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D. Hui et al.
• Iridium software can analyze images in real time to provide
both quantitative and qualitative information on perfusion.
• Display can show singular overlay images or multiple images
that display both white light and NIR light images together
without overlay.
• Two separate channels for the camera each require focus
adjustment as needed.
Quest Spectrum—Olympus Surgical Technologies, Hamburg,
Germany
Quest Spectrum (Fig.2.11) was developed by Quest Photonic
as a uorescence capable surgical system for use in minimally
invasive and open surgical procedures. The system consists of a
camera head, which can attach to one of two different scope
Fig. 2.11 Quest Spectrum System—Photo courtesy of Quest and Olympus
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components. These components are easily interchangeable and
can be exchanged during a procedure.
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Quest Spectrum Components
The system includes the following: Quest Spectrum camera with
video cable, ring light with light cable, laparoscope with light
cable, display monitor and control tower, light engine, and sterile
drapes.
Quest Spectrum utilizes a common camera head for minimally
invasive and open surgical procedures. For minimally invasive
surgery, the camera head and laparoscope base are sterilely draped
to allow for attachment of the laparoscope and light cable. The
camera cable will have already been connected to the system and
the light cable can be inserted into the light engine on the far right.
For open surgery, the ring light and light cable are attached to the
camera and are sterilely draped with xation of the connecting
lens to the ring light. The device can then be used as a handheld
device or attached to a exible arm mount over a surgical eld
with a working distance of 5–30cm. Fluorescence can be activated from the camera control or cart console. The camera contains two NIR channels and thus ultimately captures three different
images: white light image and two different NIR images. The
light engine produces the LED light for visible light images, while
the modular laser light source produces laser for excitation with
capturable infrared emission wavelengths at 700–830 mm and
830–1100nm. There are no device-specic recommendations for
timing or dosing of ICG injection [80, 81].
Quest Spectrum was originally developed by Quest Photonic
Devices (now part of Olympus Corporation) as an open and endoscopic system in 2015. At that time, it was initially known as the
Artemis Handheld System and was compatible with a ring light
for open surgery and laparoscopes for minimally invasive surgery.
The FDA determined that the Quest Spectrum system is substantially equivalent to the predicate Artemis system for use as a camera system in FGS, approved for assessment of vessels, tissue
perfusion, biliary ducts, and lymphatic vessels and nodes. The
system monitor can display visible light, monochromic uores-
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cence, and overlay of colored uorescence on visible light images.
Since the system has two NIR channels, the overlay mode can
display two different NIR emission wavelengths in two different
colors to identify multiple uorescent tagged structures [79].
The Quest Spectrum can be used in both laparoscopic and
open cases and can be used with and without uorescence imaging. Indications for use of uorescence are for the assessment of
vessels, tissue perfusion, visualization of the biliary system, and
lymphatic tracing [81, 82].
Pearls and Pitfalls
• System includes a single camera with interchangeable attach-
ments for use in either open or minimally invasive surgery.
• Both open and laparoscopic uses of the system will require
sterile drapes to cover the camera head.
• The system includes two channels for two NIR images with
ability to toggle between wavelengths in green and blue image
enhancement.
• The display can show singular overlay images or multiple
images that display both white light and near-infrared light
images together without overlay.
D. Hui et al.
Robotic Surgical Systems
Firey—Intuitive Surgical, California, USA
Firey (Fig.2.12a) was developed by Intuitive Surgical to add
uorescence-guided capabilities to its minimally invasive robotic
surgical platform. Firey is a standard integrated feature with Da
Vinci Robotic Systems and does not require additional modules or
attachments to utilize.
Firey Components
The system includes the following: 8mm 0° and 30° endoscopes
(PNs 470,026 and 470,027), endoscope controller (PN 372601),
bc
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a
Fig. 2.12 (a) Da Vinci Xi Endoscope Plus with uorescence capability—
Image courtesy of Intuitive. (b) Firey mode—Image courtesy of Intuitive.
(c) Firey sensitive mode—Image courtesy of Intuitive
uorescence imaging kit (K101077) (PN 950156), and Da Vinci
Xi Robotic Components.
Instructions forUse
The Da Vinci Xi Robotic System is set up in its usual sterile fashion. Once the robot is docked, the surgeon has full access to the
Firey system. The console allows easy switching between normal illumination and uorescence imaging modes. The camera
head optics are optimized to visualize a uorescence signal. The
surgeon will then have full control over near uorescence imaging. The camera unit is a 3D stereoscopic scope and cable that
contains an LED light source, excitation light, and camera. The
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Firey system utilizes an excitation source of a class 3R laser and
has infrared emission wavelength at 805nm. The working distance is 2–14 cm. The visualization of near-infrared frequency
can easily be toggled from the operative console and offers LED
illuminated black and white visualization with green colorenhanced uorescence (Fig.2.12b). Additionally, sensitive mode
(Fig.2.12c) will toggle off the visible light LED to better enhance
visualization of deeper near-infrared structures up to 8–10mm in
depth. In sensitive mode, the system automatically adjusts signal
intensity and brightness to allow for a consistent image regardless
of the distance between the endoscope and tissue. The imaging
LED illuminator emits a laser to excite ICG.
D. Hui et al.
Dosing, Timing, andRoute ofAdministration
The recommended dosing for ICG is 0.5–1.5ml at 2.5mg/ml concentration with the maximum daily dose not to exceed 2mg/kg
body weight. ICG has a half-life of 2–5min. It should be used
within 6h of reconstitution.
ICG stays within blood vessels for seconds and one should see
uorescence dye within 5–50seconds. ICG stays within the kidney for 20min with visibility within 1min, the liver for 1–2h
with visibility within less than 2min, and bile for 1–2h with visibility within tens of min [83–86]. This timing of onset of visibility and the time it lasts can be used by the operating surgeon as to
when to administer the ICG based on the operative case and target
tissue to be visualized.
Intuitive developed a robotic uorescence device in 2011 with
the Da Vinci Si platform. Intuitive collaborated with Novadaq to
incorporate uorescence imaging into its robotic surgery platform. The current system available is Firey and is a component
of the Intuitive Da Vinci Xi platform. This system includes a
1080i 3D stereoscopic uorescence camera with LED illuminator
and laser generator.
The indications for Firey include the assessment of vessels
and tissue perfusion and the evaluation of the extrahepatic biliary
system [87, 88].
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Pearls and Pitfalls
• Firey is easy to control from the surgical console.
• Firey can be activated using the nger clutch at the robotic
console, so visualization can be maintained as uorescence is
turned on and off.
• A surgeon can activate sensitive mode for greater visualization
of NIR images and for visualization of deeper structures.
• Overlay mode not currently available.
ActivSight™—Activ Surgical, Boston, MA, USA
ActivSight™ is an FDA-approved modular imaging device
that integrates with the standard laparoscopic vision system to
provide multimodal visual intelligence beyond the human visual
spectrum. ActivSight™ has three components: the imaging module (IM), the light engine (LE), and the bifurcated light guide
(LG). The IM is placed between the laparoscope and standard
white light camera. The IM contains a sensor that captures light
within the infrared spectrum while passing light in the visual
spectrum to the white light camera. The LE illuminates the surgical eld with white light and wavelengths of light in near-infrared
(NIR) spectrum. The images obtained from the white light and
infrared cameras are combined to create overlay images that display real-time tissue perfusion.
ActivSight™ provides two modes for assessing tissue perfu-
sion, a dye-less ActivPerfusion™ mode and a dye-mediated
ActivICG™ mode. ActivPerfusion™ mode represents a dye-free
imaging method using coherent monochromatic light, known as
laser speckle contrast imaging (LSCI), to detect blood ow and
tissue perfusion. When a red blood cell is illuminated with coherent laser light, a speckle pattern or random interference pattern is
created [89]. Because red blood cells are in motion, the speckle
pattern uctuates in time. In areas where there are more red blood
cells in motion, the camera will display more blurring of the
speckles. The wavelength of light used for LSCI is signicantly
less important than with imaging methods that rely on contrast
absorption because LSCI is solely based on scattering. A limitation of LSCI is motion artifact. The respiratory and cardiac cycles
can produce physiologic motion artifacts. However, image
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processing methods can compensate and minimize the effect of
these artifacts [89–91].
In ActivPerfusion™ mode, tissue perfusion is displayed as a
heatmap using a red-green-blue color (RGB) model. Warmer colors in the red spectrum indicate areas of high perfusion, while
cooler colors within the blue spectrum indicate areas of relatively
less perfusion. There are two imaging displays available within
the ActivPerfusion™ mode, overlay and contrast. In the perfusion
overlay mode, LSCI perfusion signals from light in the NIR spectrum are viewed over the white light display of the anatomy. The
perfusion contrast mode displays only the LSCI perfusion signals
to allow ner assessment of tissue perfusion without the interference of colors from the white light spectrum.
The ActivICG™ mode uses NIR technology to detect ICG and
superimposes the image on tissue in real time. The advantage of
the ActivPerfusion™ mode over contrast-based imaging is that
the data provided is instantaneous and reproducible. With
ActivPerfusion™, the perfusion signal is lost immediately after
vessel occlusion. In contrast, if the vessel is transected or occluded
after ICG is given, the image will not change due to the presence
of residual dye resulting in false-positive data. This represents a
pharmacokinetic limitation of ICG and additional perfusion
assessments cannot be made until the 3–4-min half-life of ICG
has passed [92]. Repeat dosing of ICG is also necessary and the
accuracy may be reduced due to the presence of residual ICG.
D. Hui et al.
Transillumination Systems
Green Egg—EndoGlow, Rochester, NewYork, USA
Green Egg (Fig.2.13) was developed as a transillumination
device for use in minimally invasive and open surgical procedures. The device contains its own uorescence polymer which
emits NIR when excited by an FGS system. The device is 30mm
in diameter and can be inserted into target tissue areas such as the
vagina or rectum. When uorescence mode is activated on the
desired system, transillumination of near-infrared images can be
visualized. This device works in a similar manner to uorophores
a
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b
Fig. 2.13 (a) Green Egg—Image courtesy of EndoGlow. (b) Transillumina-
tion with use of Green Egg—Photo courtesy of EndoGlow
with emission of NIR light when activated. EndoGlow developed
the device, which is pending FDA approval as of November
2021. It utilizes tissue reveal technology which is a uorescent
polymer device used in minimally invasive surgeries via transillumination. The indication for use of Green Egg is for transillumination of anatomic structures to assist in delineating tissue
planes, depth, and anatomic borders. It has been used in gynecologic, urologic, and colorectal minimally invasive surgeries. The
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D. Hui et al.
device has clinical use as a vaginal or rectal manipulator that can
backlight tissue to enhance tissue visualization. Its use has been
benecial in the visualization and dissection of scarred tissue,
reducing rectal injuries in prostatectomies, low anterior resections, and complex hysterectomies [93]. Pilot studies have demonstrated several benets to the transillumination effect of using
a uorescent manipulator [94]. Surgeons were able to identify
deep inltrating rectal endometriosis, better recognize surgical
planes in complex anatomy, and visualize relative tissue depth.
The ability to transilluminate vaginal tissue aided in post-hysterectomy bladder dissections during sacrocolpopexies and rectopexies. An unexpected benet was the increased communication
between the attending surgeon and surgical learners (fellows/
residents) or surgical assists. The enhanced visualization allowed
the surgical learner or rst-assist to see and understand the intricacies of the dissection more easily.
Pearls and Pitfalls
• Autoclavable device that can be inserted directly into tissue
areas (e.g., vagina and rectum).
• Sustainable autouorescence device that obviates the need for
dye injection.
Infrared Illuminating System (IRIS) Ureteral Kit—Stryker,
Kalamazoo, Michigan, USA
Infrared Illuminating System (IRIS) Ureteral Kit (Fig.2.14) is
a transilluminating ureteral stent placed intraoperatively to assist
in the identication of ureters during minimally invasive and open
surgical procedures. This device connects to Stryker’s LED light
sources to provide transillumination of the ureter. The L11 LED
light source is able to provide excitation at 830nm transillumination [95, 96]. The device catheters are inserted sterilely via cystoscopy as a ureteral stent at the onset of the case. Catheters are
advanced 20cm in each ureter which is denoted by a double black
line on the device. Once the catheters are in place, the emitting
diodes are inserted into each catheter until the stopping mechanism
on each diode is reached. The IRIS ber prongs are inserted into
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Fig. 2.14 Infrared Illuminating System Ureteral Kit—Image courtesy of
Stryker
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the Stryker light source on the far left of the unit. Once the light
source is activated, the ureteral stents will illuminate and can be
visible in any minimally invasive and open surgery. The indication
for use of IRIS Ureteral Kit is for the transillumination of ureters
to assist in delineating tissue planes during pelvic dissection in
both minimally invasive and open surgery. It has been used in
gynecologic, urologic, and colorectal surgeries to enhance tissue
visualization to help reduce the risk of ureteral injuries [71, 97].
Pearls and Pitfalls
• Catheters compatible with guidewires up to 0.038in.
• Catheters from kit can be left in place as needed for use as
general use ureteral stents.
• IRIS menu on the Stryker’s control unit can toggle IRIS illumination brightness, and the illumination can provide continuous
transillumination or pulsating transillumination.
Endolumik Fluorescence-Guided Gastric Calibration
Tube—Endolumik Inc., Morgantown, West Virginia, USA
The Endolumik Fluorescence-Guided Gastric Calibration
Tube (Figs.2.15 and 2.16) is a single-use, uorescence-guided
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