UNASSIGNED: Although major amputations can often be avoided due to evolving methods of endovascular and surgical revascularizations techniques, in patients with chronic limb-threatening ischemia, it is still necessary in some cases. Aim of this study was the detection of wound healing disorders through intraoperative microcirculation measurements in major limb amputations.
UNASSIGNED: In this single-center clinical study, patients with an indication for major amputation were enrolled prospectively. Cause of amputation, patients\' comorbidities including cardiovascular risk profile were assessed. Macrocirculation, as well as microcirculation were assessed. Microcirculation measurements were performed by fluorescence angiography with the administration of indocyanine green. A preoperative measurement was obtained at the amputation level, followed by three additional measurements of the amputation stump postoperatively. Wound healing was monitored and correlated with the microcirculatory findings, based on the perfusion parameters ingress and ingress rate, calculated in the indocyanine green fluorescence video sequences of the amputation stumps.
UNASSIGNED: Forty-five patients were enrolled, including 19 (42%) below-the-knee amputations and 26 (58%) above-the-knee amputations. When considering the need for revision, a change in the microperfusion parameters was observed postoperatively. The mean value for ingress was significantly lower directly postoperatively in stumps requiring revisions (5 ± 0 A.U. versus 40.5 ± 42.5 A.U., p < 0.001). The mean value of ingress rate behaved similarly (0.15 ± 0.07 A.U./s versus 2.8 ± 5.0 A.U./s, p = 0.005). The evaluation of indocyanine green measurements when wound healing disorders occurred also showed nonsignificant differences in the mean values.
UNASSIGNED: Fluorescence angiography after major lower limb amputations appears to be an option of depicting microperfusion. Especially, the early postoperative detection of reduced perfusion can indicate a subsequent need for revision. Therefore, this method could possibly serve as a tool for intraoperative quality control after major limb amputation.

UNASSIGNED: Intraoperative indocyanine green fluorescence angiography (ICGFA) perfusion assessment has been demonstrated to reduce complications in reconstructive surgery. This study sought to advance ICGFA flap perfusion assessment via quantification methodologies.
UNASSIGNED: Patients undergoing pedicled and free flap reconstruction were subjected to intraoperative ICGFA flap perfusion assessment using either an open or endoscopic system. Patient demographics, clinical impact of ICGFA and outcomes were documented. From the ICGFA recordings, fluorescence signal quality, as well as inflow/outflow milestones for the flap and surrounding (control) tissue were computationally quantified post hoc and compared on a region of interest (ROI) level. Further software development intended full flap quantification, metric computation and heatmap generation.
UNASSIGNED: Fifteen patients underwent ICGFA assessment at reconstruction (8 head and neck, 6 breast and 1 perineum) including 10 free and 5 pedicled flaps. Visual ICGFA interpretation altered on-table management in 33.3% of cases, with flap edges trimmed in 4 and a re-anastomosis in 1 patient. One patient suffered post-operative flap dehiscence. Laparoscopic camera use proved feasible but recorded a lower quality signal than the open system.Using established and novel metrics, objective ICGFA signal ROI quantification permitted perfusion comparisons between the flap and surrounding tissue. Full flap assessment feasibility was demonstrated by computing all pixels and subsequent outputs summarisation as heatmaps.
UNASSIGNED: This trial demonstrated the feasibility and potential for ICGFA with operator based and quantitative flap perfusion assessment across several reconstructive applications. Further development and implementation of these computational methods requires technique and device standardisation.

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.

BACKGROUND: Indocyanine green fluorescence angiography, a validated noninvasive imaging technique, is used to assess tissue vascularization. Here, we report three infant patients who underwent intraoperative indocyanine green fluorescence angiography and suffered from postoperative complications caused by the lack of weak fluorescent intestinal resection and assessed residual intestinal perfusion.
METHODS: We observed the clinical characteristics and operative findings of patients treated from January 2022 to December 2022. Indocyanine green (0.5 mg/kg) was intravenously injected. The first patient was a 29-day-old girl with surgical necrotizing enterocolitis who underwent intraoperative indocyanine green fluorescence angiography at the first- and second-look operations. The proximal jejunum was difficult to diagnose to detect blood flow during the second-look operation. The second patient was a 32-day-old boy with surgical necrotizing enterocolitis. A part of the antimesenteric mucosa of the patient that exhibited weak fluorescence was preserved; however, it formed postoperative hematomas. The third patient was a 30-day-old boy with midgut volvulus. Weak fluorescence in the intestinal wall was observed 5 cm of the small intestine from the ileocecal valve was preserved, but it formed a stricture, and the patient underwent ileocecal resection after 30 days.
CONCLUSIONS: Weak fluorescence in the intestine in infants by performing indocyanine green fluorescence angiography is associated with a high risk of non-recovering ischemic lesions and postoperative complications.

UNASSIGNED: Immediate post-mastectomy breast reconstruction offers benefits; however, complications can compromise outcomes. Intraoperative indocyanine green fluorescence angiography (ICGFA) may mitigate perfusion-related complications (PRC); however, its interpretation remains subjective. Here, we examine and develop methods for ICGFA quantification, including machine learning (ML) algorithms for predicting complications.
UNASSIGNED: ICGFA video recordings of flap perfusion from a previous study of patients undergoing nipple-sparing mastectomy (NSM) with either immediate or staged immediate (delayed by a week due to perfusion insufficiency) reconstructions were analysed. Fluorescence intensity time series data were extracted, and perfusion parameters were interrogated for overall/regional associations with postoperative PRC. A naïve Bayes ML model was subsequently trained on a balanced data subset to predict PRC from the extracted meta-data.
UNASSIGNED: The analysable video dataset of 157 ICGFA featured females (average age 48 years) having oncological/risk-reducing NSM with either immediate (n=90) or staged immediate (n=26) reconstruction. For those delayed, peak brightness at initial ICGFA was lower (p<0.001) and significantly improved (both quicker-onset and brighter p=0.001) one week later. The overall PRC rate in reconstructed patients (n=116) was 11.2%, with such patients demonstrating significantly dimmer (overall, p=0.018, centrally, p=0.03, and medially, p=0.04) and slower-onset (p=0.039) fluorescent peaks with shallower slopes (p=0.012) than uncomplicated patients with ICGFA. Importantly, such relevant parameters were converted into a whole field of view heatmap potentially suitable for intraoperative display. ML predicted PRC with 84.6% sensitivity and 76.9% specificity.
UNASSIGNED: Whole breast quantitative ICGFA assessment reveals statistical associations with PRC that are potentially exploitable via ML.

OBJECTIVE: To evaluate the effectiveness of intraoperative angiography and fluorescence navigation with indocyanine green in reducing the risks of intra- and postoperative complications, as well as resection quality in patients with gastric cancer.
METHODS: The main group consisted of patients who underwent intraoperative angiography and fluorescence navigation with indocyanine green (n=43). The control group included patients without these procedures (n=154). Both groups did not differ in gender (p=0.937) and age (p=0.437). The lower third of the stomach was the most common tumor location in the main group (62.7% of cases), the middle and lower thirds of the stomach - in the control group (37% and 38.9% of patients, respectively). There was no between-group difference in «cT» grading (p>0.05). However, there were more «cN+» patients in the main group (14 (32.6%) versus 28 (18.4%) ones of «N0» category, p=0.042). Therefore, 41.9% and 13.6% of patients underwent neoadjuvant chemotherapy in both groups, respectively (<0.001).
RESULTS: Intraoperative angiography and fluorescence navigation with indocyanine green does not increase mortality (p=0.631), incidence of major (CD 3-5) (p=0.436) and minor (CD 1-2) postoperative complications (p=0.177), surgery time (p=0.288), mean intraoperative blood loss (p=0.144) and length of hospital-stay (p=0.631). Fluorescence navigation with indocyanine green does not affect the number of detected «positive» resection margins (R1) (p=0.883) but significantly increases the number of excised lymph nodes (p<0.001).
CONCLUSIONS: Intraoperative angiography and fluorescence navigation with indocyanine green are safe for intraoperative visualization of tumor and lymph nodes, as well as assessment of arterial blood supply. This technique is effective in traditional and minimally invasive surgeries for gastric cancer. Fluorescence navigation with indocyanine green significantly increases the number of excised lymph nodes.
UNASSIGNED: Оценить эффективность интраоперационной флюоресцентной ангиографии (ФА) и флюоресцентной навигации (ФН) индоцианином зеленым (ICG) в снижении риска развития интраоперационных и послеоперационных осложнений, а также онкологического радикализма у больных, оперированных по поводу рака желудка.
UNASSIGNED: Основную группу составили пациенты, которым выполняли ФА и/или ФН ICG (n=43); в группу контроля вошли пациенты, в лечении которых ФА и/или ФН ICG не применяли (n=154). Исследуемые группы наблюдения не различались по гендерному (p=0,937) и возрастному составу (p=0,437). У пациентов группы с применением ФА и ФН ICG самой частой локализацией опухоли была нижняя треть желудка (62,7% наблюдений), у пациентов контрольной группы — средняя и нижняя треть желудка (37 и 38,9% соответственно). При клиническом стадировании больных разницы по категории «сТ» между группами не было (p>0,05), однако в основной группе было больше пациентов категории «cN+» — 14 (32,6%) по сравнению с 28 (18,4%) категории «N0» (p=0,042), исходя из этого неоадъювантную химиотерапию получили 41,9% больных основной группы и 13,6% — контрольной группы (p<0,001).
UNASSIGNED: Применение ФН и ФА ICG не увеличивает число летальных исходов (p=0,631), послеоперационных осложнений (p=0,277), как больших (CD 3-5) (p=0,436), так и малых (CD 1-2) (p=0,177), время операции (p=0,288), средний объем интраоперационной кровопотери (p=0,144) и среднюю продолжительность пребывания больного в стационаре (p=0,631). ФН ICG не влияет на количество выявляемых «положительных» краев резекции (R1) (p=0,883), однако статистически значимо позволяет увеличить количество удаленных лимфатических узлов (p<0,001).
UNASSIGNED: Флюоресцентная ангиография и флюоресцентная навигация индоцианином зеленым являются безопасными методами интраоперационной визуализации опухоли, лимфатических узлов и оценки артериального кровоснабжения анастомозируемых тканей. Методика эффективна как при традиционных, так и при миниинвазивных операциях по поводу рака желудка. Флюоресцентная навигация индоцианином зеленым статистически значимо позволяет увеличить количество удаленных лимфатических узлов.

Acute mesenteric ischemia (AMI) is still a time-critical and life-threatening clinical picture. If exploration of the abdominal cavity is necessary during treatment, an intraoperative assessment of which segments of the intestines have a sufficient potential for recovery must be made. These decisions are mostly based on purely clinical parameters, which are subject to high level of uncertainty. This review article provides an overview of how this decision-making process and the determination of resection margins can be improved using technical aids, such as laser Doppler flowmetry (LDF), indocyanine green (ICG) fluorescence angiography or hyperspectral imaging (HSI). Furthermore, this article compiles guideline recommendations on the role of laparoscopy and the value of a planned second-look laparotomy. In addition, an overview of strategies for preventing short bowel syndrome is given and other aspects, such as the timing and technical aspects of placement of a preternatural anus and an anastomosis are highlighted.
UNASSIGNED: Die akute mesenteriale Ischämie (AMI) stellt weiterhin ein zeitkritisches und bedrohliches Krankheitsbild dar. Ist im Rahmen der Therapie eine Exploration des Abdomens erforderlich, muss intraoperativ eingeschätzt werden, welche Darmabschnitte ein ausreichendes Erholungspotenzial aufweisen. Diese Entscheidungen basieren meist auf rein klinischen Parametern, die ein hohes Fehlerpotenzial aufweisen. Dieser Übersichtsartikel fasst zusammen, wie Entscheidungsprozesse und die Festlegung von Resektionsgrenzen durch technische Hilfsmittel wie Laser-Doppler-Flowmetrie (LDF), Indocyaningrün(ICG)-Fluoreszenzangiographie oder hyperspektrale Bildgebung (HSI) verbessert werden können. Darüber hinaus stellt dieser Artikel Leitlinienempfehlungen zur Rolle der Laparoskopie und zum Wert einer geplanten Second-Look-Laparotomie zusammen. Außerdem wird ein Überblick über Strategien zur Verhinderung eines Kurzdarmsyndroms gegeben und weitere Aspekte wie das Timing und technische Aspekte von Anus-praeter- und Anastomosenanlagen beleuchtet.

The breadth of pediatric surgical practice and variety of anatomic anomalies that characterize surgical disease in children and neonates require a unique level of operative mastery and versatility. Intraoperative navigation of small, complex, and often abnormal anatomy presents a particular challenge for pediatric surgeons. Clinical experience with fluorescent tissue dye, specifically indocyanine green (ICG), is quickly gaining widespread incorporation into adult surgical practice as a safe, non-toxic means of accurately visualizing tissue perfusion, lymphatic flow, and biliary anatomy to enhance operative speed, safety, and patient outcomes. Experience in pediatric surgery, however, remains limited. ICG-fluorescence guided surgery is poised to address the challenges of pediatric and neonatal operations for a growing breadth of surgical pathology. Fluorescent angiography has permitted intraoperative visualization of colorectal flap perfusion for complex pelvic reconstruction and anastomotic perfusion after esophageal atresia repair, while its hepatic absorption and biliary excretion has made it an excellent agent for delineating the dissection plane in the Kasai portoenterostomy and identifying both primary and metastatic hepatoblastoma lesions. Subcutaneous and intra-lymphatic ICG injection can identify iatrogenic chylous leaks and improved yields in sentinel lymph node biopsies. ICG-guided surgery holds promise for more widespread use in pediatric surgical conditions, and continued evaluation of efficacy will be necessary to better inform clinical practice and identify where to focus and develop this technical resource.

OBJECTIVE: To evaluate the impact of indocyanine green fluorescence angiography on the incidence of colorectal anastomotic leakage.
METHODS: We summarized the results of non-comparative and randomized clinical trials, as well as meta-analyses.
RESULTS: Indocyanine green fluorescence angiography changes the anastomosis site in 10% of patients due to inadequate blood supply to intestinal wall at the initially scheduled level. This method can decrease the incidence of «low» colorectal anastomosis leakage.
CONCLUSIONS: Routine intraoperative fluorescence angiography with indocyanine green can become a standard method for prevention of colorectal anastomotic leakage.
UNASSIGNED: Оценить влияние флуоресцентной ангиографии с индоцианином зеленым на частоту несостоятельности колоректального анастомоза.
UNASSIGNED: Проанализированы представленные в литературе результаты основных клинических несравнительных и рандомизированных исследований, а также опубликованных до настоящего момента метаанализов.
UNASSIGNED: Проведение флуоресцентной ангиографии с индоцианином зеленым приводит к изменению места формирования анастомоза в проксимальном направлении в среднем у 10% пациентов вследствие неадекватности кровоснабжения кишечной стенки на намеченном изначально хирургом уровне. Выполнение данной методики может способствовать снижению частоты несостоятельности «низких» колоректальных анастомозов.
UNASSIGNED: Рутинное использование интраоперационной флуоресцентной ангиографии с индоцианином зеленым может стать стандартной методикой при формировании колоректального анастомоза с целью снижения частоты его несостоятельности.

OBJECTIVE: To evaluate the possibility of integrating tissue perfusion assessment techniques (ICG perfusion and imaging photoplethysmography - iPPG) into the system of intraoperative control points of laparoscopic interventions with a reconstructive component.
METHODS: Quantitative assessment of ICG fluorescence and iPPG were used during 8 laparoscopically assisted interventions: gastrectomy for gastric cancer (total - 2 and distal - 1) and colorectal resections (left-sided colorectal resections - 4 and right hemicolectomy - 1).
RESULTS: Four stages are presented for the assessment of tissue perfusion: initial assessment, before intestine transection, before anastomosis formation, and evaluation of anastomosis. From the point of view of the significance of clinical decision-making, the «before intestine transection» stage is of great importance, due to the ease of transferring the resection level to the optimal tissue perfusion zone.
CONCLUSIONS: Integration of tissue perfusion assessment techniques into the system of intraoperative checkpoints is possible and promising.
UNASSIGNED: Анализ возможности интеграции методик оценки перфузии тканей (ICG-перфузии и визуализирующей фотоплетизмографии — вФПГ) в систему интраоперационных контрольных точек лапароскопических вмешательств с реконструктивным компонентом, предусматривающих формирование межкишечного анастомоза.
UNASSIGNED: Количественная оценка ICG флуоресценции и в ФПГ использованы во время 8 лапароскопически ассистированных вмешательств: гастрэктомия при раке желудка (тотальная — 2 и дистальная — 1) и колоректальные резекции (левосторонние коло- ректальные резекции — 4 и правосторонняя гемиколэктомия — 1).
UNASSIGNED: Представлены 4 этапа для оценки тканевой перфузии: исходная оценка, до пересечения кишки, до анастомозирования и оценка анастомоза. С точки зрения значимости принятия клинических решений наибольшее значение имеет этап «до пересечения» в связи с простотой переноса уровня резекции в оптимальную зону тканевой перфузии.
UNASSIGNED: Интеграции методик оценки перфузии тканей в систему интраоперационных контрольных точек возможна и перспективна.