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Application of Indocyanine Green Fluorescence as an Adjuvant to Laparoscopic Ultrasound in Minimally Invasive Liver Resection


Background: Indocyanine green (ICG) fluorescence imaging has been extensively used in a variety of applications in visceral surgery. In minimally invasive liver resections, the detection of small superficial hepatic lesions using an intravenous injection of ICG before surgery represents a promising application. Methods: We analyzed 18 consecutive patients who underwent laparoscopic liver resection for superficial malignant tumors, namely 11 patients with hepatocellular carcinoma (HCC), 5 patients with colorectal liver metastases (CRLM), 1 patient with intrahepatic cholangiocarcinoma (ICC), and 1 patient with thyroid cancer metastasis, using ICG fluorescence as an adjuvant tool to intraoperative laparoscopic ultrasound (LUS). Results: An optimal ICG 15-minute clearance retention rate (R15 < 10%) and ICG plasma disappearance rate (<18%/minute) were present in 11 patients (61.1%) and in 14 patients (77.7%), respectively. Liver tumors were 29 in total, including 14 HCCs (48.3%), 13 CRLMs (44.8%), 1 ICC (3.4%), and 1 thyroid cancer metastasis (3.4%). Twenty-nine tumors (100%) were correctly visualized with ICG/fluorescence, as compared with 21 tumors identified with LUS (72.4%). After complete liver mobilization, ICG staining allowed to identify more superficial lesions (early HCC and small CRLM) in posterolateral segments (Segments 6 and 7) as compared with LUS (14 versus 10 lesions). In addition, in segments usually treated laparoscopically (e.g., left lateral segments), ICG was superior to LUS (10 versus 6 lesions) to identify superficial early HCC in patients with macronodular cirrhosis. Conclusions: ICG visual feedback might substitute the tactile feedback of the hand and might in some cases act as a "booster" of LUS for superficial hepatic lesions.

Keywords: indocyanine green fluorescence; laparoscopic ultrasound; minimally invasive liver resection.


1Unit of HepatoBilioPancreatic and Digestive Surgery, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy.

2IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France.

3IHUStrasbourg, Institute of Image-Guided Surgery, Strasbourg, France.

4iCube Laboratory, Photonics for Health, University of Strasbourg, Strasbourg, France.

5Unit of Minimally Invasive Surgery, Department of General Surgery, The Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida, USA.

6Unit of General Surgery, ASST Fatebenefratelli Sacco, Milan, Italy.

PMID: 33651631 

DOI: 10.1089/lap.2020.0895

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