renal procedures: seven partial nephrectomies, three nephrectomies, and three renal cyst deroofings; 12 laparoscopic cholecystectomies; five robotic tumor excisions; three laparoscopic abdominal lymphoma excisions; three thoracoscopic procedures: two lobectomies and one lymph node biopsy for suspected lymphoma. The ICG solution was administered into a peripheral vein in all indications except for varicocele and lymphoma in which it was, respectively, injected into the testis body or the target organ. Regarding the timing of the administration, the ICG solution was administered intra-operatively in all indications except for cholecystectomy in which the ICG injection was performed 15-18 h before surgery. Results:No conversions to open or laparoscopy occurred. No adverse and allergic reactions to ICG or other postoperative complications were reported.Conclusions: Based upon our 2 year experience, we believe that ICG-guided NIRF is a very useful tool in pediatric MIS to perform a true imaged-guided surgery, allowing an easier identification of anatomic structures and an easier surgical performance in difficult cases. The most common applications in pediatric surgery include varicocele repair, difficult cholecystectomy, partial nephrectomy, lymphoma, and tumors excision but further indications will be soon discovered. ICG-enhanced fluorescence was technically Esposito et al.ICG-Guided NIRF in Pediatric MIS easy to apply and safe for the patient reporting no adverse reactions to the product. The main limitation is represented by the specific equipment needed to apply ICG-guided NIRF in laparoscopic procedures, that is not available in all centers whereas the ICG system Firefly ® is already integrated into the robotic platform.

The Use of Indocyanine Green Fluorescence Angiography in Pediatric Surgery: A Systematic Review and Narrative Analysis

“…In pediatric surgery and pediatric urology, ICG-FA indications included cholecystectomy ( n = 8) ( 13 , 14 , 22 , 23 , 26 , 28 , 31 , 55 ), primary and metastatic hepatoblastoma ( n = 6) ( 16 , 44 , 48 , 59 , 64 , 70 ), varicocelectomy ( n = 5) ( 22 , 24 – 26 , 31 ), nephrectomy ( n = 5) ( 22 , 25 , 26 , 28 , 32 ), chylous leaks and ascites ( n = 4) ( 15 , 47 , 51 , 56 ), colorectal procedures including cloacal, anorectal malformation, and Hirschsprung reconstructions, intestinal resection for volvulus, as well as stoma closure ( n = 4) ( 37 , 53 , 55 , 69 ), hepatocellular carcinoma ( n = 1) ( 18 ), abdominal mass excision ( n = 1) ( 22 ), and tracheoesophageal fistula ( n = 1) ( 58 ). Pediatric neurosurgeons used ICG-FA in patients with Moyamoya disease to evaluate the anatomy and confirm patency of their surgical anastomoses ( n = 4) ( 9 , 35 , 36 , 62 ).…”

Indocyanine green (ICG) fluorescent cholangiography during laparoscopic cholecystectomy using RUBINA™ technology: preliminary experience in two pediatric surgery centers

“…As recently published [17][18][19][20], the incorporation of ICG fluorescent cholangiography (FC) into LC has the potential to provide real-time visualization of the extrahepatic biliary tree prior to commencing dissection within the Calot's triangle. The evolving technologies have recently provided the surgeons perfect camera systems to achieve even better intra-operative visualization.…”

“…Once reconstituted, the ICG solution was injected via the intravenous route using a dosage of 0.35 mg/Kg. The median timing of administration was 15.6 h prior to surgery (range [8][9][10][11][12][13][14][15][16][17][18][19][20]. Following the administration, patients were monitored for any signs of allergic reaction to the dye.…”

“…We reported the feasibility of ICG near-infrared fluorescence (NIRF) imaging to obtain detailed anatomical mapping of extrahepatic biliary structures during LC in the pediatric population as well [17][18][19]. We also standardized modality of applications of ICG-NIRF, such as dosage and timing of administration, in the pediatric patients [20].…”

Technical standardization of ICG near-infrared fluorescence (NIRF) laparoscopic partial nephrectomy for duplex kidney in pediatric patients

“…In the last 5 years, we applied ICG-NIRF technology for several indications including biliary tract and gastrointestinal, oncological, thoracic, and urological diseases [12][13][14][15]. In our experience, the main indications of ICG fluorescence technology are in pediatric urology, including laparoscopic partial nephrectomy for benign pathologies such as duplex kidney with one non-functioning moiety [16].…”