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lum head, or inline head; L11 LED light source and safelight
cable; AIM HD laparoscope; display (4K resolution); connected
OR hub (optional for recording and customizing visualization settings); SPY PHI System for handheld/open procedures; and SPY
AGENT GREEN (ICG)—25mg vials.
Fig. 2.8 (a) AIM 1688 with SPY PHI System—Photo courtesy of Stryker.
(b) AIM 1688 overlay mode—Photo courtesy of Stryker. (c) AIM 1688 contrast mode—Photo courtesy of Stryker. (d) AIM 1688 ENV mode—Photo
courtesy of Stryker
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c
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d
Fig. 2.8 (continued)
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For use, 1688 AIM’s connected operating room cart is set up
similar to any other laparoscopic surgical system with placement
of monitors depending on surgical indications. The camera head
with light guide cable and laparoscopes are autoclavable and will
be handed to the surgeon sterilely. Depending on the type of
camera head, a coupler may need to be installed to connect the
camera head to the laparoscope eyepiece. The laparoscope eyepiece is attached to the coupler on the camera head and the light
cable attached to the laparoscope via the threaded connector. The
light cable and camera cable are then handed off to a non-sterile
assistant. The camera cable connector is protected by a soaking
cap which is removed, and the connector is plugged into the input
on the camera control unit. The safelight cable is plugged into the
L11 LED light source. From the camera control unit, the type of
surgery can be selected from an option of nine different surgical
specialties which individually optimize the camera settings based
on the desired surgical procedure. The specialty selected on the
camera control unit should be “laparoscopy” or “standard”; otherwise, uorescence mode will not activate. After the cable inputs
have been plugged in, the camera can be white balanced and
“auto” light setting can be turned on if desired. Auto light will
automatically adjust the brightness as needed throughout the case.
SPY mode is the uorescence mode of the 1688 AIM and is controlled by pressing “AIM” on the camera control unit. Additionally,
SPY mode can be activated by the surgeon by pressing the menu
button on the right of the camera head. The L11 LED light source
for the 1688 AIM System utilizes both RGB (red, green, blue)
LEDs and a class 1M laser for excitation with wavelength of
806 nm for NIR uorescence. The preferred uorophore with
AIM 1688 is SPY AGENT GREEN (ICG) with similar timing and
dosing as with SPY Elite [69, 70].
D. Hui et al.
Dosing, Timing, andRoute ofAdministration
For angiography for visualization of blood vessels and tissue perfusion, ICG can be given immediately intraoperatively. For
patients less than or equal to 90kg, use 0.5 ml of a 2.5 mg/ml
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concentration. For patients greater than 90kg, use 1–1.5ml of a
2.5mg/ml concentration. Maximum dose is 2mg/kg.
For visualization of extrahepatic biliary duct for use in patients
ages 12 and older, ICG should be given at least 45min prior to
surgery as an intravenous bolus injection of 1ml of a 2.5mg/ml
concentration. For lymphangiography, visualization of lymph
nodes, and lymphatic mapping, ICG can be injected directly into
target tissue as multiple direct injections of 0.5ml of a 2.5mg/ml
concentration as needed.
1688 AIM 4K Platform was developed by Stryker and is the
endoscopic portion of the system that includes the SPY PHI handheld device. Stryker developed an endoscopic uorescence device
in 2014 with the Stryker Infrared Fluorescence (IRF) Imaging
System. The currently available system is the 1688 AIM 4K camera system with L11 LED light source. The FDA determined that
the system was substantially equivalent to the predicate devices
1588 AIM and Stryker IRF for use as a camera system in all endoscopic procedures and as an FGS system approved for the visual
assessment of vessels, blood ow and tissue perfusion, biliary
ducts, and lymphatic vessels and nodes. The L11 LED light source
is also intended to attach to Stryker’s IRIS Ureteral Kit to transilluminate the ureters producing NIR emissions at 830nm for open
and laparoscopic cases. 1688 AIM provides real-time visible and
NIR imaging with uorescence activated in SPY mode. The operating principle for SPY mode is overlay mode (Fig.2.8b), contrast
mode (Fig.2.8c), and ENV mode (Fig.2.8d). The different SPY
modes can be changed by pressing the up button on the camera
head. Overlay mode allows for real-time visualization in the visible and NIR spectrum simultaneously with uorescence overlaid
in green. Contrast mode is a pure uorescence image, displayed in
monochromatic format to detect only NIR images as white color.
ENV mode displays visible light in grayscale with uorescence
overlay in green [68–70].
The 1688 AIM camera system can be used with and without
uorescence. There are nine surgical specialties that can be supported by this system and are selectable from the camera control
unit for specic image optimization. The nine specialties for use
with the camera system are general laparoscopy, ENT/skull
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endoscopy, arthroscopy, cystoscopy, exi-scope, hysteroscopy,
laser, microscope, and standard use. The uorescence functionality is only available for laparoscopy and standard and intended for
use in minimally invasive surgical cases as an adjunctive visual
assessment in tissue perfusion, biliary ducts, and lymphatic
mapping. Open surgical cases can use the SPY PHI attached to
the platform. The L11 LED light source can connect to IRIS ureteral stents for transillumination of the ureters in open and laparoscopic cases. This has proven benecial in difcult pelvic
dissections to visualize the ureters and prevent injury [71].
Pearls and Pitfalls
• The platform has an independent handheld uorescenceguided system, SPY PHI, which can be used in conjunction
with 1688 AIM.
• The system displays images in 4K resolution.
• The display can show singular overlay images or multiple
images in parallel that display both white light and NIR light
images together without overlay.
• Specialty select on the camera control unit should be set to
“laparoscopy” or “standard” in order for uorescence SPY
mode to activate.
• L11 LED light source needs to be connected to the camera
control unit for auto light to work.
• If image quality remains poor, the coupler may not be attached
correctly to the camera head and laparoscope eyepiece.
Image 1S Rubina—Karl Storz, Tuttlingen, Germany
The Image 1S Rubina (Fig.2.9) was developed by Karl Storz
as a uorescence capable, modular system for use in minimally
invasive and open surgical procedures. Rubina builds on the
Image 1S Camera System and can incorporate 4K, 3D, NIR/ICG,
and LED components as needed. The uorescence-guided surgical system consists of a Rubina camera head that attaches to a
laparoscope or exoscope for capturing visible and NIR images in
minimally invasive and open surgical procedures, respectively.
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Fig. 2.9 Image 1s Rubina System—Photo courtesy of Karl Storz
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Rubina: ICG Imaging System Components
The system includes the following: Rubina LED light source;
camera control unit, TC201US; TC 304US; light cable; camera
head options, OPAL 1 (NIR/ICG); IMAGE 1S Rubina (4K, NIR/
ICG); TIPCAM 1 Rubina (4K/3D, NIR/ICG); laparoscope,
Hopkins ICG/NIR (5 mm, 10 mm); exoscope, VITOM II ICG;
footswitch; monitors with 4K or 4K/3D resolution; and 3D clip on
glasses.
For use, the Image 1S Rubina’s operating room cart is set up
similarly to any other laparoscopic surgical system, with monitors
placed for optimal visualization. 4K and 4K/3D displays can be
used. The camera head with light cable and scopes are autoclavable and will be handed to the surgeon sterilely. There are multiple camera head options that provide NIR/ICG images. The
camera head, scope, and light cables are attached to one another,
and the camera and light cables are then handed off to a nonsterile assistant. The camera cable inserts into the camera control
unit and the light cable inserts into the Rubina LED light source.
For open surgical procedures, the exoscope and camera head can
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be attached to a exible arm mount as needed. Fluorescence is
activated by the lower button on the camera head or via a connectable footswitch. The system utilizes a laser-free excitation source
of an LED and has infrared emission wavelength at 720–810nm.
There are no device-specic recommendations for timing or dosing of ICG injection with this system.
Image 1S Rubina System was developed by Karl Storz as a
uorescence capable system for minimally invasive and open surgeries. Karl Storz developed an ICG imaging system in 2016 with
the OPAL ICG/NIR systems. The FDA has determined that the
Image 1S Rubina is substantially equivalent to predicate device
for use as a camera system in all endoscopic procedures and as an
FGS system approved for assessment of vessels, tissue perfusion,
biliary ducts, and lymphatic vessels and nodes. Rubina is compatible with a variety of camera head options to allow for standard
imaging, NIR imaging, and imaging in 4K or 4K/3D.The camera
system can be tted for both endoscopes in laparoscopic cases
and an exoscope with exible arm mount for open cases. For NIR
images, the system can accommodate an overlay of white light
and NIR images on a single display with either green or blue NIRenhanced images. Intensity map displays the intensity of signals
in an overlay image while removing white light images to maximize visualization of uorescently labeled structures.
Monochromatic NIR imaging can overlay NIR images and black
and white visible light images for visual contrast [72–74].
The compatibility of the system with multiple camera heads
and scopes allows for high-denition and 3D-compatible imaging
which can be used for laparoscopic and arthroscopic procedures.
The Image 1S Rubina can be used with and without uorescence
imaging. Indications for use with uorescence include assessment
of blood vessels, tissue perfusion, visualization of the biliary system, and lymphatic tracing [75, 76].
Pearls for Use
• Image 1S camera compatible with both laparoscope and exo-
scope for minimally invasive and open surgery.
• System includes a foot pedal for toggling fluoroscopic
imaging.
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• System is compatible with 4K and 4K/3D imaging.
• System can display NIR images in two colors (blue and green).
• User can modulate intensity of NIR images to optimize visualization.
EleVision IR Platform—Medtronic, Dublin, Ireland
EleVision (Fig.2.10) was developed by Medtronic as a uores-
cence capable surgical system for use in minimally invasive and
open surgical procedures. The system is able to be used in both
minimally invasive and open surgery by having a camera capable
of attaching to either a laparoscope or a microscope.
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EleVision IR Platform Components
The system includes the following: uorescence camera,
Visionsense 3 Iridium (VS3-IR); Iridium Module Scope,
Visionsense 3 Miniature Microscope (VS3-MMS); camera control unit; laser light source (LLS); xenon light source; touchscreen
monitor; VS3 Iridium Endoscopes (5mm, 10 mm); VS3 Light
Cable and Iridium Light Beam Combiner; sterile drapes for VS3MMS; VS3-IR Fluorescence ICG Kit; and Iridium software.
The EleVision IR Platform tower’s main components for uo-
rescence imaging are the camera control unit and laser light
source. For minimally invasive surgery, the camera head, scopes,
and light cable are autoclavable and are handed to the surgeon
sterilely. The camera is assembled and the camera cable and light
cable are handed to a non-sterile assistant. The camera cable has a
protective cap which is removed prior to insertion into the camera
control unit with its input located on the left side of the unit. The
light cables are attached to the laser light source and the xenon
light source (which is the standard light for use in general laparoscopy). For open surgery, the VS3-IR camera is attached to a nonautoclavable iridium module scope: VS3-MMS which can be
handheld or attached to a cart-mounted arm for positioning over a
surgical eld with a working distance of 17–50cm. It must be
sterilely draped prior to use during operative procedures with
xation of the drape window to the scope. Fluorescence can be
activated and controlled from the handheld camera head. The
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Fig. 2.10 EleVision IR System—Photo courtesy of Medtronic
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device utilizes a laser excitation light source and has infrared
emission wavelengths at 785–805nm with penetration 3–5mm of
tissue. There are no specic timing or dose recommendations for
injection of the ICG [77, 78].
EleVision IR Platform was developed by Medtronic as a uo-
rescence capable system for minimally invasive and open/microscopic surgeries. Visionsense, now a part of Medtronic, had
developed its endoscopic and handheld uorescence device in
2014 with the VS3-IR and VS3-MMS, respectively. This system
has since been integrated into Medtronic’s EleVision IR Platform
as of 2018, and the FDA determined that the system was substantially equivalent to predicate devices for use as a camera system in
FGS, approved for the visual assessment of vessels, tissue perfusion, biliary ducts, and lymphatic vessels and nodes. Both cameras utilize a dual-channel camera system for imaging of both
standard visible light and NIR light images at high resolution up
to 4K.Fluorescence images are displayed in monochromatic NIR
imaging, in false color NIR imaging, and in overlay mode. False
color NIR assigns different colors based on NIR intensity (blue
being the lowest to yellow and then red as the highest). Infrared
intensity can also be assessed by the Iridium software which
offers quantitative and qualitative measurements of infrared signal intensity based on absolute and relative pixelations of images.
This software can offer real-time relative quantitative values
regarding tissue perfusion with heat mapping [77–79].
The compatibility of the VS3-IR camera with a laparoscope or
miniature microscope allows the system to be used in laparoscopic and open cases. EleVision IR Platform can be used with
and without uorescence imaging. Indications for use of uorescence using the EleVision IR are for the assessment of vessels,
tissue perfusion, visualization of the biliary system, and lymphatic tracing.
Pearls for Use
• Available as either open, minimally invasive, or combined system.
• Capable of 4K high-resolution images.
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