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10 Use ofFluorescence Guidance inBurn Surgery
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299
Conclusion
Using ICGA precise marking to guide indeterminate burn excision resulted in an excellent rate of complete wound closure and
an improvement in short-term and long-term wound outcomes.
Therefore, ICGA is an effective method to aid decision-making in
burn surgeries of the indeterminate areas. The current level of evidence in using ICGA in burn excision is III.The future direction
should pursue in the randomization of using versus not using
ICGA in the treatment of burn.
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Guidance inAcute Care
11
Surgery andTrauma
ElwinTham, JenniferKnight,
andNovaSzoka
Introduction
Fluorescence-guided surgery (FGS) is a medical imaging technique that uses a uorescent dye or a near-infrared-emitting light
source to identify anatomic structures during surgical procedures.
The present chapter will describe the history and mechanism of
action of indocyanine green (ICG) dye as well as review the use
of uorescence guidance in acute care surgery (ACS) and trauma
surgery. Two of the primary applications of FGS in ACS are ICG
cholangiography during cholecystectomy to dene anatomic
Supplementary Information The online version contains supplementary
material available at
https://doi.org/10.1007/978- 3- 031- 40685- 0_11.
E. Tham · N. Szoka (*)
Department of Surgery, West Virginia University, Morgantown,
WV, USA
e-mail: elwinjennhui.tham@hsc.wvu.edu; nova.szoka@hsc.wvu.edu
J. Knight
Department of Surgery, The Ohio State University,
Werner Medical Center, Columbus, OH, USA
e-mail: Jennifer.knightdavis@osumc.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
N. Szoka et al. (eds.), The SAGES Manual of Fluorescence-Guided
Surgery, https://doi.org/10.1007/978-3-031-40685-0_11
307
308
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structures and ICG angiography to evaluate bowel perfusion. In
addition, an evolving area of use for uorescence guidance in
acute care surgery is in the management of wounds and soft tissue
infections. In trauma surgery, the primary application of ICG is
for evaluating tissue perfusion following traumatic injury; however, there are evolving applications for the assessment of other
types of traumatic injuries. ICG dosing and administration, as
well as coding and reimbursement, will be discussed for each
respective procedure.
E. Tham et al.
History andPhysiology ofIndocyanine
GreenDye
Originally employed for the quantitative measurement of hepatic
and cardiac function as early as the mid-1950s, indocyanine
green (ICG) is a nontoxic, uorescent iodide dye with rapid
hepatic clearance. In the initial studies, research centered around
the measurement of serum ICG levels as a method to assess
hepatic and cardiac function. Later studies in the 1970s expanded
the use of ICG to the eld of ophthalmology for macular hole
surgery. Due to technological limitations, the development of
ICG into ICG uorescence angiography did not occur until the
mid-1990s. With further technological advancement in the early
2000s, the development of improved digital imaging resolution
that paralleled lm-based photography resulted in the widespread
acceptance of ICG angiography [1]. Since then, the utility of ICG
angiography for assessing tissue perfusion has been studied, with
numerous ongoing studies assessing other applications of this
compound [1].
ICG is an amphiphilic, tricarbocyanine iodide dye that can be
reconstituted into an aqueous solution of pH 6.5 for intravenous
injection in patients. Once injected, ICG binds to plasma proteins
taken up by the liver and later excreted in bile. Typically, 98% of
injected ICG is plasma protein-bound, while the remaining 2%
remains free in the serum. Free ICG is then transported into the bile
via the enzyme glutathione S-transferase, while bound ICG remains
in the intravascular space for a longer period of time [2–6].
Due to its well-tolerated biopharmacological prole, ICG can be
used in a wide variety of medical applications and has a low inci-
11 Use of Fluorescence Guidance in Acute Care Surgery…
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dence of adverse reactions [7]. Adverse reactions from ICG are
commonly mild, with nausea and urticaria being the most common.
The main contraindication to ICG use is iodine allergy. Typical dosing of ICG varies with the procedure, with standard vials containing
25mg of ICG that are reconstituted in 10ml sterile water and each
single milliliter containing 2.5mg of ICG.Individual doses range in
size from 2.5 to 15mg. Standard dosing is far below the lethal dose
(LD50) for this drug, which is 50–80mg/kg [2–8].
Once injected, ICG uorescence has high contrast and sensitivity as the near-infrared light used to measure uorescence makes
tissues appear more translucent allowing visualization through
several millimeters of tissue compared to visible light wavelengths.
This is achieved by the excitation of the molecule via an external
laser or light source, causing it to uoresce at near- infrared wavelengths (750–800nm with a maximum peak of 832nm) [2, 3]. The
near-infrared camera then captures the images and reveals realtime perfusion in the tissue assessed by quantifying the dye’s uorescence, providing objective information regarding which regions
have the best blood supply. Real-time viewing of these images via
video angiography also allows clinicians to make decisions immediately without the need for additional studies [2, 9].
ICG is cleared by the liver at a rate of 18–24% per min. With a
half-life of 3 to 4min, the dye is cleared from the intravascular
space in the rst 10 to 20min after application. The rapid clearance rate allows ICG to be used for multiple injections during a
procedure yielding signicant benets over other analogous substances. Following initial metabolism, the drug clearance rate
slows, allowing trace amounts of ICG to remain in the plasma for
more than an hour [2, 3, 10]. Due to ICG’s hepatic clearance and
excretion into bile, ICG can effectively be used to visualize biliary
anatomy in cholecystectomy [11, 12].
309
Fluorescence Guidance inAcute Care Surgery
ICG inLaparoscopic Cholecystectomy
ICG is being applied as an adjunct to many procedures due to its
ability to improve visualization of surgical anatomy via augmented reality; one such area is minimally invasive cholecystec-
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