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and outow, and permitting detection of the presence of irreversible ischemia and adequacy of venous drainage. Especially in
laparoscopic surgery, the use of ICG overcomes limitations of
laparoscopic assessment, which includes the lack of hand-eye
inspection of mesenteric pulsation and a three-dimensional view
[48–51]. ICG may also widen the proportion of procedures that
can be completed minimally invasively by reducing the number of
conversions due to the inability to fully assess compromised
bowel; furthermore, it is proposed that the ability of ICG to aid in
objective decision-making could translate into reduced medicolegal actions [50]. However, these studies were limited by a sample
size of seven and 14 patients, respectively. The use of ICG for
SBO in the emergent setting must also consider that arterial
perfusion may be diminished during acute SBO due to splanchnic
hypoperfusion resulting from shock, metabolic acidosis, and sepsis [52]. Therefore, the decision to resect bowel in borderline vascularity cases should depend not only on local bowel viability
factors such as perfusion, pulsation, color, and peristalsis but also
on general systemic factors such as the patient’s overall condition.
Similarly, the use of ICG in the setting of SBO for prediction
of bowel survival [53] and development of delayed ischemic
small bowel stricture [54] has only been reported in animal studies and case reports, respectively. Due to the limited reports and
lack of human studies, further studies are required to dene the
role of ICG in clinical practice and establish more objective perfusion thresholds to support intraoperative use in the SBO.
E. Tham et al.
ICG Dosing andAdministration forEvaluation
ofBowel Perfusion
For use to assess bowel perfusion, after determining the patient
has no contraindications to ICG such as an iodine allergy, the
authors recommend injecting 2ml (5mg) of ICG, which will illuminate the vasculature approximately 30–45 seconds after IV
administration. For open operations, near-infrared cart-based
imaging systems, such as the Stryker SPY Elite System, or handheld imaging systems, such as the Stryker SPY-Portable Handheld
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Imaging (PHI) system, can be used (Video 11.2). For laparoscopic
or robotic operations, a minimally invasive camera system capable of near-infrared imagining can be used.
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Coding forICG Angiography
The current procedural terminology (CPT) codes that the authors’
use for coding ICG angiography are CPT 44799 [unlisted procedure, small intestine] to evaluate the small bowel in an inpatient
open surgery and CPT 44238 [unlisted laparoscopy procedure,
intestine (except rectum)] to evaluate bowel in an inpatient laparoscopic surgery.
Indocyanine Green Use inTrauma
Trauma and traumatic injuries are a major cause of mortality and
injury around the world. Injury results in over 150,000 deaths and
over three million nonfatal injuries in the USA each year. Trauma
is the third largest contributor to the global burden of disease
around the world [55].
Reviewing the literature, the use of uorescence guidance and
ICG in trauma has been described in small case series for the
diagnosis and treatment of various traumatic injuries of the following areas: ophthalmic injury [56], bowel trauma [57], and
skin/soft tissue wounds [58]. Additionally, investigational research
is being performed to better understand the use of contrastenhanced near-infrared spectroscopy (NIRS) with indocyanine
green (ICG) as a continuous, noninvasive bedside neuromonitoring tool for patients with traumatic brain injuries [59, 60].
However, large prospective studies on ICG use in trauma patients
are warranted.
After ocular contusion, indocyanine green angiography
allowed the analysis of various degrees of choroidal vascular
damage, even in eyes that had no abnormality revealed by uorescein angiography [56]. Following abdominal injury with bowel
trauma, ICG angiography to evaluate bowel perfusion and anasto-
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E. Tham et al.
motic perfusion is described in a small case series. Specically,
ICG was used to evaluate the vascular perfusion in bowel segments with mesenteric lacerations and guide appropriate repair by
assessing the viability of the anastomotic edges, as well as to
diagnose microvascular injury in a segment of bowel that appeared
macroscopically perfused under white light but was ischemic
when viewed with ICG and near-infrared light.
In the setting of soft tissue wounds from high-energy mechanisms like ballistic or blast injuries or low-energy crush injuries,
the ability to determine the zone of injury and thus establish initial
debridement can be difcult when using the naked eye alone.
Upon initial inspection, the area surrounding a traumatic wound
may appear viable. These wounds often require repeated
debridement and monitoring of the tissues to determine timing of
reconstruction.
Fluorescence angiography has been described as a tool to
assess skin ap necrosis in postmastectomy and breast reconstruction [61, 62]. However, little is reported on trauma patients,
although its application in the assessment of skin perfusion can
provide additional information compared to standard clinical
evaluation. A review of traumatic and reconstruction cases at
Walter Reed National Military Medical Center over a three-year
period found that intraoperative uorescence angiography modied the operative plan in almost 19% of cases. These modications were seen with extremity ap reconstructions, avulsions,
amputations and revisions, pedicle and free ap reconstructions,
and gastrointestinal operations [63]. Another case series by
Kamolz etal. examined the clinical impact of ICG video angiography to determine the extent of skin injury in a cohort of 40
patients [58]. The various injury mechanisms included mechanical crush, degloving, burn, and snakebite. Qualitative and quantitative analysis of the videos and images (evaluation of ICG uptake,
steady-state distribution, and clearance of dye-marked blood from
the injured area), in combination with the clinical assessment,
provided additional information regarding the vascular patency of
injured skin and allowed for more precise treatment plans.
With regard to the available literature, some of the most compelling data regarding the use of ICG and wound treatment comes
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from recent burn research [64, 65]. In their 2019 publication,
Wongkietkachorn et al. conducted a prospective, multicentered,
triple-blinded study to compare the accuracy of ICG angiography
to that of clinical assessment of indeterminate burn wounds and
whether said wounds were supercial second-degree versus deep
second-degree burns. In the 30 burn sites that were assessed, the
accuracy of ICG angiography was 100.0%, compared with 50.0%
for clinical assessment (p<0.001) [64]. In subsequent work, the
same group used ICG assessment to recharacterize indeterminate
depth burns as supercial second-degree burns or deep seconddegree burns and mark the latter for excision; the deep seconddegree burns were then excised in the operating room. Using ICG
angiography for precise marking, the overall rate of short-term
complete wound closure was 96.7%, and long-term complete
wound closures at 2months yielded 100.0% [65].
The following two clinical cases further demonstrate the use of
ICG to evaluate tissue perfusion following traumatic injury.
Figure11.10 shows the skin of the forehead of an elderly female
who fell while on anticoagulation. Fluorescence angiography was
used in the operating room to assess the perfusion of her skin
before (Fig.11.11) and after (Fig.11.12) the hematoma was evacuated. The use of uorescence angiography in this case conrmed
there was no need to resect the skin, and the patient made a full
recovery with a good cosmetic result.
Morel-Lavallee lesions are an internal degloving of the supercial skin and subcutaneous fat from the fascial layers. High-
Fig. 11.10 Skin
necrosis from a forehead
hematoma with
ecchymosis and
blistering
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Fig. 11.11 Fluorescence angiography with perfusion evident to the skin on
the eyes and but no skin perfusion above eyebrows prior to evacuation of the
hematoma
Fig. 11.12 Fluorescence
angiography after
evacuation of the
forehead hematoma with
restoration of perfusion
E. Tham et al.
energy, blunt force trauma, or crush injuries are the leading
causes of such defects, which commonly occur in the lower
extremities but can occur anywhere on the body. Their management is varied and includes compression, drainage, and resection. Operative drainage and debridement are recommended for
large lesions [66].
When debridement is required, ICG can guide the resection on
devitalized tissue. A Morel-Lavallee lesion in a young patient
ejected from a motor vehicle crash was managed operatively due
to signicant skin and fat necrosis present that required multiple
operative takebacks and resections. The initial injury (Figs.11.13
and 11.14) can be compared to subsequent resections (Fig.11.15)
and the nal resection that was guided with ICG uorescence
angiography (Figs.11.16, 11.17, and 11.18).
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Fig. 11.13 A MorelLavallee lesion of the
right lower extremity
with disruption of the
anterior skin and
subcutaneous fat from
the muscles of the thigh
from the inguinal
ligament to the knee
Fig. 11.14 A MorelLavallee lesion of the
left lower extremity with
disruption of the anterior
skin and subcutaneous
fat from the muscles of
the thigh from the
inguinal ligament to the
knee
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Fig. 11.15 Further
demarcation of a
Morel-Lavallee lesion of
bilateral lower
extremities prior to the
use of uorescence
angiography
Fig. 11.16 Fluorescence
angiography of the right
lower extremity of a
Morel-Lavallee lesion
E. Tham et al.
Fig. 11.17 Final
resection to healthy
tissue with the use of
uorescence
angiography
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Fig. 11.18 Fluorescence
angiography of a
Morel-Lavallee lesion of
the left lower extremity
ICG Dosing andAdministration forEvaluation
ofFlap Perfusion
327
For use to assess skin ap perfusion, after determining the patient
has no contraindications to ICG such as an iodine allergy, the
authors recommend injecting 2ml of ICG, which will illuminate
the tissue ap for approximately 30–45s after IV administration.
As discussed above, for open operations, near-infrared cart-based
imaging systems (Stryker SPY Elite) or handheld imaging systems (Stryker SPY-PHI) can be used.
Coding forICG Evaluation ofSkin andSoft Tissue
The current procedural terminology (CPT) code that the authors’
use for coding ICG evaluation of skin and soft tissue as an inpatient procedure is CPT 15860 [intravenous injection of agent (e.g.,
uorescein) to test vascular ow in ap or graft].
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E. Tham et al.
Fluorescence Guidance andWound Care
Additional areas within acute care surgery where the use of uorescence guidance is being actively studied include the evaluation
of wound depth in chronic wounds, as well as assessment of tissue
necrosis [67, 68]. With the profound angiothrombotic effects in
necrotizing fasciitis and necrotizing soft tissue infection, the ability of ICG uorescence to assess perfusion may aid in establishing the diagnosis and be used as an adjunct to help guide the
extent of debridement. Although there are currently no published
studies examining the use of ICG in necrotizing infection, there is
an ongoing clinical trial (NCT04839302) assessing the use of ICG
as a noninvasive modality for the diagnosis of necrotizing fasciitis. This study hypothesizes that ICG should demonstrate reduced
uorescence compared to the patient’s unaffected tissues. If ICG
uorescence voids are characteristic of NF, ICG use could lead to
a more accurate diagnosis of NF, leading to improved management and patient management outcomes.
Conclusion
The role of ICG in acute care and trauma surgery varies depending on the operative case and the patient. With regard to laparoscopic cholecystectomies, ICG has proven to be a time- and
cost-effective adjunct to delineate biliary structures, though denitive benet to prevent biliary injuries has yet to be identied. In
the setting of mesenteric ischemia and bowel pathologies, ICG
uorescence video angiography yields signicant potential as an
adjunct to optimize visualization and assessment of bowel viability compared to the human eye and decrease the need for multiple
returns to the operating room to evaluate bowel viability. Due to
the high variability in the assessment of viability and the impact
of physiologic derangements in these patients, further studies are
required to rene the utility of ICG in these settings. In the setting
of trauma patients, many case reports have proven the utility of
ICG for assessing tissue viability. This has been further reinforced
by research in burn patients, which is discussed in a separate
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chapter of this manual. Nevertheless, additional research with
well-designed and appropriately powered studies is required to
further validate the use of uorescence guidance in the elds of
acute care and trauma surgery.
Source of Funding None.
Conict of Interest Dr. Szoka is the founder of Endolumik Inc.
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