Indocyanine green fluorescence imaging to evaluate graft perfusion during liver transplantation

A bibliometric analysis of indocyanine green (ICG) in hepatobiliary surgery from 2008 to 2021

Hundreds of scientific documents have reported on the application of indocyanine green (ICG) in hepatobiliary surgery in the past 13 years, but few bibliometric studies have been conducted. This study aimed to identify the situations of authors, countries/regions, institutions, journals, and hot topics in this field. The overall status and prospects of the current research in this field can be elucidated by bibliometric analysis. Publications from 2008 to 2021 were retrieved from the Web of Science (WoS) Core Collection. The search terms included "liver," "hepatic," "gallbladder," "bile duct," "surgery," "hepatectomy," "ICG," "indocyanine green," and related synonyms. The full records of the search results were exported in text, and the cooperation network and hot topics were evaluated and visualized using CiteSpace software. The number of publications increased between 2008 and 2021. A total of 1527 publications were included in the results, and the frequency of citations was 30,742. The largest proportion of the publications emanated from Japan, and the majority of the papers were published by Kokudo. Tian Jie contributed the largest number of papers in China. Research was relatively concentrated among one country/region. The latest hotspots, "preservation" and "resistance", frequently occurred. Cooperation between authors, countries, and institutions needs to be strengthened for high-quality research. Recent studies have focused on hepatectomy, bile duct resection, liver transplantation, and tumors in this field. Future research may focus on other aspects, such as liver preservation and resistance.

Indocyanine green fluorescence quantification during normothermic ex situ perfusion for the assessment of porcine liver grafts after circulatory death

Current graft evaluation during normothermic ex situ liver perfusion lacks real-time parameters for predicting posttransplant hepatocyte and biliary function. Indocyanine green (ICG) imaging has been widely used in liver surgery, enabling the visualization of hepatic uptake and excretion through bile using near-infrared light. In this research, porcine livers under various ischemic conditions were examined during a 5-hour normothermic ex situ liver perfusion procedure, introducing ICG at 1 hour through the hepatic artery. These conditions included livers from heart-beating donors, donation after circulatory death (DCD) with warm ischemic durations of 60 minutes (DCD60) and 120 minutes (DCD120), as well as interventions utilizing tissue plasminogen activator in DCD120 cases (each n = 5). Distinct hepatic fluorescence patterns correlated with different degrees of ischemic injury ( p = 0.01). Low ICG uptake in the parenchyma (less than 40% of maximum intensity) was more prevalent in DCD120 (21.4%) compared to heart-beating donors (6.2%, p = 0.06) and DCD60 (3.0%, p = 0.02). Moreover, ICG clearance from 60 minutes to 240 minutes was significantly higher in heart-beating donors (69.3%) than in DCD60 (17.5%, p < 0.001) and DCD120 (32.1%, p = 0.01). Furthermore, thrombolytic intervention using tissue plasminogen activator in DCD120 resulted in noteworthy outcomes, including significantly reduced ALP levels ( p = 0.04) and improved ICG clearance ( p = 0.02) with a trend toward mitigating fibrin deposition similar to DCD60, as well as enhancements in bile production ( p = 0.09). In conclusion, ICG fluorescence imaging during normothermic ex situ liver perfusion provides real-time classification of hepatic vascular and biliary injuries, offering valuable insights for the more accurate selection and postintervention evaluation of marginal livers in transplantation.

Utilization of Indocyanine Green (ICG) Fluorescence in Patients with Pediatric Colorectal Diseases: The Current Applications and Reported Outcomes

In pediatric colorectal surgery, achieving and visualizing adequate perfusion during complex reconstructive procedures are paramount to ensure postoperative success. However, intraoperative identification of proper perfusion remains a challeng. This review synthesizes findings from the literature spanning from January 2010 to March 2024, sourced from Medline/PubMed, EMBASE, and other databases, to evaluate the role of indocyanine green (ICG) fluorescence imaging in enhancing surgical outcomes. Specifically, it explores the use of ICG in surgeries related to Hirschsprung disease, anorectal malformations, cloacal reconstructions, vaginal agenesis, bladder augmentation, and the construction of antegrade continence channels. Preliminary evidence suggests that ICG fluorescence significantly aids in intraoperative decision-making by improving the visualization of vascular networks and assessing tissue perfusion. Despite the limited number of studies, initial findings indicate that ICG may offer advantages over traditional clinical assessments for intestinal perfusion. Its application has demonstrated a promising safety profile in pediatric patients, underscoring the need for larger, prospective studies to validate these observations, quantify benefits, and further assess its impact on clinical outcomes. The potential of ICG to enhance pediatric colorectal surgery by providing real-time, accurate perfusion data could significantly improve surgical precision and patient recovery.

Indocyanine green: A novel marker for assessment of graft quality during ex situ normothermic machine perfusion of human livers

BACKGROUND

Ex situ machine perfusion facilitates the assessment of livers prior to transplantation. However, currently available markers of liver function poorly predict long-term graft function. Indocyanine green (ICG) is a liver-specific dye which, although common in vivo, has never been comprehensively evaluated for the assessment of graft quality during ex situ machine perfusion. This study aimed to assess the utility of ICG in the ex situ setting.

METHODS

Using a customized long-term perfusion system, human livers that were not suitable for transplantation were perfused using a red cell-based perfusate. ICG was delivered into the perfusate on days 0, 1, and 4 to assess ICG clearance (spectrophotometric absorbance at 805 nm) and ICG fluorescence (near-infrared camera).

RESULTS

Sixteen partial livers were perfused for a median duration of 172 h (7.2 days). On day 0, the median ICG perfusate disappearance rate (PDR) was 7.5%/min and the median ICG retention at 15 min was 9.9%. Grafts that survived ≥7 days had a significantly higher median ICG PDR on day 0 (14.5%/min vs. 6.5%/min, p = 0.005) but not on days 1 or 4. ICG perfusion demonstrated that long-surviving grafts had a significantly lower median red-value (89.8 vs. 118.6, p = 0.011) and a significantly lower median blue-value (12.9 vs. 22.6, p = 0.045) than short-surviving grafts.

CONCLUSION

ICG is a novel marker for the assessment of liver function during ex situ normothermic machine perfusion. ICG PDR and quantitative ICG perfusion can distinguish between long- and short-surviving grafts and demonstrate the utility of ICG in the assessment of graft quality prior to transplant.

Intraoperative indocyanine green fluorescence imaging to predict early hepatic arterial complications after liver transplantation

The purpose of this study was to propose an innovative intraoperative criterion in a liver transplantation setting that would judge arterial flow abnormality that may lead to early hepatic arterial occlusion, that is, thrombosis or stenosis, when left untreated and to carry out reanastomosis. After liver graft implantation, and after ensuring that there is no abnormality on the Doppler ultrasound (qualitative and quantitative assessment), we intraoperatively injected indocyanine green dye (0.01 mg/Kg), and we quantified the fluorescence signal at the graft pedicle using ImageJ software. From the obtained images of 89 adult patients transplanted in our center between September 2017 and April 2019, we constructed fluorescence intensity curves of the hepatic arterial signal and examined their relationship with the occurrence of early hepatic arterial occlusion (thrombosis or stenosis). Early hepatic arterial occlusion occurred in 7 patients (7.8%), including 3 thrombosis and 4 stenosis. Among various parameters of the flow intensity curve analyzed, the ratio of peak to plateau fluorescence intensity and the jagged wave pattern at the plateau phase were closely associated with this dreaded event. By combining the ratio of peak to plateau at 0.275 and a jagged wave, we best predicted the occurrence of early hepatic arterial occlusion and thrombosis, with sensitivity/specificity of 0.86/0.98 and 1.00/0.94, respectively. Through a simple composite parameter, the indocyanine green fluorescence imaging system is an additional and promising intraoperative modality for identifying recipients of transplant at high risk of developing early hepatic arterial occlusion. This tool could assist the surgeon in the decision to redo the anastomosis despite normal Doppler ultrasonography.

Indocyanine green fluorescence patterns of hepatocellular carcinoma correlate with pathological and molecular features

BACKGROUND

Intraoperative Indocyanine Green Dye (ICG) routinely used in hepatobiliary surgery identifies different fluorescent patterns of hepatocellular carcinoma (HCC), a highly heterogeneous cancer. We aimed to correlate these patterns with gene mutations and extensive pathological features beyond the well-known tumor differentiation.

METHODS

Between February 2017 and December 2019, 21 HCC in 16 consecutive patients who underwent intraoperative ICG fluorescence imaging were included. Pathological review was performed by one pathologist blinded to fluorescence features. Random forest machine learning algorithm correlated pathological features of the tumor, peritumoral and non-tumoral liver, and gene mutations from a 28 gene-panel with rim and intra-lesion fluorescence.

RESULTS

Three HCC had negative intra-lesion and rim-like emission, 7 HCC had homogeneous pattern and 11 heterogeneous patterns in whom 3 with rim-like emission. Rim emission was associated with peritumoral vascular changes, lower differentiation and lower serum AFP level. Homogeneous intra-lesion fluorescence was associated with lower necrosis rate, thinner capsule, absence of peritumoral liver changes, and higher serum AFP level. Heterogeneous HCC without rim harbored lesser TP53 and ARID1A mutations.

CONCLUSION

Tumoral and peri-tumoral fluorescence classification of HCC yielded a possible intraoperative pathological and molecular characterization. These preliminary observations could lead to intraoperative refinement in surgical strategy.

Intra-operative indocyanine green fluorescence imaging in hepatobiliary surgery: a narrative review of the literature as a useful guide for the surgeon

INTRODUCTION

In hepatobiliary surgery, intra-operative indocyanine green (ICG) fluorescence imaging use started in the late 2000s with Japanese surgical teams and is now gaining popularity among surgeons all over the world to improve accuracy and safety of surgical procedures. However, even if ICG fluorescence has been shown to be a safe imaging modality, only a few clinical efficacity studies have been performed and no guidance has been established. This narrative review aims at assessing the potential applications of ICG fluorescence imaging in hepatobiliary surgery.

METHODS

We screened the available international literature to identify the most used applications of ICG fluorescence imaging in hepatobiliary surgery.

RESULTS

Three main fields were identified: biliary duct visualization, hepatic segments' delimitation, and liver tumor detection. Comments, application protocols, prospects, and limitations of each technique were described.

DISCUSSION

These results could guide hepatobiliary surgeons in their use of ICG fluorescence imaging; nevertheless, further prospective studies are needed to assess the sensitivity and specificity of this modality.

[Indocyanine green in liver transplantation]

The purpose of this study was to evaluate the first own experience of using indocyanine green (ICG) in liver transplantation compared to literature data and to determine its potential for clinical practice. Liver transplantation is an effective option for patients with end-stage disease, but this procedure is associated with many problems such as graft rejection, graft dysfunction, surgical risk and postoperative management. Modern methods for assessing graft function have their limitations, so a more efficient method is needed. According to this review, ICG fluorescence is valuable for effective intraoperative blood flow control, assessment of graft function, intraoperative and postoperative monitoring of clinical status. ICG fluorescence can also predict clinical status of patients at all stages of liver transplantation. Routine ICG fluorescence method is advisable in liver transplantation to improve outcomes and optimize treatment process.

Intraoperative uses of near-infrared fluorescence spectroscopy in pediatric surgery: A systematic review

BACKGROUND

The application of near infrared spectroscopy (NIRS) imaging in surgery is growing. This study aimed to systematically review the literature to summarize the intraoperative uses of NIRS in pediatric surgery.

METHODS

A PRISMA-compliant literature search was conducted in PubMed, Embase, Scopus, and Web of Science from inception to February 2020. Title/abstract and then full-text screening were performed. The Oxford centre for Evidence Based Medicine tool (OCEBM) was used to evaluate the level of evidence of included studies.

RESULTS

Reviewers identified 53 articles. Of which, 34 studies (64.2%) were case-series and 11 (20.8%) were case reports. Most of the studies (n = 45, 84.9%) were level 4 on the OCEBM tool. The most common uses of NIRS were to visualize the biliary tree and to identify primary and metastatic malignant tissues. Other applications include assessment of perfusion of tissues including bowel anastomoses, and lymphatic surgery. Several advantages of the introduction of NIRS in pediatric surgery exist including having the potential to reduce operative time and intra/post-operative complications. Moreover, NIRS helps in detecting malignant tissues that can be missed by conventional imaging. However, NIRS has important limitations such as difficulty in identification of the biliary tree in obese patients or inflamed gallbladder, detection of small deeply localized malignant tissues, as well as the high cost.

CONCLUSIONS

NIRS is a promising modality that can be used intraoperatively to augment different pediatric surgical procedures. NIRS has important advantages and limitations compared to conventional surgery, however, more studies are required to evaluate its outcomes and cost-effectiveness.

LEVEL OF EVIDENCE

IV.

Hyperspectral Imaging as a Tool for Viability Assessment During Normothermic Machine Perfusion of Human Livers: A Proof of Concept Pilot Study

Normothermic machine perfusion (NMP) allows for ex vivo viability and functional assessment prior to liver transplantation (LT). Hyperspectral imaging represents a suitable, non-invasive method to evaluate tissue morphology and organ perfusion during NMP. Liver allografts were subjected to NMP prior to LT. Serial image acquisition of oxygen saturation levels (StO2), organ hemoglobin (THI), near-infrared perfusion (NIR) and tissue water indices (TWI) through hyperspectral imaging was performed during static cold storage, at 1h, 6h, 12h and at the end of NMP. The readouts were correlated with perfusate parameters at equivalent time points. Twenty-one deceased donor livers were included in the study. Seven (33.0%) were discarded due to poor organ function during NMP. StO2 (p < 0.001), THI (p < 0.001) and NIR (p = 0.002) significantly augmented, from static cold storage (pre-NMP) to NMP end, while TWI dropped (p = 0.005) during the observational period. At 12-24h, a significantly higher hemoglobin concentration (THI) in the superficial tissue layers was seen in discarded, compared to transplanted livers (p = 0.036). Lactate values at 12h NMP correlated negatively with NIR perfusion index between 12 and 24h NMP and with the delta NIR perfusion index between 1 and 24h (rs = -0.883, p = 0.008 for both). Furthermore, NIR and TWI correlated with lactate clearance and pH. This study provides first evidence of feasibility of hyperspectral imaging as a potentially helpful contact-free organ viability assessment tool during liver NMP.

Intraoperative reperfusion assessment of human pancreas allografts using hyperspectral imaging (HSI)

Background

The most common causes of early graft loss in pancreas transplantation are insufficient blood supply and leakage of the intestinal anastomosis. Therefore, it is critical to monitor graft perfusion and oxygenation during the early post-transplant period. The goal of our pilot study was to evaluate the utility of hyperspectral imaging (HSI) in monitoring the microcirculation of the graft and adequate perfusion of the intestinal anastomosis during pancreatic allotransplantation.

Methods

We imaged pancreatic grafts and intestinal anastomosis in real-time in three consecutive, simultaneous pancreas-kidney transplantations using the TIVITA^® HSI system. Further, the intraoperative oxygen saturation (StO₂), tissue perfusion (near-infrared perfusion index, NIR), organ hemoglobin index (OHI), and tissue water index (TWI) were measured 15 minutes after reperfusion by HSI.

Results

All pancreas grafts showed a high and homogeneous StO₂ (92.6%±10.45%). Intraoperative HSI analysis of the intestinal anastomosis displayed significant differences of StO₂ (graft duodenum 67.46%±5.60% vs. recipient jejunum: 75.93%±4.71%, P<0.001) and TWI {graft duodenum: 0.63±0.09 [I (Index)] vs. recipient jejunum: 0.72±0.09 [I], P<0.001}. NIR and OHI did not display remarkable differences {NIR duodenum: 0.68±0.06 [I] vs. NIR jejunum: 0.69±0.04 [I], P=0.747; OHI duodenum: 0.70±0.12 [I] vs. OHI jejunum: 0.68±0.13 [I], P=0.449}. All 3 patients had an uneventful postoperative course with one displaying a Banff 1a rejection which was responsive to steroid treatment.

Conclusions

Our study shows that contact-free HSI has potential utility as a novel tool for real-time monitoring of human pancreatic grafts after reperfusion, which could improve the outcome of pancreas transplantation. Further investigations are required to determine the predictive value of intraoperative HSI imaging.

Current and Potential Applications for Indocyanine Green in Liver Transplantation

Indocyanine green (ICG) is a fluorescent dye taken up and almost exclusively cleared by the liver. Measurement of its clearance and visualization of its fluorescence make it suitable for a number of potential applications in liver transplantation including assessment of liver function and real-time assessment of arterial, venous, and biliary structures. ICG clearance can be used to assess donor graft quality before procurement and graft metabolic function before transplant using normothermic ex vivo machine perfusion. ICG clearance in the post-liver transplantation period is able to predict recipient outcomes with correlations to early allograft dysfunction and postoperative complications. After absorbing light in the near-infrared spectrum, ICG also emits fluorescence at 835 nm. This allows the assessment of vascular patency after reconstruction and patterns of liver perfusion in real time. ICG perfusion patterns after revascularization are also associated with posttransplant graft function and survival. ICG fluorescence cholangiography is routine in a number of centers and acts as an aid to identifying the optimal point of bile duct division during living donor liver transplantation to optimize safety for both donor and recipient. In summary, ICG is a versatile tool and has a number of useful applications in the liver transplantation journey including assessment of liver function, perfusion assessment, and cholangiography. Further research and clinical trials are required to validate and standardize its routine use in liver transplantation.

Indocyanine green staining for intraoperative perfusion assessment

Indocyanine green (ICG) is a fluorescent iodide-based dye which is used in hepatic surgery to evaluate the biliary tree, liver perfusion, and function. While liver perfusion assessment and delineation of anatomic regions has been performed using ultrasound, ischemic demarcation, or indigo carmine/methylene blue staining, ICG staining can overcome limitations associated with these techniques, such as rapid washout, lack of precision, non-demarcation in damaged livers, and lack of intraparenchymal fidelity. ICG can be used to fluoresce target segments/tumors (Positive staining) or counterstain normal liver tissue leaving areas of interest unstained (negative staining). Moreover, ICG enhancement patterns vary for different tumors, such as colorectal liver metastases vs. hepatocellular carcinoma, providing not only help with detection but also assessment of differentiation. In the field of oncology, benefits of ICG include detection of small radiographically occult tumors, distinction between cirrhotic nodules and cancer, identification of necrotic tumors in chemotherapy-damaged livers, and determining margins when intraoperative ultrasound is inadequate. While ICG has important and expanding indications in hepatic surgery, limitations include small depth of penetrance, need for special monitors/equipment, and potential for dye spillage. ICG is well tolerated, has a small learning curve, minimally invasive surgical integration, and options of both portal vein and peripheral vein injection and hence is a safe and versatile method of anatomic liver mapping, tumor visualization, and liver graft perfusion evaluation in oncologic surgery and liver transplantation. Advancements in technique and technology associated with ICG will aid in increasing the indications in hepato-biliary surgery.

Near-infrared intraoperative imaging of pelvic autonomic nerves: a pilot study

BACKGROUND

The pelvic autonomic nerves control and regulate anorectal and urogenital function. The dysfunction of pelvic autonomic nerves lead to disorders of anorectum, bladder and male sex organs. Thus the intraoperative identification of pelvic autonomic nerves could be crucial in complications prevention and diseases treatment. Our clinical trial aims at estimating the effectiveness and validity of intraoperative indocyanine green fluorescence imaging in pelvic autonomic nerves identification.

METHODS

Intraoperative fluorescence imaging using indocyanine green was performed in ten patients and the feasibility was determined. From February 2019 to June 2019, the seven patients undergoing laparoscopic colorectal resection was administrated 4.5 mg/Kg indocyanine green 24 h before surgery. The near-infrared fluorescence imaging was conducted during surgery. A novel white light and near-infrared dual-channel laparoscopic equipment was applied. For each patient, signal-background ratio values for pelvic autonomic nerves were recorded and analyzed.

RESULTS

We confirmed the dose and timing of indocyanine green administration was 4.5 mg/Kg and 24 h before surgery. Using the dual laparoscopic equipment, we could observe the splanchnic plexus, inferior mesenteric artery plexus, and sacral plexus successfully with a high signal background ratio value of 3.18 (standard deviation: 0.48).

CONCLUSION

This pilot trial shows feasibility of intraoperative indocyanine green fluorescence imaging in pelvic autonomic nerves observation. It demonstrates that nerves can be visualized using alternative imaging techniques but it is not ready yet for prime time. This technique might aid observation with white light alone. Registration number: ChiCTR1900025336.

Fluorescence-guided hepatobiliary surgery with long and short wavelength fluorophores

Importance

Fluorescence-guided surgery (FGS) is a potentially powerful tool for hepatobiliary (HPB) surgery. The high sensitivity of fluorescence navigation is especially useful in settings where tactile feedback is limited.

Objective

The present narrative review evaluates literature on the use of FDA-approved fluorophores such as methylene blue (MB), 5-aminolevulinic acid (5-ALA), and indocyanine green (ICG) for clinical intra-operative image-guidance during HPB surgery.

Evidence Review

Approaches such as dosing, timing, imaging devices and comparative endpoints are summarized. The feasibility and safety of fluorophores in visualizing the biliary tree, identify biliary leaks, outline anatomic hepatic segments, identify tumors, and evaluate perfusion and graft function in liver transplants are discussed.

Findings

Tumor-specific probes are a promising advancement in FGS with a greater degree of specificity. The current status of tumor-specific probes being evaluated in clinical trials are summarized.

Conclusions and Relevance for Reviews

Relevant discussion of promising tumor-specific probes in pre-clinical development are discussed. Fluorescence-guidance in HPB surgery is relatively new, but current literature shows that the dyes are reliably able to outline desired structures with a variety of dosing, timing, and imaging devices to provide real-time intra-operative anatomic information to surgeons. Development of tumor-specific probes will further advance the field of HPB surgery especially during oncologic resections.

Indocyanine Green Fluorescence Imaging to Predict Graft Survival After Orthotopic Liver Transplantation: A Pilot Study

The incidence of primary nonfunction (PNF) after liver transplantation (LT) remains a major concern with the increasing use of marginal grafts. Indocyanine green (ICG) fluorescence is an imaging technique used in hepatobiliary surgery and LT. Because few early predictors are available, we aimed to quantify in real time the fluorescence of grafts during LT to predict 3-month survival. After graft revascularization, ICG was intravenously injected, and then the fluorescence of the graft was captured with a near infrared camera and postoperatively quantified. A multiparametric modeling of the parenchymal fluorescence intensity (FI) curve was proposed, and a predictive model of graft survival was tested. Between July 2017 and May 2019, 76 LTs were performed, among which 6 recipients underwent retransplantation. No adverse effects of ICG injection were observed. The parameter a₁₅₀ (temporal course of FI) was significantly higher in the re-LT group (0.022 seconds^-1 (0.0011-0.059) versus 0.012 seconds^-1 (0.0001-0.054); P = 0.01). This parameter was the only independent predictive factor of graft survival at 3 months (OR, 2.4; 95% CI, 1.05-5.50; P = 0.04). The best cutoff for the parameter a₁₅₀ (0.0155 seconds^-1 ) predicted the graft survival at 3 months with a sensitivity (Se) of 83.3% and a specificity (Spe) of 78.6% (area under the curve, 0.82; 95% CI, 0.67-0.98; P = 0.01). Quantitative assessment of intraoperative ICG fluorescence on the graft was feasible to predict graft survival at 3 months with a good Se and Spe. Further prospective studies should be undertaken to validate these results over larger cohorts and evaluate the clinical impact of this tool.

Intraoperative Imaging Techniques to Visualize Hepatic (Micro)Perfusion: An Overview

The microcirculation plays a crucial role in the distribution of perfusion to organs. Studies have shown that microcirculatory dysfunction is an independent predictor of morbidity and mortality. Hence, assessment of liver perfusion offers valuable information on the (patho)physiological state of the liver. The current review explores techniques in perfusion imaging that can be used intraoperatively. Available modalities include dynamic contrast-enhanced ultrasound, handheld vital microscopes, indocyanine green fluorescence angiography, and laser contrast speckle imaging. Dynamic contrast-enhanced ultrasound relays information on deep tissue perfusion and is a commonly used technique to assess tumor perfusion. Handheld vital microscopes provide direct visualization of the sinusoidal architectural structure of the liver, which is a unique feature of this technique. Intraoperative fluorescence imaging uses indocyanine green, a dye that is administered intravenously to visualize microvascular perfusion when excited using near-infrared light. Laser speckle contrast imaging produces non-contact large surface-based tissue perfusion imaging free from movement- or pressure-related artefacts. In this review, we discuss the intrinsic advantages and disadvantages of these techniques and their clinical and/or scientific applications.

[Intraoperative fluorescence angiography and cholangiography with indocyanine green in hepatobiliary surgery]

Intraoperative fluorescence angiography and cholangiography with indocyanine green (ICG) are increasingly used in routine hepatobiliary surgery. Its usage is manifold. It improves and facilitates navigation especially in minimal invasive and robotic surgery and therefore increases the safety of the surgical intervention. In laparoscopic cholecystectomy for example, the bileduct anatomy can be easily visualized, even in complicated cholecystitis or anatomical variants without being too time consuming. ICG fluorescence also enables the visualization of vascular structures and perfusion. Anatomical liver resections, for example in hepatocellular carcinoma (HCC), can be performed easily as liver segments and territories can be identified. Anatomical resection is becoming more important, e.g. in the treatment of HCC. Another useful application is the intraoperative detection of bile leakages after liver resection. In particular, the intraoperative control of a biliodigestive anastomosis is possible with ICG fluorescence cholangiography and therefore reduces morbidity. Even primary and secondary liver tumors can be detected with ICG fluorescence. Whereas well-differentiated HCCs homogeneously take up ICG, poorly differentiated HCCs and metastases do not: however, in these cases the adjacent liver parenchyma stores ICG more intensively than healthy liver tissue, which creates a ring-like fluorescence pattern. To conclude, the use of ICG fluorescence in hepatobiliary surgery is diverse but in Germany it is still at the beginning compared to other countries.