Is there a role for near-infrared technology in laparoscopic resection of pancreatic neuroendocrine tumors? Results of the COLPAN "colour-and-resect the pancreas" study

Fluorescence and tracers in surgery: the coming future

The revolution that we are seeing in the world of surgery will determine the way we understand surgical approaches in coming years. Since the implementation of minimally invasive surgery, innovations have constantly been developed to allow the laparoscopic approach to go further and be applied to more and more procedures. In recent years, we have been in the middle of another revolutionary era, with robotic surgery, the application of artificial intelligence and image-guided surgery. The latter includes 3D reconstructions for surgical planning, virtual reality, holograms or tracer-guided surgery, where ICG-guided fluorescence has provided a different perspective on surgery. ICG has been used to identify anatomical structures, assess tissue perfusion, and identify tumors or tumor lymphatic drainage. But the most important thing is that this technology has come hand in hand with the potential to develop other types of tracers that will facilitate the identification of tumor cells and ureters, as well as different light beams to identify anatomical structures. These will lead to other types of systems to assess tissue perfusion without the use of tracers, such as hyperspectral imaging. Combined with the upcoming introduction of ICG quantification, these developments represent a real revolution in the surgical world. With the imminent implementation of these technological advances, a review of their clinical application in general surgery is timely, and this review serves that aim.

Indocyanine green: The guide to safer and more effective surgery

In this editorial we comment on the article by Kalayarasan and co-workers published in the recent issue of the World Journal of Gastrointestinal Surgery. The authors present an interesting review on the use of indocyanine green fluorescence in different aspects of abdominal surgery. They also highlight future perspectives of the use of indocyanine green in mini-invasive surgery. Indocyanine green, used for fluorescence imaging, has been approved by the Food and Drug Administration and is safe for use in humans. It can be administered intravenously or intra-arterially. Since its advent, there have been several advancements in the applications of indocyanine green, especially in the surgical field, such as intraoperative mapping and biopsy of sentinel lymph node, measurement of hepatic function prior to resection, in neurosurgical cases to detect vascular anomalies, in cardiovascular cases for patency and assessment of vascular abnormalities, in predicting healing following amputations, in helping visualization of hepatobiliary anatomy and blood vessels, in reconstructive surgery, to assess flap viability and for the evaluation of tissue perfusion following major trauma and burns. For these reasons, the intraoperative use of indocyanine green has become common in a variety of surgical specialties and transplant surgery. Colorectal surgery has just lately begun to adopt this technique, particularly for perfusion visualization to prevent anastomotic leakage. The regular use of indocyanine green coupled with fluorescence angiography has recently been proposed as a feasible tool to help improve patient outcomes. Using the best available data, it has been shown that routine use of indocyanine green in colorectal surgery reduces the rates of anastomotic leak. The use of indocyanine green is proven to be safe, feasible, and effective in both elective and emergency scenarios. However, additional robust evidence from larger-scale, high-quality studies is essential before incorporating indocyanine green guided surgery into standard practice.

Indocyanine green dye and its application in gastrointestinal surgery: The future is bright green

Indocyanine green (ICG) is a water-soluble fluorescent dye that is minimally toxic and widely used in gastrointestinal surgery. ICG facilitates anatomical identification of structures (e.g., ureters), assessment of lymph nodes, biliary mapping, organ perfusion and anastomosis assessment, and aids in determining the adequacy of oncological margins. In addition, ICG can be conjugated to artificially created antibodies for tumour markers, such as carcinoembryonic antigen for colorectal, breast, lung, and gastric cancer, prostate-specific antigen for prostate cancer, and cancer antigen 125 for ovarian cancer. Although ICG has shown promising results, the optimization of patient factors, dye factors, equipment, and the method of assessing fluorescence intensity could further enhance its utility. This review summarizes the clinical application of ICG in gastrointestinal surgery and discusses the emergence of novel dyes such as ZW-800 and VM678 that have demonstrated appropriate pharmacokinetic properties and improved target-to-background ratios in animal studies. With the emergence of robotic technology and the increasing reporting of ICG utility, a comprehensive review of clinical application of ICG in gastrointestinal surgery is timely and this review serves that aim.

Intraoperative Imaging in Hepatopancreatobiliary Surgery

Hepatopancreatobiliary surgery belongs to one of the most complex fields of general surgery. An intricate and vital anatomy is accompanied by difficult distinctions of tumors from fibrosis and inflammation; the identification of precise tumor margins; or small, even disappearing, lesions on currently available imaging. The routine implementation of ultrasound use shifted the possibilities in the operating room, yet more precision is necessary to achieve negative resection margins. Modalities utilizing fluorescent-compatible dyes have proven their role in hepatopancreatobiliary surgery, although this is not yet a routine practice, as there are many limitations. Modalities, such as photoacoustic imaging or 3D holograms, are emerging but are mostly limited to preclinical settings. There is a need to identify and develop an ideal contrast agent capable of differentiating between malignant and benign tissue and to report on the prognostic benefits of implemented intraoperative imaging in order to navigate clinical translation. This review focuses on existing and developing imaging modalities for intraoperative use, tailored to the needs of hepatopancreatobiliary cancers. We will also cover the application of these imaging techniques to theranostics to achieve combined diagnostic and therapeutic potential.

Consensus Statement on the Use of Near-Infrared Fluorescence Imaging during Pancreatic Cancer Surgery Based on a Delphi Study: Surgeons' Perspectives on Current Use and Future Recommendations

Indocyanine green (ICG) is one of the only clinically approved near-infrared (NIR) fluorophores used during fluorescence-guided surgery (FGS), but it lacks tumor specificity for pancreatic ductal adenocarcinoma (PDAC). Several tumor-targeted fluorescent probes have been evaluated in PDAC patients, yet no uniformity or consensus exists among the surgical community on the current and future needs of FGS during PDAC surgery. In this first-published consensus report on FGS for PDAC, expert opinions were gathered on current use and future recommendations from surgeons' perspectives. A Delphi survey was conducted among international FGS experts via Google Forms. Experts were asked to anonymously vote on 76 statements, with ≥70% agreement considered consensus and ≥80% participation/statement considered vote robustness. Consensus was reached for 61/76 statements. All statements were considered robust. All experts agreed that FGS is safe with few drawbacks during PDAC surgery, but that it should not yet be implemented routinely for tumor identification due to a lack of PDAC-specific NIR tracers and insufficient evidence proving FGS's benefit over standard methods. However, aside from tumor imaging, surgeons suggest they would benefit from visualizing vasculature and surrounding anatomy with ICG during PDAC surgery. Future research could also benefit from identifying neuroendocrine tumors. More research focusing on standardization and combining tumor identification and vital-structure imaging would greatly improve FGS's use during PDAC surgery.

Safety and usefulness of fluorescence imaging using methylene blue as a fluorophore in a Japanese population with hepatobiliary and pancreatic diseases: A phase I study

BACKGROUND

Methylene blue (MB) has been used to treat methemoglobinemia. Recently, a fluorescence imaging technique using MB as a fluorophore was used in several region but still not in hepatobiliary and pancreatic surgery; thus, information on the safety of intraoperative fluorescence imaging using MB in a healthy Japanese population is lacking. We aimed to evaluate the usefulness of MB fluorescence imaging in patients undergoing hepatobiliary and pancreatic surgery and the safety of intraoperative administration of MB in patients without methemoglobinemia.

METHODS

Eighteen patients undergoing hepatobiliary and pancreatic surgery were enrolled. We developed and used a fluorescence imaging system to visualize MB as fluorescence. The fluorescence intensity of the blood vessels, tumors, liver, and intestine were measured. The primary endpoint was the ability of the MB fluorescence imaging to visualize vessels and tumors with fluorescence. The secondary endpoint was the safety of fluorescence imaging using MB in patients without methemoglobinemia.

RESULTS

For the 18 patients undergoing MB fluorescence imaging, no intraoperative and postoperative complications related to MB administration occurred. Seventeen patients (94%) successfully visualized the target object as fluorescence by MB fluorescence imaging, including 100% of neuroendocrine tumors (four tumors) and peripancreatic vessels (n = 13).

CONCLUSION

The administration of MB and application of fluorescence imaging using MB can visualize blood vessels and pancreatic neuroendocrine neoplasms. And it also showed the safety of using MB as a fluorophore in Japanese patients without methemoglobinemia.

Systematic review, meta-analysis and single-centre experience of the diagnostic accuracy of intraoperative near-infrared indocyanine green-fluorescence in detecting pancreatic tumours

BACKGROUND

During pancreatic resections assessing tumour boundaries and identifying the ideal resection margins can be challenging due to the associated pancreatic gland inflammation and texture. This is particularly true in the context of minimally invasive surgery, where there is a very limited or absent tactile feedback. Indocyanine green (ICG) fluorescence imaging can assist surgeons by simply providing valuable real-time intraoperative information at low cost with minimal side effects. This meta-analysis summarises the available evidence on the use of near-infrared fluorescence imaging with ICG for the intraoperative visualization of pancreatic tumours (PROSPERO ID: CRD42021247203).

METHODS

MEDLINE, Embase, and Web Of Science electronic databases were searched to identify manuscripts where ICG was intravenously administered prior to or during pancreatic surgery and reporting the prevalence of pancreatic lesions visualised through fluorescence imaging.

RESULTS

Six studies with 7 series' reporting data on 64 pancreatic lesions were included in the analysis. MINOR scores ranged from 6 to 10, with a median of 8. The most frequent indications were pancreatic adenocarcinoma and neuroendocrine tumours. In most cases (67.2%) ICG was administered during surgery. ICG fluorescence identified 48/64 lesions (75%) with 81.3% accuracy, 0.788 (95%CI 0.361-0.961) sensitivity, 1 (95%CI 0.072-1) specificity and positive predictive value of 0.982 (95%CI 0.532-1). In line with the literature, ICG fluorescence identified 5/6 (83.3%) of pancreatic lesions during robotic pancreatic resections performed at our Institution.

CONCLUSION

This meta-analysis is the first summarising the results of ICG immunofluorescence in detecting pancreatic tumours during surgery, showing good accuracy. Additional research is needed to define optimal ICG administration strategies and fluorescence intensity cut-offs.

Indocyanine green (ICG) fluorescence guide for the use and indications in general surgery: recommendations based on the descriptive review of the literature and the analysis of experience

Indocyanine Green is a fluorescent substance visible in near-infrared light. It is useful for the identification of anatomical structures (biliary tract, ureters, parathyroid, thoracic duct), the tissues vascularization (anastomosis in colorectal, esophageal, gastric, bariatric surgery, for plasties and flaps in abdominal wall surgery, liver resection, in strangulated hernias and in intestinal ischemia), for tumor identification (liver, pancreas, adrenal glands, implants of peritoneal carcinomatosis, retroperitoneal tumors and lymphomas) and sentinel node identification and lymphatic mapping in malignant tumors (stomach, breast, colon, rectum, esophagus and skin cancer). The evidence is very encouraging, although standardization of its use and randomized studies with higher number of patients are required to obtain definitive conclusions on its use in general surgery. The aim of this literature review is to provide a guide for the use of ICG fluorescence in general surgery procedures.

A novel tool for visualization and detection of pancreatic neuroendocrine tumours. A 'fluorescent' world is calling for exploration?

AIM OF THE STUDY

Pancreatic neuroendocrine tumours (pNETs) are rare tumours with a propensity to metastasize. Physicians frequently face a huge clinical challenge during the localization of these lesions. The aim of this study is to investigate whether fluorescence-guided localization techniques with indocyanine green (ICG) can be utilized as a detection tool in pNETs, along with any other clinical implications of this technique.

MATERIAL AND METHODS

A thorough literature search in PubMed and Google Scholar, under the terms 'ICG OR Indocyanine OR Fluorescence AND Neuroendocrine' until 31 June 2021, regarding the utilization of indocyanine-fluorescence in localization of pancreatic neuroendocrine, was conducted by the authors, and the associated results are presented.

RESULTS

Indocyanine fluorescence imaging may facilitate the efforts of surgeons to identify occult pancreatic neuroendocrine lesions, assisting them in the identification of resection margins and delineation of the surgical anatomy when it is difficult to clarify.

CONCLUSIONS

Indocyanine-fluorescence imaging might play a pivotal role in pancreatic surgery in terms of localization for neuroendocrine tumours. However, further large-scale clinical studies are needed to assess the absolute indications and optimal use of this technique.

Technical aspects of paediatric robotic pancreatic enucleation based on a case of an insulinoma

BACKGROUND

Insulinomas are rare insulin-producing pancreatic neuroendocrine tumours leading to severe episodes of hypoglycaemia. Surgery is the predominant curative therapy.

METHODS

We report here the first paediatric case of an insulinoma of the pancreatic body resected completely robotically under ultrasound guidance in a 10-year-old male with multiple endocrine neoplasia type 1. The port set-up was adapted for the narrowed dimensions of the paediatric peritoneal space. We comment on technical key steps for the organ-preserving procedure that was performed in close proximity to critical anatomic structures, with supporting video. Preoperative diagnostics, including endoscopic ultrasound, to determine surgical management are highlighted.

RESULTS

Following an uneventful post-operative course, the boy was discharged on day 11 with normalised glucose-metabolism. A pseudocyst developing after 4 weeks was treated with endoscopic stenting.

CONCLUSIONS

The applicability of a robotic surgical system in limited space conditions such as found in the paediatric abdominal cavity is demonstrated here for pancreatic surgery.

Development of a drug-device combination for fluorescence-guided surgery in neuroendocrine tumors

SIGNIFICANCE

The use of cancer-targeted contrast agents in fluorescence-guided surgery (FGS) has the potential to improve intraoperative visualization of tumors and surgical margins. However, evaluation of their translational potential is challenging.

AIM

We examined the utility of a somatostatin receptor subtype-2 (SSTR2)-targeted fluorescent agent in combination with a benchtop near-infrared fluorescence (NIRF) imaging system to visualize mouse xenografts under conditions that simulate the clinical FGS workflow for open surgical procedures.

APPROACH

The dual-labeled somatostatin analog, Ga67-MMC(IR800)-TOC, was injected into mice (n  =  24) implanted with SSTR2-expressing tumors and imaged with the customized OnLume NIRF imaging system (Madison, Wisconsin). In vivo and ex vivo imaging were performed under ambient light. The optimal dose (0.2, 0.5, and 2 nmol) and imaging time point (3, 24, 48, and 72 h) were determined using contrast-to-noise ratio (CNR) as the image quality parameter. Video captures of tumor resections were obtained to provide an FGS readout that is representative of clinical utility. Finally, a log-transformed linear regression model was fitted to assess congruence between fluorescence readouts and the underlying drug distribution.

RESULTS

The drug-device combination provided high in vivo and ex vivo contrast (CNRs  >  3, except lung at 3 h) at all time points with the optimal dose of 2 nmol. The optimal imaging time point was 24-h post-injection, where CNRs  >  6.5 were achieved in tissues of interest (i.e., pancreas, small intestine, stomach, and lung). Intraoperative FGS showed excellent utility for examination of the tumor cavity pre- and post-resection. The relationship between fluorescence readouts and gamma counts was linear and strongly correlated (n  =  334, R2  =  0.71; r  =  0.84; P  <  0.0001).

CONCLUSION

The innovative OnLume NIRF imaging system enhanced the evaluation of Ga67-MMC(IR800)-TOC in tumor models. These components comprise a promising drug-device combination for FGS in patients with SSTR2-expressing tumors.

Successful Localization and Resection of Small Pancreatic Cystic Insulinoma Using Intraoperative Near-Infrared Fluorescence Imaging: A Case Report and Literature Review

Pancreatic cystic insulinoma is an uncommon tumor. Perioperative localization remained challenging if the tumor is atypical with cystic feature or in small size. Near-infrared (NIR) imaging is a technique by injecting fluorescent dye intravenously, which accumulates to the target lesion and creating signal by laser sources. The signal helps surgeons to identify the lesion during operation, but little experience has been reported regarding the use of imaging NIR technique for localizing cystic insulinoma. We present a 29-year-old female patient with a symptomatic pancreatic cystic insulinoma (1.2 cm) as assessed by clinical symptom, laboratory evidence, and magnetic resonance cholangiopancreatography. With an aid of NIR imaging technique, this cystic tumor was localized easily at operation. Also, the fluorescence imaging visualized the tumor part, guided us to identify the safe margin, and preserved the normal pancreatic structure. Pathologic report confirmed that the tumor was a well-differentiated cystic insulinoma. This case demonstrates that pancreatic cystic insulinoma in small size can be intraoperatively localized by NIR imaging, a relatively safe and easy technique.

Simultaneous multipurpose fluorescence imaging with IRDye® 800BK during laparoscopic surgery

BACKGROUND

IRDye® 800BK is a fluorophore, currently undergoing clinical translation, which has both biliary and renal clearance. To date, there is no description of a fluorophore, which can be simultaneously used for non-invasive, near-infrared fluorescence-based (NIRF) visualization of different structures and perfusion evaluation. The purpose of this study was to evaluate IRDye® 800BK for the simultaneous assessment of bowel perfusion, lymphography, ureter and bile duct delineation.

METHODS

Six pigs received a 0.15 mg/kg dye as a single bolus intravenous injection (IV). With the FLER (fluorescence-based enhanced reality) software, fluorescence intensity (FI) of 5 regions of interest (ROI) in an ischemic bowel loop was measured along with the time to reach the FI peak, and capillary lactate was measured from the same ROI, followed by the assessment of the ureters and bile ducts for a maximal duration of 180 min after dye administration. In 3 animals, the procedure was initiated via gastroscopic injection of a 0.6 mg (1 mg/mL) dye in the gastric submucosa followed by lymphography in a NIRF setting.

RESULTS

Excellent visualization of the ureters and bowel perfusion was obtained under NIRF imaging. Additionally, the bile duct and gastric lymph ducts and nodes were visualized. A positive correlation was found between the time to peak FI in the ischemic bowel loop and the corresponding capillary lactate levels (rho 0.59, p < 0.001).

CONCLUSION

In this study, we successfully demonstrated the simultaneous multipurpose IRDye® 800BK applicability during laparoscopic surgery. This fluorophore has the potential to become a powerful and versatile image-guided surgery tool.

Radioguided surgery with β- radiation in pancreatic Neuroendocrine Tumors: a feasibility study

The possibility to use β- decaying isotopes for radioguided surgery (RGS) has been recently proposed, and first promising tests on ex-vivo samples of Meningioma and intestinal Neuroendocrine Tumor (NET) have been published. This paper reports a study of the uptake of 68Ga-DOTATOC in pancreatic NETs (pNETs) in order to assess the feasibility of a new RGS approach using 90Y-DOTATOC. Tumor and healthy pancreas uptakes were estimated from 68Ga-DOTATOC PET/CT scans of 30 patients with pNETs. From the obtained SUVs (Standardised Uptake Value) and TNRs (Tumor Non tumor Ratio), an analysis algorithm relying on a Monte Carlo simulation of the detector has been applied to evaluate the performances of the proposed technique. Almost all considered patients resulted to be compatible with the application of β--RGS assuming to administer 1.5 MBq/kg of activity of 90Y-DOTATOC 24 h before surgery, and a sampling time of few seconds. In just 2 cases the technique would have required a mildly increased amount of activity or of sampling time. Despite a high physiological uptake of 68Ga-DOTATOC in the healthy pancreas, the proposed RGS technique promises to be effective. This approach allows RGS to find application also in pancreatic diseases, where traditional techniques are not viable.

A proof-of-concept methodology to validate the in situ visualization of residual disease using cancer-targeted molecular agents in fluorescence-guided surgery

Introduction

The clinical need for improved intraoperative tumor visualization has led to the development of targeted contrast agents for fluorescence-guided surgery (FGS). A key characteristic of these agents is their high tumor specificity, which could enable detection of residual lesions that would likely be missed by visual inspection. Here, we examine the utility of a promising somatostatin receptor subtype-2 (SSTR2)-targeted fluorescent agent for detecting residual disease in mouse xenografts using FGS and post-operative histopathological validation.

Methods

Mice (n=2) implanted with SSTR2 overexpressing tumors were injected with 2 nmol of the dual-labeled somatostatin analog, ⁶⁷Ga-MMC(IR800)-TOC, and tumors were resected 48 h post-injection using traditional white light reflectance and palpation. Tumors underwent gamma counting and histopathology analysis. The wide-field FGS imaging platform (OnLume) was used to evaluate residual disease in situ under ambient light representative of an operating room.

Results

The tumor was resected with grossly negative margins using conventional inspection and palpation; however, additional in situ residual disease was found in the tumor cavity using FGS imaging. In situ fluorescent tumor contrast-to-noise ratios (CNRs) were 3.0 and 5.2. Agent accumulation was 7.72 and 8.20 %ID/g in tumors and 0.27 and 0.20 %ID/g in muscle. Fluorescence pixel values and gamma counts were highly correlated (r = 0.95, P < 0.048). H&E and IHC staining confirmed cancer positivity and SSTR2-overexpression, respectively.

Conclusion

Our findings demonstrate that the use of clinically relevant fluorescence imaging instrumentation enhances the evaluation of promising FGS agents for in situ visualization of residual disease.

Clinical utility of transanal indocyanine green near-infrared fluorescence imaging for evaluation of colorectal anastomotic perfusion

BACKGROUND

Although indocyanine green (ICG) fluorescence imaging has been reported to be useful for assessing colorectal perfusion, unstable quantification remains an issue. We performed ICG fluorescence observation from the luminal side and examined the usefulness of the transanal approach.

METHODS

A total of 69 patients who underwent left-side colon surgery were enrolled in this cohort study. After the anastomosis had been constructed, ICG 0.2 mg/kg was injected intravenously. The anastomotic site was then observed by a scope inserted transanally. The following items were examined in the areas of the anastomotic site with the highest- and lowest-fluorescence intensity: maximum fluorescence (Fmax), time from ICG injection to Fmax (Tmax), time from start of dyeing to Fmax (ΔT), and the contrast pattern of the mucosa.

RESULTS

Anastomotic leakage (AL) occurred in nine cases. Tmax and ΔT values of the lowest-fluorescence area in the distal intestine showed significant differences in the cases with AL (P = 0.015 and P = 0.040, respectively). Regarding the contrast pattern of the mucosa of the lowest-fluorescence area in the proximal and distal intestine, the patients in whom the vessels were not depicted in the area had a significantly higher incidence of AL than those in whom vessels were depicted in the area (P = 0.031 and P = 0.030, respectively). Some of the areas in which vessels were not depicted by ICG fluorescence observation from the luminal side corresponded to the points of leakage. There were heterogeneous changes that might not be grasped by observation from the serosal side.

CONCLUSION

Transanal ICG fluorescence imaging can evaluate perfusion over the entire circumference of the anastomosis in detail and aid in assessing the risk of AL. Therefore, the examination of the detailed low-perfusion area enables us to take measures for AL and to search for safer operative managements.

Near infrared light examination as part of the management of sporadic pancreatic head insulinoma: Case report

INTRODUCTION

We report the case of a 77-year-old female patient with the diagnosis of pancreatic head insulinoma, in whom we used near infrared light (NIR) to detect synchronous pancreatic tumors and potential secondary lymph node or liver involvement. The patient presented with hypoglycemia manifesting by lipothymia. With the diagnosis of secretory neuroendocrine tumor (insulinoma) of the pancreatic head, cephalic pancreatoduodenectomy with the preservation of the pylorus was performed after NIR visualization of the pancreatic tumor mass. At 6, 12, 18 months postoperatively, the patient no longer had hypoglycemia and her general state was good.

CONCLUSION

NIR with indocyanine green (ICG) evidences pancreatic neuroendocrine tumors, as well as possible synchronous tumors and secondary lymph node or liver involvement.

Indocyanine green-based fluorescence imaging in visceral and hepatobiliary and pancreatic surgery: State of the art and future directions

In recent years, the use of fluorescence-guided surgery (FGS) to treat benign and malignant visceral, hepatobiliary and pancreatic neoplasms has significantly increased. FGS relies on the fluorescence signal emitted by injected substances (fluorophores) after being illuminated by ad hoc laser sources to help guide the surgical procedure and provide the surgeon with real-time visualization of the fluorescent structures of interest that would be otherwise invisible. This review surveys and discusses the most common and emerging clinical applications of indocyanine green (ICG)-based fluorescence in visceral, hepatobiliary and pancreatic surgery. The analysis, findings, and discussion presented here rely on the authors' significant experience with this technique in their medical institutions, an up-to-date review of the most relevant articles published on this topic between 2014 and 2018, and lengthy discussions with key opinion leaders in the field during recent conferences and congresses. For each application, the benefits and limitations of this technique, as well as applicable future directions, are described. The imaging of fluorescence emitted by ICG is a simple, fast, relatively inexpensive, and harmless tool with numerous different applications in surgery for both neoplasms and benign pathologies of the visceral and hepatobiliary systems. The ever-increasing availability of visual systems that can utilize this tool will transform some of these applications into the standard of care in the near future. Further studies are needed to evaluate the strengths and weaknesses of each application of ICG-based fluorescence imaging in abdominal surgery.