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E. Tham et al.
tomy [13]. In the eld of acute care surgery, laparoscopic
cholecystectomies are frequently performed. In the United States
alone, approximately 20 million people have gallstones. Of this
group, approximately 300,000 cholecystectomies are performed
annually [14]. In the advanced laparoscopy era, a retrospective
review of 217,774 cases from the National Surgical Quality
Improvement Program (NSQIP) reported bile duct injury incidence of 0.19% [15]. In addition, cholecystectomy performed on
patients with acute cholecystitis has a higher risk of complications
based on disease severity [16].
Many techniques can be performed to assess hepatobiliary
anatomy during a cholecystectomy. Intraoperative cholangiogram
(IOC) remains the historical standard of care technique for bile
duct clarication. With an odds ratio for bile duct injury of 0.60
(95% condence interval= 0.52–0.70) based on a forest plot of
the six largest population-based studies assessing IOC, the association between reduced risk of bile duct injury and use of IOC
has been shown convincingly [17, 18]. IOC, however, can be difcult to interpret, is associated with higher costs, prolongs operative time by 10 to 23minutes, and requires additional medical
specialists and equipment. ICG uorescence cholangiography, on
the other hand, does not prolong operating time, uses radiation, or
requires additional medical specialists, and cannot cause bile duct
injury, yielding signicant benets as an adjunct for optimizing
visualization of hepatobiliary anatomy (Fig.11.1) [19].
ICG use for intraoperative uorescence cholangiography as an
adjunct to better delineate hepatobiliary anatomy (Fig. 11.2,
Video 11.1) was rst described in 2010 [20]. It was initially proposed to be an alternative to traditional radiographic IOC in a
cohort of patients that underwent elective cholecystectomy [21].
From that study, the authors proposed that ICG uorescence cholangiography could improve visualization of hepatobiliary anatomy (Fig. 11.3), especially in patients who were unable to be
cannulated for IOC [23]. A more recent study by Broderick etal.
examined outcomes in 1389 patients who underwent laparoscopic
cholecystectomy with (28.8%) and without (71.2%) uorescence
guidance and found that ICG use signicantly reduced operative
time, rate of conversion to open operation, and hospital length of
11 Use of Fluorescence Guidance in Acute Care Surgery…
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Fig. 11.1 ICG cholangiography during a robotic cholecystectomy, white
light view (top image), initial near-infrared view of cystic duct (bottom left
image), near-infrared view illuminating cystic artery (bottom right image).
(Image source Nova Szoka MD FACS)
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Fig. 11.2 ICG cholangiography during a laparoscopic cholecystectomy,
white light view (top image), initial near-infrared view of cystic duct and
common bile duct (bottom left image), near-infrared view illuminating cystic
artery (bottom right image). (Image source Nova Szoka MD FACS)
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Fig. 11.3 ICG cholangiography during a robotic cholecystectomy, with
images of cystic duct and cystic artery, shown with white light (left) and nearinfrared light (right). Cystic artery is scarred to the liver. (Image source Nova
Szoka MD FACS, citation [22])
E. Tham et al.
stay. The ICG group also had decreased Strassburg classication
biliary ductal injuries, decreased common bile duct injury, and
decreased mortality [24]. Although many studies have been performed to assess ICG use for elective cholecystectomy, few
studies address the utility and benets of ICG use in the acute
surgical patient population [21–26].
For laparoscopic cholecystectomy, 5 mg of ICG is typically
injected intravenously 1h prior to intubation in our institution to
allow accumulation of the uorescent dye within the hepatobiliary structures. In a systematic review of the optimal techniques to
administer ICG for laparoscopic cholecystectomy, the authors
found that patients undergoing laparoscopic hepatic or biliary
operations received ICG doses ranging between 0.02 and 0.25mg/
kg, typically 10 to 180 minutes prior to uorescence imaging.
This review found that a prolonged interval was optimal for uorescence cholangiography but could not identify specic time
intervals for the best visualization of biliary anatomy [19, 27].
Regarding the timing of ICG administration, one study found that
administration of ICG 24h prior to cholecystectomy led to better
discrimination of bile ducts. Despite this, administration of ICG
24h prior to surgery is not usually feasible, especially in the acute
setting [27]. In another study, the authors found that a prolonged
interval (at least 3h) between ICG injection and intraoperative
ICG uorescence cholangiography resulted in better contrast
between bile ducts and liver tissue.
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313
In ICG uorescence cholangiography, the binding of ICG to
plasma proteins allows intraoperative identication of bile duct vasculature. This, in combination with a short half-life, makes ICG an
excellent contrast agent for perfusion angiography. As the uorescence is visualized only under near-infrared wavelengths, a nearinfrared capable camera must be utilized. The system typically
consists of an infrared uorescence light source, light cable, camera
control unit (CCU), camera head, coupler, 0° and 30° 10mm laparoscopes, and surgical display unit. At the specic wavelength emitted by the light source (visible and near-infrared wavelength),
excitation of the molecules allows for several millimeter penetration through the tissue to visualize the underlying biliary structures
which the camera captures. Image signals captured by the camera
are then transmitted from the laparoscope to the CCU for processing, and a nal image is displayed on the monitor. A button on the
camera head can be used to toggle from visible light to near-infrared image, and many recent camera platforms now display an overlay mode that combines white light and near-infrared images [21].
Following the appropriate equipment setup, the laparoscopic cholecystectomy should be performed in a standard fashion adhering to
principles described by Strasberg [28] with the benet of ICG uorescence cholangiography to better visualize the biliary structures.
Although ICG uorescence cholangiography has demonstrated
feasibility and safety as an adjunct for identifying biliary anatomy, there are several challenges that surgeons commonly face.
Due to hepatic clearance, the liver background remains a signicant problem in ICG uorescence cholangiography. One method
to reduce the liver background signal while maintaining CBD signal stability is to inject the ICG 24h prior to surgery. However,
this is not feasible for same-day surgical patients or patients with
acute cholecystitis where early surgical intervention is preferred
[26]. Another limitation is the inability of ICG uorescence cholangiography to detect common bile duct (CBD) stones.
Additionally, due to limited depth of penetration (approximately
1cm of light in the near-infrared spectrum) of ICG uorescence
cholangiography, patients (especially patients with obesity) with
biliary structures that lay beneath a layer of (periductal) fat are
more difcult to identify [26].
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The utility of ICG uorescence cholangiography to assess biliary anatomy has been studied extensively. With a goal for ICG to
reduce bile duct injuries, the low incidence of bile duct injury
makes the denitive determination of biliary injury risk reduction
challenging. Additionally, comparisons between ICG uorescence cholangiography and other modalities that visualize biliary
anatomy have been assessed in multiple studies. Most notably,
ICG utility for biliary visualization has been compared with
IOC.In a meta-analysis comparing ICG uorescence cholangiography and IOC, the authors reported that ICG led to improved
visualization of the cystic duct (CD), CBD, CD-CBD junction,
and common hepatic duct compared to IOC [29]. ICG uorescence cholangiography can also be performed in addition to IOC
if necessary. In another study aiming to assess the clinical impact
of ICG uorescence cholangiography, the authors interestingly
found that the use of ICG in the acute care surgery population did
not decrease operative time or need for change in operative plan
(i.e., conversion to open, subtotal cholecystectomy) compared to
patients who did not undergo ICG uorescence cholangiography
(6.7% vs. 4.3%, P = 0.468). This, however, is the rst series
looking at the use of ICG uorescence cholangiography specically in an acute care surgery population [30]. Although ICG has
demonstrated the ability to optimize hepatobiliary anatomical
visualization in a time- and cost-effective manner in elective settings, further well-powered, randomized, multicenter studies are
necessary to determine the clinical impact of ICG use in cholecystectomy for both elective and acute care surgical populations.
E. Tham et al.
ICG Dosing andAdministration
forCholecystectomy
For use during cholecystectomy, after determining the patient has
no contraindications to ICG such as an iodine allergy, we recommend intravenously injecting 2ml of ICG 1h prior to starting the
operation; this provides sufcient time for the dye to be excreted
into the bile and enable visualization of the bile ducts. To conrm
the identication of the cystic artery, once the critical view of
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safety is obtained, injecting 3ml of ICG will illuminate the vasculature approximately 30–45s after IV administration (Video 11.1).
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Coding forICG Cholangiography
The current procedural terminology (CPT) code we use for coding ICG cholangiography is 47563.
Indocyanine Green Use inMesenteric Ischemia
Accounting for approximately 1in 1000 hospital admissions [31,
32], acute mesenteric ischemia (AMI) is a surgical emergency
that is associated with very high in-hospital mortality rates of up
to 63% [33]. The etiology of AMI can be classied into thrombotic and non-thrombotic causes. Thrombotic causes include arterial thromboembolism and venous thrombosis, while
non-thrombotic causes, termed non-occlusive mesenteric
ischemia (NOMI), result from low ow states, i.e., hypovolemia,
cardiogenic shock, heart failure, or drugs that cause spasm of the
vessels [33]. In a meta-analysis assessing mortality after acute
primary mesenteric infarction, the authors reported that patients
with arterial mesenteric infarction or NOMI are over three times
more likely to die during the rst hospital admission than those
with venous mesenteric infarction [31–33]. Regardless of etiology, the lack of perfusion leads to intestinal ischemia causing
transmural necrosis of the bowel wall, resulting in an overwhelming inammatory response and death. Management of AMI
includes gastrointestinal decompression, uid resuscitation, antibiotics, and frequently, operative intervention. In the operating
room, the goal of the intervention centers around assessment of
bowel perfusion, restoration of blood ow to compromised bowel
segments, and resection of nonviable bowel while leaving viable
bowel intact to prevent short gut syndrome. One of the biggest
challenges associated with surgery is the intraoperative assessment of bowel viability to determine the extent of resection.
Patients who survive the initial operative intervention often
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Fig. 11.4 White light
view of small intestines
(a) and large intestines
(b) with patchy ischemia
(*) and necrosis (**)
present (Image source
Nova Szoka MD FACS
[34])
E. Tham et al.
undergo multiple and extended bowel resections, which causes up
to 30% of surviving patients to develop short gut syndrome,
requiring permanent parenteral nutrition [32].
Traditionally, the assessment of bowel viability is performed
with the surgeon’s hands and eyes. The extent and severity of
intestinal ischemia are determined through evaluation of the
appearance of the bowel (color, distension), peristalsis, arterial
pulsation of mesenteric arcades, and bleeding from cut surfaces.
Bowel that appears dark compared to surrounding healthy bowel
is presumed to be nonviable or ischemic and is often resected.
Additionally, bowel loops that are distended with thinning of the
bowel wall or perforated are also considered nonviable and are
resected. In cases where the bowel is frankly necrotic, the decision to resect is obvious. However, bowel appearance does not
denitively determine viability, i.e., “patchy,” “dusky” bowel,
causing surgeon hesitation when deciding on resection (Fig.11.4).
In situations where a signicant portion of the bowel has already
been removed, the fear of causing complications associated with
extensive bowel resections (short gut syndrome, electrolyte
derangements, intestinal failure, undernutrition) and the lack of
objective information in assessing bowel viability create a
dilemma for the surgeon. Often, this results in a damage control
approach with temporary abdominal closure with the return to the
intensive care unit (ICU) for further resuscitation and a plan for
second-look laparotomy in 24–48 h to reassess bowel viability.
Second-look laparotomies have the benet of reducing morbidity
and mortality in select patients, though they are also associated
with risks including enteroatmospheric stula formation, fascial
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Fig. 11.5 Indocyanine
green perfusion to the
edge of small bowel
mesentery but not
beyond; no perfusion is
present to the small
bowel serosa. (Image
source Nova Szoka MD
FACS [34])
Fig. 11.6 Perfusion to
the edge of small bowel
mesentery but not
beyond (*); the small
bowel serosa has no
perfusion to either
micro- or
macrovasculature.
(Image source Nova
Szoka MD FACS [34])
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retraction, and hernia formation. With that said, several techniques, such as ICG uorescence angiography, have been assessed
to aid in the objective assessment of bowel viability (Figs.11.5
and 11.6, Video 11.2).
ICG uorescence angiography involves visualization of perfusion using intravenous administration of ICG, typically at doses
of 2.5 to 7.5 mg. This is typically injected intravenously, after
which a near-infrared camera system is utilized to assess vascular
perfusion of the tissue. Perfusion of the bowel can typically be
assessed approximately 45 s after ICG is injected (Figs. 11.7,
11.8, and 11.9). Although studies have been performed to quanti-
tatively assess colonic perfusion using ICG angiography, a denitive criterion stratifying uorescence intensity with different
levels of perfusion or bowel viability has not been dened [35].
However, ICG angiography, despite being a qualitative assessment of bowel viability, provides the surgeon with more informa-
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Fig. 11.7 Perfusion to
the edge of small bowel
mesentery but not
beyond (*) and one focal
area of small bowel
perfusion (**). (Image
source Nova Szoka MD
FACS [34])
Fig. 11.8 Nonperfused/ischemic colon
(a) proximal to the
splenic exure and
well-perfused colon (b)
distal to splenic exure.
(Image source Nova
Szoka MD FACS [34])
Fig. 11.9 Perfusion to
the edge of mesentery
but not beyond (*)
indicating nonperfusion
to the serosa and mucosa
of small intestines (a)
and large intestine (b).
(Image source Nova
Szoka MD FACS [34])
E. Tham et al.
tion regarding microvascular tissue perfusion that is not available
using traditional clinical assessment. In the setting of NOMI (i.e.,
small bowel obstructions (SBO), strangulated hernias, and volvulus), several case reports and studies have demonstrated the utility
of ICG uorescence angiography as an adjunct to evaluate bowel
viability and perfusion of anastomosis [36–42]. In a retrospective
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analysis of 52 patients who underwent ICG uorescence angiography during operative intervention for AMI, the authors report
that ICG led to a major change in operative strategy in 11.5% of
the patients resulting in a clinically signicant benet [43]. Albeit
a retrospective study with small sample size, ICG uorescence
angiography use as an adjunct to optimize visualization and
assessment of bowel viability yields signicant potential in
improving overall patient outcomes in a signicantly morbid disease. Development of a denitive criterion, such as percent of
maximal perfusion, to assist in quantitative analysis of bowel
viability would synergistically contribute to the utility of ICG in
the assessment of bowel viability in AMI [44].
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Indocyanine Green Use inSmall Bowel
Obstruction
Small bowel obstructions (SBO) account for approximately 3% of
emergency surgical admission. With signicant morbidity and
nancial cost due to the recurrent nature of the disease, the etiology of SBO ranges from adhesive disease to hernias and malignancy [45]. In 2018, the American Association for the Surgery of
Trauma (AAST) proposed a grading criteria for SBO ranging
from grade I to V.Depending on the grading, management ranges
from nonoperative management with gastrointestinal decompression, uid and electrolyte resuscitation, and hypertonic contrast to
expeditious surgery for higher grades of SBO [46, 47].
During operative intervention for SBO, assessment of bowel is
essential to determine viability and extent of resection if indicated
just as in mesenteric ischemia. The role of ICG in assessing bowel
viability in SBO remains limited, with only a few case reports and
series reporting its use [40, 48, 49]. The studies assessing the utility of ICG as an adjunct to laparoscopic surgery for SBO found
that selective use of ICG in patients with concerns about vascular
impairment provides a direct, objective tool for assessing bowel
viability and supports the surgeon in the intraoperative decisionmaking process. The authors reported that the technique is reliable in determining bowel viability, assessing both vascular inow
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