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Hepatobiliary surgery in pediatric patients offers the most obvi­ous use of ICG given its excretion into bile and resultant immuno­uorescence of the biliary tree. Hepatobiliary surgery using ICG can be limited by bowel interference if given intraoperatively. Due to this concern, ICG is given at least 72–96h prior to the hepatic procedure operation and 2 to 4h prior to ICG uorescence cholangiography (ICG-FC). This allows the biliary structures to strongly uoresce without concurrent bowel uorescence. ICG- FC has utility in the pediatric population for cholecystec­tomy, Kasai portoenterostomy, and hepatic resection for hepato­blastoma or other liver tumors. As with other uses of ICG in pediatric patients, the evidence is limited to mostly case series. We will review the current evidence and discuss techniques in using ICG for hepatobiliary surgery in the pediatric population.

ICG-FC is of particular interest for use in laparoscopic chole­cystectomy in pediatric patients. As in adult patients undergo-

There have been multiple case series in the literature regard­ing the utility of ICG-FC in laparoscopic cholecystectomies in pediatric patients. In 2019, a case series demonstrated successful use of ICG-FC in ve pediatric patients [9]. Another case series in 2019 of ICG-FC in 15 laparoscopic cholecystectomies is com­pared to 200 cases at the same center where ICG-FC was not utilized [10]. The analysis demonstrated shorter operative time and no complications in the ICG-FC group. There were four complications and two bile duct injuries in the non-ICG-FC group. In this series, ICG was given 18h pre-op which mini­mized liver interference. A 2020 series compared 31 laparoscopic cholecystectomies using ICG-FC with 68 cases without the use of ICG-FC [11]. In this series, ICG was injected intraoperatively which led to a high amount of liver interference. However, analy­sis still demonstrated shorter operative times, lower costs, and no complications associated with ICG-FC in these patients. Another series in 2020 demonstrated successful use in 12 cases, and a nal series in 2021 demonstrated use in 13 cases [12, 13]. Larger studies of prospective randomized trials are needed to determine ICG-FC impact on CBD injuries in pediatric laparoscopic chole­cystectomy.

An exciting potential use for ICG-FC in the pediatric population is patients undergoing Kasai portoenterostomy (KPE) for biliary atresia (BA). This operation requires extensive dissection of the brous cone at the porta hepatis. For a successful biliary drainage into the enteric system, it is important to ensure patency of the bile duct at the level of transection of the porta hepatis as well as ensuring that exposed micro bile ducts are not inadvertently closed during anastomosis. ICG-FC can serve as an adjunct to ensure patency at the level of transection and can even identify hilar micro bile ductules. Use of ICG in an operation for BA does demonstrate background liver uorescence as ICG is not nor­mally excreted as in patients with a normal biliary tract (Fig.12.2). In BA cases, ICG application can be useful to aid the laparoscopic or open cholangiogram (Fig.12.3), for complete dissection of the brous cone of the porta hepatis, and possibly as a predictor of postoperative drainage if bile accumulates in a Gelfoam patch during preparation of the Roux limb (Fig.12.2).

adult patients with hepatocellular carcinoma (HCC) with success­ful results. In 2009, a study demonstrated that ICG is particularly useful for liver tumors as ICG is not excreted normally from HCC as with normal liver parenchyma leading to retained ICG in the tumor for days following IV administration [16]. This novel dis­covery demonstrates the special utility of ICG in improving R0 resection of primary and metastatic liver tumors. After successful use in HCC in adult patients, use was extended to assess utility in HB for pediatric liver resections. In 2015, a cases series of three pediatric patients with HB demonstrated successful use of ICG in detecting viable recurrent and metastatic disease [17]. Two 2019 case series of 13 operations in one and ten operations in another demonstrated successful use of ICG in hepatic resections for HB [18, 19]. In a 2021 series, 29 patients had 25 liver resections with 13 specimens positive for HB on pathology [20]. Twelve of 13 were ICG-avid yielding a sensitivity of 92%. Ten lesions were ICG-avid with no evidence of HB yielding on specicity of 17%. This demonstrates the high level of false positivity utilizing ICG for detection of malignant tissue in the liver. Most false positives were due to liver inammation or steatosis. Two other series in 2021 demonstrated efcacy of ICG-FC in resection of HB in 19 and 11 hepatic resections [21, 22]. ICG-FC has been utilized to resect several hepatoblastoma tumors with a high sensitivity and low specicity. This demonstrates that surgeons should be aware of the possibility of false positivity when utilizing this technology. ICG-FC is safe and sensitive in hepatic resection for HB.Larger prospective trials with long-term follow-up are needed to deter­mine impact of ICG-FC on early recurrence and overall survival.