Fluorescence Guided Surgery To Reduce Complications
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1 To Reduce Complications Luigi Boni, MD, FACS Associate Professor of Surgery Department of Surgery - IRCCS Policlinico Hospital University of Milan
2 The Dream of a Surgeon
3 Image Guided Surgery
4 Basic Principles
5 Indocyanine Green Developed in the Second World War as a dye for photography In 1957 tested at Mayo Clinic for Liver function test Angiography of Retinal Veins ICG it is NOT metabolized in human body 95% binds with human albumin It is rapidly removed from the body by the liver Its half time for healthy liver is few minutes Very high toxic dose (5mg/kg/day)
6 Intravenous injection of ICG 0,1-0,3 mg/kg ICG binds to plasma proteins and remains in the vascular bed Excitation of ICG fluorescence with near infra-red (NIR at 805 nm) Detection of fluorescence signal at 835 nm with special telescopes Evaluation of the fluorescence signal
7 Available Systems - Open Surgery FLUOBEAM (Fluoptics, France) Artemis (Quest Medical, NL) Gray scale RGB color Gray scale Gray scale
8 Available Systems - Laparoscopic Surgery
9 Available Systems - Robotic Surgery
10 Karl Storz ICG System
11 ICG Fluorescent Cholagiography
12 Biliary Tract Lesions in 2015 in USA x 0,3%= 2.250
13 Can We Accept This Figures? 1400 flight at Heathrow each day x 0,3% 42 Plane Crashes/ Day
14 Biliary Tract Lesions During Laparoscopic Cholecystectomy
15 Fluorescence Guided Cholecystectomy
16 Fluorescence Guided Cholecystectomy
17 Fluorescence Guided Cholecystectomy
18
19 Laparoscopic Cholecystectomy for Acute Cholecystitis
20 Laparoscopic Cholecystectomy for Acute Cholecystitis
21 Biliary Leak Identification
22 ICG Fluorescent Bowel Perfusion
23 Anastomotic Leaks Facts Esophagectomy: Leaks: 4-25% Colonic Resection: Leaks: 2-7% Leak Mortality: Up to 50% Leak Mortality: Up to 15% Total/Partial Gastrectomy: Leaks: 5-12% Rectal Resection: Leaks: 5-20% Leak Mortality: Up to 20% Leak Mortality: Up to 10% Sleeve Gastrectomy: Leaks: 1-4% Leak Mortality: Up to 5%
24 Anastomotic Leaks
25 Blood Supply & Anastomotic Leaks Facts: Techniques to Assess Bowel Perfusion Surgeon s Visual Evaluation Color Bleeding Vessels Pulsation Laser Doppler Ultrasound Oxigen Spectroscopy Polarographic Measurement of Oxygen Tension Hydrogen Gas Clearance Radioisotope Studies Microdialysis Fluorescent Angiography
26 Anterior Resection
27 Ischemia Where is the Ischemic Segment????
28 Ischemia TA-TME
29 Bowel Perfusion Control : Colorectal
30 Colonic Perfusion Control
31 Bowel Perfusion Control for Anterior Resection: Case Match Analysis
32 Laparoscopic Esophagectomy
33 Bowel Perfusion Control : Esophageal
34 Sleeve Gastrectomy
35 ICG Fluorescent Ureter Identification
36 Ureter Identification
37 ICG Fluorescent Lymphnodes Mapping
38 < Fluorescence Guided Surgery Iliac-Obturatory Lymphadenectomy for Melanoma
39 Lymph Nodes Mapping in Gastric Cancer The Concept of Lymphatic Basin
40 < Fluorescence Guided Surgery Lymph Node Mapping in Gastric Cancer
41 Complete Mesocolic Excision During Right Colectomy For Everyone?
42 Lymphnode Mapping
43 Lymphnode Mapping in Rectal Cancer
44 ICG Fluorescence Guided Liver Resection
45 Fluorescent Appearance of Liver Tumor
46 Colorectal Metastases Segment VII Invisible Deep Metastases Segment VI Visible Superficial Metastases
47 Future Perspective
48 The Future INDEPENDENT FROM THE DISTANCE LIGHT SOURCE-TARGET DOES NOT REQUIRE A CALIBRATION TOOL ENABLES REPETITIVE INJECTIONS ENABLES REPRODUCIBILITY AND STANDARDIZATION
49 The Future
50 The Future
51 The Future
52 The Future
53 The Future
54 Conclusions ICG Fluorescence Enhanced Surgery is an effective tool to increase visualization during laparoscopic surgery The technique is safe and easy to replicate ICG is virtually harmless Costs effective Multiple and multidisciplinary possible applications Significant possible medico-legal repercussion Fluorescence tumor targeting will be the next revolution in the field of real personalized surgery
55
56 SPECIAL THANKS Department of General and Emergency Surgery Policlinico Hospital of Milan University of Milan Minimally Invasive Surgery Research Center University of Insubria
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