Image-Guided Pediatric Surgery Using Indocyanine Green (ICG) Fluorescence in Laparoscopic and Robotic Surgery

Ciro Esposito, Alessandro Settimi, Fulvia Del Conte, Mariapina Cerulo, Vincenzo Coppola, Alessandra Farina, Felice Crocetto, Elisabetta Ricciardi, Giovanni Esposito, Maria Escolino, Ciro Esposito, Alessandro Settimi, Fulvia Del Conte, Mariapina Cerulo, Vincenzo Coppola, Alessandra Farina, Felice Crocetto, Elisabetta Ricciardi, Giovanni Esposito, Maria Escolino

Abstract

Background: Indocyanine green (ICG)-guided near-infrared fluorescence (NIRF) has been recently adopted in pediatric minimally invasive surgery (MIS). This study aimed to report our experience with ICG-guided NIRF in pediatric laparoscopy and robotics and evaluate its usefulness and technique of application in different pediatric pathologies. Methods: ICG technology was adopted in 76 laparoscopic and/or robotic procedures accomplished in a single division of pediatric surgery over a 24-month period (January 2018-2020): 40 (37 laparoscopic, three robotic) left varicocelectomies with intra-operative lymphography; 13 (10 laparoscopic, three robotic) renal procedures: seven partial nephrectomies, three nephrectomies, and three renal cyst deroofings; 12 laparoscopic cholecystectomies; five robotic tumor excisions; three laparoscopic abdominal lymphoma excisions; three thoracoscopic procedures: two lobectomies and one lymph node biopsy for suspected lymphoma. The ICG solution was administered into a peripheral vein in all indications except for varicocele and lymphoma in which it was, respectively, injected into the testis body or the target organ. Regarding the timing of the administration, the ICG solution was administered intra-operatively in all indications except for cholecystectomy in which the ICG injection was performed 15-18 h before surgery. Results: No conversions to open or laparoscopy occurred. No adverse and allergic reactions to ICG or other postoperative complications were reported. Conclusions: Based upon our 2 year experience, we believe that ICG-guided NIRF is a very useful tool in pediatric MIS to perform a true imaged-guided surgery, allowing an easier identification of anatomic structures and an easier surgical performance in difficult cases. The most common applications in pediatric surgery include varicocele repair, difficult cholecystectomy, partial nephrectomy, lymphoma, and tumors excision but further indications will be soon discovered. ICG-enhanced fluorescence was technically easy to apply and safe for the patient reporting no adverse reactions to the product. The main limitation is represented by the specific equipment needed to apply ICG-guided NIRF in laparoscopic procedures, that is not available in all centers whereas the ICG system Firefly® is already integrated into the robotic platform.

Keywords: children; fluorescence; indocyanine green; laparoscopy; robotics; technology.

Copyright © 2020 Esposito, Settimi, Del Conte, Cerulo, Coppola, Farina, Crocetto, Ricciardi, Esposito and Escolino.

Figures

Figure 1
Figure 1
Lymphatics sparing at standard white light (A) and ICG-guided NIRF (B). Clipping and division of the spermatic bundle at standard white light (C) and ICG-guided NIRF (D).
Figure 2
Figure 2
ICG-guided NIRF aided to identify the dissection plane between upper and lower moiety during upper pole partial nephrectomy.
Figure 3
Figure 3
ICG-guided NIRF aided to identify the biliary anatomy (Cystic Duct, CD; Common Bile Duct, CBD; CD-CBD junction) during laparoscopic cholecystectomy.
Figure 4
Figure 4
ICG-guided NIRF was helpful to identify the different structures (cystic duct; cystic artery) in presence of adhesions or inflammation.
Figure 5
Figure 5
ICG-guided NIRF was useful to identify the tumor mass that appeared hypo-fluorescent (A), to respect the resection edges during removal (B), and to check the vascularization of the uterus following the resection (C).
Figure 6
Figure 6
Thoracoscopic biopsy of a 2-cm hilar lymph node: pre-operative CT imaging (A), intra-operative view (B), ICG-guided NIRF imaging (C).

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